NURSES’ PERCEPTION REGARDING THE PROMOTION OF OLDER PEOPLE’S AUTONOMY AT COVID-19: A DESCRIPTIVE CORRELATIONAL STUDY

ABSTRACT

Objective

to identify and compare the perception of general care nurses and specialist nurses about the development of interventions promoting older people’s autonomy

Method

descriptive-correlational, cross-sectional study. The Self-Assessment Scale for the Promotion of Older People’s Autonomy was applied to Portuguese nurses in September/October 2020

Results

the sample consisted of 356 nurses, specialists and general practitioners. All nurses had the perception of promoting older people’s autonomy, with less visibility in the development of interventions involving instrumental activities of daily living. Specialist nurses have a perception of more promotion of autonomy to older people through the development of physical and cognitive interventions (p<0.01), of interventions of instrumental activities of daily living (p<0.05), and in the training of the caregiver (p<0.05)

Conclusion

this study allowed emphasizing the potential relevance of developing interventions that promote older people’s autonomy, as well as the importance of raising nurses’ awareness to carry them out

DESCRIPTORS
Patient Care; Personal Autonomy; Health promotion; Nurses; Specialties, Nursing

RESUMO

Objetivo

identificar e comparar a percepção dos enfermeiros de cuidados gerais e enfermeiros especialistas sobre o desenvolvimento de intervenções promotoras da autonomia dos idosos

Método

estudo descritivo-correlacional, transversal. Foi aplicada aos enfermeiros portugueses a Escala de Autoavaliação da Promoção da Autonomia dos Idosos, em setembro e outubro de 2020

Resultados

a amostra foi composta por 356 enfermeiros, especialistas e generalistas. Todos tiveram a percepção de promover a autonomia dos idosos, com menos visibilidade no desenvolvimento de intervenções de atividades instrumentais de vida diária. Os enfermeiros especialistas percebem promover mais a autonomia dos idosos, através do desenvolvimento de intervenções físicas e cognitivas (p<0,01), de intervenções de atividades instrumentais de vida diárias (p<0,05) e da capacitação do cuidador (p<0,05)

Conclusão

este estudo permitiu enfatizar a potencial relevância do desenvolvimento de intervenções promotoras da autonomia dos idosos, assim como a importância da consciencialização dos enfermeiros para a sua realização

DESCRITORES
Assistência ao Paciente; Autonomia Pessoal; Promoção da Saúde; Enfermeiros; Especialidades de Enfermagem

RESUMEN

Objetivo

identificar y comparar la percepción de enfermeros de cuidados generales y enfermeros especializados sobre el desarrollo de intervenciones que promuevan la autonomía de los ancianos

Método

estudio descriptivo-correlacional, transversal. La Escala de Autoevaluación para la Promoción de la Autonomía de las Personas Mayores se aplicó a enfermeros portugueses en septiembre/octubre de 2020

Resultados

la muestra estuvo conformada por 356 enfermeros, especialistas y generales. Todos los enfermeros tuvieron la percepción de promover la autonomía de los ancianos, con menor visibilidad en el desarrollo de intervenciones que involucren actividades instrumentales de la vida diaria. Los enfermeros especialistas perciben promover más autonomía para los ancianos, a través del desarrollo de intervenciones físicas y cognitivas (p <0.01), intervenciones en actividades instrumentales de la vida diaria (p <0.05) y en la formación del cuidador (p <0.05). 0,05)

Conclusión

este estudio permitió enfatizar la potencial relevancia de desarrollar intervenciones que promuevan la autonomía de los ancianos, así como la importancia de sensibilizar a los enfermeros para que las lleven a cabo

DESCRIPTORES
Atención al paciente; Autonomía personal; Promoción de la salud; Enfermeros; Especialidades de enfermería

INTRODUCTION

Longevity is an achievement resulting from the scientific and technological advances of the last centuries. However, when followed by decrease in fertility, it promotes changes in societies that make them weaker. It is predicted that, in the global context, between 2017 and 2050, the world population aged over 60 will increase from 962 million to 2.1 billion. By 2050, about 80% of older people will live in low- or middle-income countries; thus, most countries face major challenges in maintaining adequate care for these people⁽¹⁾.

The increase in average life expectancy is not always accompanied by quality of life and dignity for the elderly. Sometimes, aging processes are accompanied by debilitating chronic diseases, which place older people in situations of great vulnerability and fragility⁽²⁾. On their own, the physiological processes resulting from aging, such as impaired neuromuscular performance - evidenced by weakness or loss of muscle strength, slowed movement, decreased balance, mobility and involuntary weight loss⁽³⁾, restrain the elderly and make them vulnerable and very fragile^(2,4). Although aging progresses at a variable rate from person to person, in general the decline in physical and physiological functions begins during the third decade of life, and increases substantially after the age of 60 years⁽⁴⁾.

During the life cycle, the implementation of physical exercise, cognitive training, social integration and even emotional management programs is warranted, through work groups. This issue assumes greater relevance in older people, and the implementation of these programs has shown great effectiveness in reducing the frailty markers of older people⁽²⁾.

All aging processes, as well as the chronic pathologies that are often associated with them, make older people vulnerable and reflect on their autonomy^(2,4). Autonomy is a complex concept and encompasses dimensions such as cognitive status, emotional intelligence, social integration, intellectual condition, and physical condition, with homeostasis being essential to consummate an autonomous life within these dimensions⁽⁵⁾.

Due to the importance of maintaining autonomy for the quality of life of older people, the nurse, and very distinctly the specialist nurse, shall analyze their behavior in this context, as given the purpose of their work and proximity to the people who needs care, they have a critical role in promoting people’s autonomy, particularly in older people⁽⁶⁾. Thus, the basic principle of respect and the search for autonomy are expected in the relationship among health professionals (among them, nurses and specialist nurses).

Older people’s autonomy involves the expansion of the skills described above and health empowering. It should be noted that this is only possible if the person has cognitive and social skills. Empowerment facilitates the process for managing health conditions and promotes autonomy⁽⁷⁾. The nursing interventions promoting this empowerment are “teaching-like” and “instructing-like”, as they allow the improvement of the person’s “knowledge” on a given topic and perceive the need to deepen this knowledge and reduce the existing gap⁽⁸⁾.

The increase in skills that the concept of autonomy encompasses is achieved through “training-like” nursing interventions⁽⁸⁾. Intervention programs carried out by specialist nurses demonstrate their effectiveness in health gains, directly or indirectly, in what regards autonomy^(6,9-14).

Specialist nurses, according to the Portuguese Order of Nurses^(15:4745):

Have common skills, regardless of their area of expertise, demonstrated through their high capacity for designing, managing and supervising care, and also through effective support to specialized professional practice in the field of training, research and advice.

These skills are reflected in nursing interventions that, as a whole, promote people’s autonomy throughout the life cycle and in the health-disease transition processes.

The specific competences of specialist nurses allow the nurses to develop their practices more specifically and effectively. In their area of expertise, all nurses, specially general care nurses, have knowledge that allows them to promote autonomy⁽¹⁵⁾, since in the study plans of the Nursing Undergraduate Course this theme is contemplated.

According to the Portuguese Order of Nurses, general care nurses have skills that allow them to respond to the person’s needs, at all levels of performance, using techniques of interpersonal relationship, critical thinking. They are also capable of systemic and systematic decision-making, respecting the person’s capabilities, for freedom of choice and dignity⁽¹⁶⁾. In Portugal, since 1999, general care nurses have received a four-year basic training that gives them a degree in nursing. The specialist nurses, on their turn, can only apply for this training after two years of professional practice in the areas of rehabilitation, infant and pediatric health, medical-surgical, mental health and psychiatric, and maternal and obstetric health⁽¹⁷⁾. Thus, all nurses have knowledge that allows them to promote people’s autonomy, regardless of whether they are specialist nurses or not.

The Nursing process equates and systematizes Nursing care through the identification of diagnoses; it allows prescribing, implementing, and evaluating interventions that respond to the needs of the people they care for, which in this context concern those promoting older people’s autonomy⁽¹⁸⁾.

The present study aims to identify and compare the perception of general care nurses and specialist nurses about the development of interventions promoting older people’s autonomy, testing the hypothesis: is there a difference in the self-assessment of older people’s autonomy promotion among specialist nurses and general care nurses?

METHOD

This is a cross-sectional, quantitative, descriptive, and correlational study. We opted for this type of study because we considered it to be the one to best respond to the objectives. The non-probabilistic snowball sampling technique was used, and the link created on the online platform Google Forms^® was sent via email to the nurses from the contact list of all researchers for them to fill in the questionnaire. These nurses were asked to share the questionnaire with other nurses with the same characteristics.

The sample consisted of 356 nurses working in Portugal, who responded to the following inclusion criteria: working with older people.

The present study was carried out during the pandemic period of the Coronavirus Disease 2019 (COVID-19), as in Portugal the first case appeared in March 2020, and data collection was carried out between September and October 2020, that is, during the period when the arrival of the second wave of the disease was imminent.

The data collection instrument included the following sociodemographic and professional data of the participants: age, sex, length of work at the service, specialty, length of work as a specialist, and the specialty, as well as the Self-Assessment Scale for the Promotion of Older People’s Autonomy (EAPAI)⁽¹⁹⁾, to self-evaluate how they promote older people’s autonomy.

The scale EAPAI is a validated instrument for the Portuguese population⁽¹⁹⁾, consisting of 68 items organized into six factors (development of emotional, social, and self-care interventions; development of physical and cognitive interventions; development of interventions for instrumental activities of daily living; development of evaluative interventions in the area of self-care; development of evaluative interventions in the emotional, cognitive, and social areas, and caregiver training), with a Cronbach’s Alpha of 0.98. Items are evaluated using a Likert-like response – allowing positioning on a continuum of self-perception variation: 0) do not apply it; 1) I apply it a few times; 2) I frequently apply it; 3); I apply it many times; 4) I always apply it. Thus, the higher the final scale score, the more nurses perceive they promote older people’s autonomy.

For the statistical treatment of the data, the IBM SPSS^® version 26 was used. For data analysis, descriptive (for nominal and ordinal variables, frequencies and percentages were analyzed, and for scalar variables, means and standard deviations were analyzed) and inferential statistics were used, the 95% confidence interval was adopted, with p-value <0.05 to assume the hypothesis that there was an association between the studied variables.

For statistical analysis purposes, continuous variables referring to the full scale and its factors were not categorized, as they do not have cutoff points. The normality of distribution of variables was evaluated using the Kolmogorov-Smirnov test. As the normality in the distribution of the variables was observed, the inferential statistics was carried out using Student’s t test.

The study was approved by the Ethics Committee of two health institutions in the North of Portugal (opinions no. 324/17 and no. 11/18), before data collection. All participants were informed of the study and of its objectives, as well as of the fact that all data provided would be treated anonymously, thus ensuring confidentiality and anonymity.

RESULTS

The study included 356 nurses from Portugal. The sociodemographic characteristics of the participants are shown in Table 1.

Table 1
Sociodemographic and professional characteristics of the study sample (n=356). Porto, Portugal, 2020

Variables		n	%	x	SD	Min	Max
Sex
	Female	308	86,5
	Male	48	13,5
Age (years)				37,44	8,76	22	62
Specialty
	Rehabilitation nursing	72	47,7
	Community nursing	22	14,6
	Medical-surgical nursing	33	21,9
	Mental health nursing and psychiatry	16	10,6
	Infant health nursing and pediatrics	2	1,3
	Maternal Health Nursing and Midwifery	6	4
Length of service (years)				14,14	8,77	0	37
Time of service as a specialist (years)				8,07	6,67	0	32
Where they work
	In-patient institutions	275	77,2
	In the community	81	22,8

• Source: the authors (2020)

The mean age of participants was 37.44 years (SD=8.76) and 308 (86.5%) were women. Most participants were general care nurses, 205 (57.6%), with 151 (42.4%) being specialist nurses, and from the latter ones, 72 (47.7%) were specialists in rehabilitation nursing. On average, the group of participants had worked for 14.14 years (SD = 8.77), and the group of experts had been working in this category, on average, for 8.07 years (SD = 6.67), and 272 (77.2%) nurses worked in inpatient institutions and 81 (22.8%) worked in the community. The sample consisted, in similar proportions, of nurses from all over the country (Portugal), including, therefore, participants from large urban areas and others from more rural settings.

Regarding the descriptive analysis, it is important to point out that there was no missing data regarding the variables of interest. Regarding the self-assessment of older people’s autonomy promotion, perceived by general care nurses and specialist nurses, considering that zero corresponds to “does not promote” and four to “always promote”, for all factors of the EAPAI scale, nurses, in most of the factors and for the total EAPAI, perceived that they promote older people’s autonomy. These professionals demonstrated that the development of interventions of instrumental activities of daily living (factor three), on average, is the factor in which they invest the least in their practice, being the development of evaluative interventions in the emotional, cognitive and social areas (factor five) the factor in which they invest the most, as shown in Table 2.

Table 2
Descriptive statistics of the EAPAI factors for nurses (n=356). Porto, Portugal, 2020

Scale factors	Nurses
	x	DP
Factor 1 - development of emotional, social and self-care interventions	3,14	0,79
Factor 2 - development of physical and cognitive interventions	2,21	1,19
Factor 3 - development of interventions for instrumental activities of daily living	1,55	1,04
Factor 4 - development of evaluative interventions in the area of self-care	2,56	0,9
Factor 5 - development of evaluative interventions in the emotional, cognitive and social areas	3,25	0,95
Factor 6 - caregiver training	2,62	1,16
Total EAPAI	2,56	0,77

• Source: the authors (2020)

In the inferential analysis between general care nurses and specialist nurses, there are statistically significant differences between the self-assessment of the promotion of older people’s autonomy, in what regards the development of physical and cognitive interventions, the development of interventions of instrumental activities of daily living and the training of the caregiver. Thus, regarding self-assessment of older people’s autonomy promotion, specialist nurses perceive that they promote more autonomy to the older people, with the difference being statistically significant for factor two (t = - 3.29; df = 354; for<0.01), for factor three (t = - 2.15; df = 354; for <0.05) and for factor six (t = - 2.36; df = 354; for<0.05), as shown in Table 3.

Table 3
Description of factors by general care nurses and specialist nurses (n=356). Porto, Portugal, 2020

Scale factors	General care nurses		Specialist nurses		P
	x	DP	x	DP
Factor 1	3,11	0,81	3,19	0,76	0,307
Factor 2	2,03	1,16	2,44	1,19	0,001
Factor 3	1,45	1,03	1,69	1,04	0,033
Factor 4	2,57	0,87	2,55	0,95	0,875
Factor 5	3,26	0,93	3,25	0,99	0,895
Factor 6	2,49	1,18	2,78	1,11	0,019
Total EAPAI	2,5	0,77	2,65	0,76	0,062

• Source: the authors (2020)

DISCUSSION

The sample sociodemographic and professional data are consistent with the data from the Portuguese Order of Nurses⁽²⁰⁾, with most nurses in Portugal being women, and the age groups that comprise the largest number of nurses being between 31 and 35 and 36 to 40 years old, with 13,607 and 13,164 nurses, respectively. Rehabilitation nursing is the specialty with the largest number of specialists and the sector with the largest number of nurses are inpatient institutions. In this sample, the intention was not to obtain its representativeness. Although there seems to be some convergence between the sample and the data available in relation to the population, it cannot be ensured that this will be the case, since the calculation of the sample size was not performed previously, and the representativeness of the sample is not ensured. The potential for generalization of the results should be analyzed with parsimony.

In this study, nurses in general notice that they are promoting older people’s autonomy, as can be seen from the results obtained for each of the scale factors and for the total EAPAI, thus responding to the objective of the study.

The development of interventions of instrumental activities of daily living is the area least promoted by the professionals, data that corroborate the study results⁽²¹⁾, whose objective was to describe the nurses’ perception about priorities of the foci of attention of the most common nursing interventions directed to hospitalized older people. This study concluded that nursing professionals prioritized self-care such as grooming, dressing/undressing, and transferring, due to the need for hospitalized people to respond to priority areas such as basic activities of daily living, since in a situation of illness these are the main areas of nursing intervention⁽²¹⁾.

On the other hand, poor working conditions can also have repercussions on the quality of care provided, particularly in the context of older people’s autonomy, predisposing health professionals to situations of burnout⁽²²⁾.

In this study, it was found that factor 3 (development of interventions of instrumental activities of daily living) was the one in which the average presented was lower for the entire sample. This result is in line with the findings of the study⁽²³⁾, which demonstrate that promoting the capacity to perform instrumental activities of daily living in older people is not a priority in the implemented nursing processes.

When comparing the group of general care nurses and specialist nurses, it appears that there are no statistically significant differences for the total EAPAI, and, therefore, the research hypothesis is rejected. Even so, in the analysis for each of the factors, there are significant differences for three of the scale’s factors, namely in the development of physical and cognitive interventions, in the development of interventions for instrumental activities of daily living and in the training of the caregiver.

With regard to differences in the development of physical and cognitive interventions, it should be noted that most specialist nurses are from the field of rehabilitation nursing, which may have enhanced the differences found. These professionals, according to their specific skills, design, implement, supervise, monitor and evaluate rehabilitation programs, which aim not only to minimize the impact of existing disabilities⁽²⁴⁾, but act at all levels of prevention.

In this context, there are many studies corroborating the results of this study, highlighting the study⁽⁶⁾ whose objective was to know the influence of the confusional state in the recovery of functional independence, concluding that even confused people, when undergoing a rehabilitation nursing program, tend to recover their independence. These gains can also be observed through the results of the study⁽²⁵⁾, which lead to the conclusion that the implementation of the TEIA program, carried out by specialist nurses in rehabilitation nursing, translates into significant gains in improving balance, muscle strength of the pelvic floor muscles and cognitive performance in older people.

The results show the importance perceived by nurses in the assessment of cognitive ability. However, these professionals, compared to other interventions in the scope of older people’s autonomy, perceive that they work less on this aspect. This is a relevant aspect, since as evidenced by studies^(26-27) it is important to stimulate cognition in older people.

In our study, it is observed, regarding the development of interventions of instrumental activities of daily living, that specialist nurses stand out in this aspect too. These results are supported by the study⁽²⁸⁾, which cites physical training programs carried out by specialist nurses and which promote autonomy in what regards carrying out activities of daily living.

In the present study, the training of caregivers, in the perception of specialist nurses, was also an important factor to promote older people’s autonomy in their clinical practice. These results are supported by the study⁽²⁹⁾, revealing that there is evidence that nurses’ interventions contribute to better training of informal caregivers, with effective improvement of the caregiver’s autonomy.

Even during the pandemic, nurses realize that they promote older people’s autonomy, despite all the challenges they face, due to the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), which limit the care provided and to be provided, for several reasons. Due to the presence of this virus, professionals face increased amount of care to be provided, especially with regard to preventing the spread of the disease, which goes beyond the seriousness of the health status of the people they care for⁽³⁰⁾.

This study also has limitations. No previous calculation of the sample size was performed, so it is not possible to conclude that the results can be generalized. It should be noted, however, that the calculation of the sample size was not performed as it was not possible to know the size of the population in advance (number of nurses working in the provision of care to the older people). Another potential limitation is related to the fact that no adjustment was made for potential confounders in the statistical analysis. Even so, this option is justified by the fact that potential confounders of the construct under analysis were not clearly found in the literature. Future investigations should be carried out, trying to use the same instrument in a larger sample of nurses.

CONCLUSION

This study aimed to identify and compare the perception of general care nurses and specialist nurses about the development of interventions promoting older people’s autonomy. It was found that, in general, Portuguese nurses noticed that they promote older people’s autonomy, although there are differences in the perception between specialist nurses and general care nurses, especially those related to the scale factors level regarding the development of physical and cognitive interventions, of interventions of instrumental activities of daily living, and the training of the caregiver. Even so, in the analysis of the instrument as a whole, no differences are found. Nurses perceived that they implement these interventions more frequently in clinical practice to respond to the promotion of older people’s autonomy.

Thus, it was observed that more specialist nurses shall be hired, or general care nurses shall be encouraged to invest in their specialized training. Older people’s autonomy is essential for them to maintain their quality of life and dignity. Since there are many factors that can impair this quality of life, there is an urgent need to prevent its consequences through measures that promote older people’s autonomy. In nursing care, through nursing interventions, general and specialized care nurses are able to respond to these needs.

As this promotion is essential for the quality of life of these people, nurses need instruments that allow them to self-assess how this promotion is carried out. These instruments facilitate the identification of gaps in the promotion of older people’s autonomy, promoting the implementation of corrective measures, either through operational management, organizational management, or research, and can thus serve for the improvement and, consequently, for the quality of the provision of nursing care.

HOW TO REFERENCE THIS ARTICLE

• Lima AMN, Martins MMF da S, Ferreira MSM, Sampaio F, Schoeller SD, Parola VSO. Nurses’ perception regarding the promotion of older people’s autonomy at covid-19: a descriptive correlational study. Cogit. Enferm. [Internet]. 2021 [accessed “insert day, monh and year”]; 26. Available from:http://dx.doi.org/10.5380/ce.v26i0.79124

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Edited by

Associate editor: Susanne Elero Betiolli

Publication Dates

• Publication in this collection
  10 Dec 2021
• Date of issue
  2021

History

• Received
  28 Jan 2021
• Accepted
  29 July 2021