Health education strategies directed to caregivers during patient hospitalization

Abstracts

OBJETIVO: Avaliar a repercussão de estratégias de educação em saúde direcionadas aos cuidadores durante a internação. MÉTODOS: Pesquisa qualitativa, realizada com cuidadores principais de sujeitos incluídos em projeto de educação para cuidados domiciliares, por meio de entrevista semiestruturada. Os dados foram analisados de acordo com o conteúdo temático, organizados em categorias. RESULTADOS: Houve predomínio das orientações verbais com demonstração prática dos cuidados e entrega de cartilhas educativas. Identificou-se baixa renda e escolaridade entre os cuidadores, dependência severa dos sujeitos cuidados e dificuldades das equipes de atenção domiciliar para suprimento de recursos materiais. CONCLUSÃO: As estratégias de educação em saúde direcionadas aos cuidadores durante a internação auxiliaram a execução das técnicas de cuidado no domicílio. Ainda assim o cuidado domiciliar apresentou domínios comprometidos pelas condições socioeconômicas.

Cuidadores; Educação em saúde; Cuidados de enfermagem; Serviço hospitalar de enfermagem; Pesquisa em enfermagem

ORIGINAL ARTICLE

Health education strategies directed to caregivers during patient hospitalization

Danielli Piatti Carvalho^I; Rosa Maria Rodrigues^II; Elizabeth Braz^II

^IHospital Universitário do Oeste do Paraná, Universidade Estadual do Oeste do Paraná, Cascavel, PR, Brazil

^IIEscola de Enfermagem, Universidade Estadual do Oeste do Paraná, Cascavel, PR, Brazil

Corresponding author

ABSTRACT

OBJECTIVE: To evaluate the impact of health education strategies directed to caregivers during patient hospitalization.

METHODS: Qualitative research conducted with semi-structured interviews with primary caregivers of patients in a home care education project. Data were analyzed according to thematic content, and organized into categories.

RESULTS: There was a predominance of verbal instruction with practical demonstration of care, and delivery of educational booklets. Low income and education among the caregivers, severe dependence of patients, and difficulties of home care teams to supply material resources were identified.

CONCLUSION: The health education strategies directed to caregivers during hospitalization helped the implementation of home care techniques.Yet some aspects of home care were compromised by socioeconomic conditions.

Keywords: Caretakers; Health Education; Nursing caretaking; Nursing hospital service; Nursing research

Introduction

Home care is a recent type of care in the Brazilian Unified Health System (SUS, as per its acronym in Portuguese), which involves different health professionals and care in users' homes. In recent decades, it has become an important health care service in Brazil, driven by changes in the demographic profile of the users, population aging, increase in chronic degenerative diseases and overcrowding of hospitals.⁽¹⁾

Studies on health education practices prove the importance of this strategy and the possibility of health care professionals to effectively use them in health promotion.⁽²⁾ Regardless, caregivers inserted into the context of home care expressed uncertainty, unpreparedness and lack of information regarding home care activities. This context expresses the fragility of educational practices in both the hospital and home environments, in addition to detachment from the perspective of qualification of subjects working to improve patients' living conditions.^(3,4)

The Brazilian government established three types of home care, and the teams responsible for this care have the responsibility to identify and train family members and/or caregivers of patients in the period before and after hospital discharge, to involve them in the care, and respect their limits and potential.⁽⁵⁾ In this context, studies and researches on the demands of caregivers contribute so that health care teams can assist caregivers in their individual needs, as well as consider them as a specific group, as subjects and actors in health care actions.^(6,7)

In this sense, it is necessary to consider the need for studying and expanding health care activities, since the care of individuals admitted to a hospital is not limited to the treatment of signs and symptoms, clinical or surgical management, nor does it end in the context of discharge. Therefore, the aim of this study was to evaluate the impact of health education strategies directed to caregivers during hospitalization.

Methods

This exploratory study, using a qualitative approach, was developed with primary caregivers of patients in the home care education project of a university hospital located in the state of Paraná, in southern Brazil, who showed a G degree of dependence in the Katz Index of Independence in Activities of Daily Living.

The Katz index used in the measurement of basic activities of daily living includes six groups of activities, allowing for the evaluation of different levels of independence/dependence for each of the items observed (bathing, dressing, using the toilet, getting in and out of bed, continence and eating).⁽⁸⁾ The G degree includes patients dependent for all activities, which were referred to a home care program after hospital discharge. To determine the Katz index level, hospital registration and admission forms of the patients in the home care education project were used, as well as hospital electronic medical records.

According to these criteria, ten caregivers who were included in this service between March 2012 and March 2013 participated in the study. Data were collected at the caregivers' homes using semi-structured interviews. The data collection instrument was a script composed of personal and socioeconomic information and open questions regarding educational practices and home care.

The data collected were subjected to the thematic content analysis technique, and organized into thematic categories.⁽⁹⁾ The development of the study complied with national and international ethical guidelines for studies involving humans.

Results

The mean age of the caregivers was 50.6 years; however, the age range between 70-75 years prevailed. In terms of socioeconomic conditions, caregivers had earnings of up to 1.5 minimum wages, most of which resulted from benefits or retirement of the patient. Two caregivers had retained their jobs in the household; four requested dismissal to become caregivers, and four were retired or in the process of retirement.

Most of the caregivers depended on public transportation. All of them resided in urban areas, owned their homes, and had good sanitary conditions. The number of inhabitants per household was up to three for five caregivers, and more than three for the others. With regard to education, there was a predominance of up to seven years of study, and one caregiver said s/he had not attended school.

Regarding the health status of caregivers, heart disease and arterial hypertension prevailed. Less frequently cited were respiratory diseases, diabetes mellitus and gastritis. Three caregivers developed health problems during the time they assumed this role.

The patients under care characterized a highly dependent sample, consisting of eight men and two women. The mean age of these patients was 55.7 years. All patients were classified with a G dependence level according to the Katz Index (total dependence for self-care). Disabling neurological disorders prevailed: traumatic brain injury and stroke. Less frequently identified were diagnoses of pneumonia, severe anemia and diabetes mellitus. In addition to dependence for comfort, safety and hygiene activities, all patients were using enteral tube nutrition, gastrostomy or jejunostomy at the time of hospital discharge, eight were tracheostomized and dependent on intermittent aspiration, and eight were dependent on oxygen therapy.

Because the purpose of the study was to evaluate the impact of health education strategies directed to caregivers during hospitalization, three thematic categories were organized: 1) educational strategies used by health professionals during patient hospitalization; 2) caregivers' perceptions regarding the educational practices; and 3) limitations presented by caregivers for performing home care.

Regarding educational strategies used by health professionals during patient hospitalization, verbal directions with practical demonstration predominated. Among the professionals who provided information or performed practical activities, nurses, nursing technicians, nursing assistants, nutritionists and physiotherapists were cited. Instructions from physicians were cited by two caregivers. Most of the instructions were provided in the patient's hospital room, a few times per week. Three caregivers were given directions only at the time of discharge. In addition to verbal instructions and practical directions, caregivers received educational booklets related to activities such as bathing, feeding, tracheal suctioning, nasoenteric tube handling, and general care of bedridden patients.

Regarding the teaching material used, caregivers attributed positive value to the available content. Yet caregivers' statements showed that consultation of the material was more frequent in the first month after discharge, becoming sporadic as caregivers acquired practice in the care techniques and procedures. Due to the low level of education of the sample, two caregivers reported difficulties in understanding the material, whose language was described as overly technical, implying the need for adjustments. Nevertheless, all caregivers stated that the printed material with diagrams facilitated their understanding of the content.

In the second category, caregivers' perceptions regarding the educational practices, the caregiver's time in the hospital was identified as the appropriate moment for them to observe and practice procedures for the patient's home care. Their statements revealed important learning, from simple activities such as bathing, to more complex activities such as handling enteral feeding, aspiration and tracheostomy care. The caregivers affirmed that the learning and activities undertaken during the hospitalization period facilitated their understanding of the directions provided by the home care teams. All caregivers considered themselves to be adequately trained for the performance of home care.

In the third category, limitations presented by the caregivers for the performance of home care, although caregivers had reported positive experiences regarding the learning process, in practice, it was clear that care was compromised due to social or economic problems. Although caregivers have received assistance from other family members for the performance of tasks, difficulties were reported in the mobilization of aid from family or friends to perform strenuous activities. In some cases, caregivers reported depending on the solidarity of others. Another important aspect to the quality of life of caregivers and care subjects is related to financial difficulties.

Considering that family income was up to 1.5 minimum wages, direct implications for care were reported, among them difficulties in the maintenance of enteral feeding. The difficulty of the home care teams to supply resources for the patient's care stood out among the caregivers' statements. The partial assignment of costs to caregivers to maintain oxygen therapy, lack of adequate and free transportation for returns and specialized consultations (ambulance), and primarily insufficient supply of diapers from home care teams were all cited.

Discussion

Non-transmittable chronic diseases are rapidly becoming a public health priority in Brazil, demanding the resizing of health care actions, in a manner that addresses the current demographic and epidemiological profiles.⁽¹⁰⁾ Nevertheless, the shift of care to the home environment alone does not guarantee an appropriate health policy; investments in human and physical resources that are skilled and capable of ensuring care that is responsive to users' demands, in the context in which they live and free of harm, are necessary. In this perspective, the deinstitutionalization of the individual does not end in the context of the discharge, especially in cases in which patients will depend on continuing care at home.

In the case of chronic, degenerative, incapacitating diseases, in addition to the physical and emotional fatigue of the patient and family, financial expenditures are excessive, with special medicines, supplies, food and equipment. Home care interventions amount to one-third of the costs of interventions performed in the hospital setting, and provide benefits not only for hospitals, but for the health system as a whole. In this sense, the prominent role of the family in the feasibility of home care, and changes observed in the family structure for maintenance of home care, demand action and accountability by managers of the SUS for these users.^(11,12)

The statements revealed important weaknesses regarding the supply of materials for home use, with insufficient provision of diapers and transportation being the most frequently cited and important among caregivers. In addition to evaluation of technical ability and the provision of practical care training and scheduled visits, it is necessary to consider whether the caregivers are able to act as providers of home care, and if home care favors the autonomy of the patient and family in regard to this care strategy.⁽¹²⁾ For the respondents, in addition to the advanced age of the caregivers, social components such as the previously mentioned socioeconomic issues substantially compromised the quality of care provided to patients.

Consistent with other studies,^(13,14) the family income of the patients was among the variables that negatively interfered with quality of care, resulting in major difficulties for the maintenance of minimum conditions for survival. In this sense, the support of the teams is limited in scope, health services and primary care are often poorly integrated and do not provide effective support and protection to the caregiver, so that they resort to the help of volunteers, friends and family members to maintain home care in a dignified manner, and decrease its physical, emotional, economic and social burden.

Considering that the caregivers interviewed did not have previous training for the care, combined with the complexity of the patients and their needs, it can be affirmed that the educational practices during the patients' hospitalization greatly contributed to the caregivers' learning, as they expressed in their statements that they were adequately prepared for home care. In this sense, educational practices should be maintained, prioritized and especially systematized so that they can support caregivers to cope with the experience of becoming a caregiver.

Continuity of therapeutic care and implementation of educational practices for the caregiver were perceived as a very important strategy, since they provide important learning to caregivers, facilitating the performance of home care techniques. The socioeconomic aspects of caregivers and care subjects were major determinants that compromised some areas of home care, hurting the quality and continuity of care actions. The difficulties faced in the home can be eased when caregivers are carefully prepared beginning at patient hospitalization, but there are aspects of this context that are not resolved with educational activities alone.

Socioeconomic determinants such as family income, level of education, housing conditions and the everyday stress of continuous care are elements for which interventions based on teaching technical care are poor solutions. These determinants are in another field of intervention, and require educational actions guided by the emancipation of the caregivers, in their individual and collective organization in the struggle to guarantee rights and adequate care for themselves and patients.

Conclusion

Health education strategies directed to caregivers during patient hospitalization helped the implementation of home care techniques. Yet home care showed areas compromised by socioeconomic conditions.

Acknowledgements

The authors thank the teaching hospital and the colleagues from the Alta Programada Project; the Master's Program in Health Biosciences and the Center of Health and Biological Sciences of Universidade Estadual do Oeste do Paraná; and the caregivers interviewed for their participation and receptivity.

Collaborations

Carvalho DP; Rodrigues RM and Braz E have contributed to the project design, analysis and interpretation of data. They collaborated in writing the article, with the relevant critical review of its intellectual content, and the approval of the final version to be published.

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Publication Dates

• Publication in this collection
  13 Jan 2014
• Date of issue
  2013

History

• Received
  29 Oct 2013
• Accepted
  11 Nov 2013