Acessibilidade / Reportar erro

PROFESSIONAL PRACTICE OF NURSING AT LONG-TERM CARE INSTITUTIONS FOR THE ELDERLY: A RETROSPECTIVE STUDY1 1 Paper taken from the thesis - Results of ethical-professional nursing surveillance in long-term care institutions for the elderly: retrospective study, presented to the Professional Master’s Program in Clinical Nursing at Universidade Federal Fluminense (UFF), in 2015.

ABSTRACT

Objective:

to assess the results of the ethical-professional nursing inspection at Long-Term Care Institutions for the Elderly.

Method:

observational, retrospective study with documentary analysis. Between January 2010 and December 2013, 2,650 control inspections were undertaken in the Rio de Janeiro Regional Nursing Council. Of these, 159 (6%) were Long-Term Care Institutions for the Elderly. The final sample consisted of 51 processes that complied with the criterion of having at least two inspections for comparison. The data collection instrument rested on the four pillars of inspection: legal practice of the profession; staffing; systemization of nursing care and laws related to professional practice. For the descriptive and inferential data analysis, SPSS and Excel 2007 were used.

Results:

of the 51 institutions assessed, 80.4 were private. The main motive for the inspections was to comply legal orders by the Public Prosecution (56.9%) difference was found between the first and last inspection: nursing professionals registered in the council (0.006); classification of care by dependence level (0.008); presenting a scale of professionals (0.006); not having other professional in the nursing scale, mainly caregivers (0.001); single file (0.039); nursing standards and routines (0.000); presenting standard operating protocols (0.000); and Nursing Process (0.001).

Conclusion:

the strengthening of the inspections is recommended, in line with the Public Prosecution and the National Health Surveillance Agency. In addition, the functioning in compliance with ethical-professional regularities should be made feasible, including the Long-Term Care Institutions for the elderly in the social-health sphere, with nursing at the largest group of workers.

DESCRIPTORS:
Nursing assessment; Long-term care institution for elderly; Ethics, nursing; Legislation, nursing; Personnel downsizing

RESUMO

Objetivo:

avaliar os resultados da fiscalização ético-profissional de enfermagem em Instituições de Longa Permanência para Idosos.

Método:

estudo observacional, retrospectivo de análise documental. No período de janeiro de 2010 a dezembro de 2013 realizaram-se 2.650 inspeções fiscalizatórias no Conselho Regional de Enfermagem do Estado do Rio de Janeiro. Dessas, 159 (6%) eram referentes a Instituições de Longa Permanência para Idosos. A amostra final foi composta por 51 processos que atenderam ao critério de possuir, no mínimo, duas fiscalizações para comparações. O instrumento de coleta de dados norteou-se pelos quatro pilares da fiscalização: exercício legal da profissão; dimensionamento de pessoal; sistematização da assistência de enfermagem e legislações afins ao exercício profissional. Para a análise dos dados descritiva e inferencial, utilizaram-se os programas SPSS e Excel 2007.

Resultados:

das 51 instituições avaliadas, 80,4% eram privadas. O principal motivo das fiscalizações foi cumprir ordens do Ministério Público (56,9%). Houve diferença entre a primeira e a última fiscalização: profissionais de enfermagem com registro no conselho (0,006); classificação de cuidados por dependência (0,008); apresentar escala de profissionais (0,006); não possuir outros profissionais na escala de enfermagem, principalmente cuidadores (0,001); prontuário único (0,039); normas e rotinas de enfermagem (0,000); apresentar protocolos operacionais padrões (0,000); e Processo de Enfermagem (0,001).

Conclusão:

recomenda-se fortalecer as fiscalizações em consonância com o Ministério Público e a Agência Nacional de Vigilância Sanitária. Deve-se ainda viabilizar o funcionamento conforme as regularidades ético-profissionais incluindo as Instituições de Longa Permanência para Idosos na esfera sociossanitárias, que tem a enfermagem como sua maior classe trabalhadora.

DESCRITORES:
Avaliação em enfermagem; Instituição de longa permanência para idosos; Ética em enfermagem; Legislação de enfermagem; Dimensionamento de pessoal

RESUMEN

Objetivo:

evaluar los resultados de la fiscalización ético-profesional de enfermería en Instituciones de Larga Permanencia para Ancianos.

Método:

estudio observacional y retrospectivo de análisis documentario. En el período de Enero del 2010 hasta Diciembre del 2013 se realizaron 2.650 inspecciones fiscales en el Consejo Regional de Enfermería del Estado de Rio de Janeiro. Así, 159 (6%) de las mismas se referían a las Instituciones de Larga Permanencia para Ancianos. La muestra final incluyó 51 procesos que atendieron al criterio de poseer, como mínimo, dos fiscalizaciones para comparaciones. El instrumento de recolección de datos se fundamentó en los cuatro pilares de la fiscalización: ejercicio legal de la profesión; dimensionamiento del personal; sistematización de la asistencia de enfermería y legislaciones afines con el ejercicio profesional. Para el análisis descriptivo e inferencial de los datos se usaron los programas SPSS y Excel 2007.

Resultados:

el 80,4% de las 51 instituciones evaluadas eran privadas. El principal motivo de las fiscalizaciones fue cumplir órdenes del Ministerio Público (56,9%). Hubo diferencia entre la primera y la última fiscalización: profesionales de enfermería con registro en el consejo (0,006); clasificación de cuidados por dependencia (0,008); presentar la escala de los profesionales (0,006); no tener otros profesionales en la escala de enfermería, principalmente cuidadores (0,001); prontuario único (0,039); normas y rutinas de enfermería (0,000); presentar protocolos operacionales estándares (0,000) y Proceso de Enfermería (0,001).

Conclusión:

se recomienda fortalecer las fiscalizaciones en consonancia con el Ministerio Público y la Agencia Nacional de Vigilancia Sanitaria. Además, se debe viabilizar el funcionamiento conforme a las regularidades ético-profesionales, incluyendo a las Instituciones de Larga Permanencia para Ancianos en la esfera socio-sanitaria que tiene a la enfermería como su mayor clase trabajadora.

DESCRIPTORES:
Evaluación en enfermería; Institución de larga permanencia para ancianos; Ética en enfermería; Legislación de enfermería; Dimensionamiento del personal

INTRODUCTION

One of the concerns for society, class associations and oversight departments is the need to regularize the Long-Term Care Institutions for the Elderly (LTCI), which arise excessively and too precariously in the Brazilian context. This is mainly due to the increase in the elderly population and the difficulties the family members present to take care of them. In view of this reality, the demand for places in LTCI tends to increase, characterized by the physical and / or mental dependence of the elderly.11 Schumacher KL, Marren J. Home care nursing for older adults: state of the science. Nurs Clin North Am [Internet]. 2004 Sep [cited 2017 Mar 10]; 39(3):443-71. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15331297
http://www.ncbi.nlm.nih.gov/pubmed/15331...

2 Ministério da Saúde (BR). Agência Nacional de Vigilância Sanitária (ANVISA). Resolução RDC n. 283 de 26 de setembro de 2005. Regulamento Técnico que define normas de funcionamento para as Instituições de Longa Permanência para Idosos [Internet]. 2005 Sep [cited 2017 Mar 10]. Available from: http://bvsms.saude.gov.br/bvs/saudelegis/anvisa/2005/res0283_26_09_2005.html
http://bvsms.saude.gov.br/bvs/saudelegis...

3 Carvalho VL. [Profile of long-stay institutions for the elderly located in a capital of Northeast]. Cad Saúde Colet [Internet]. 2014 Abr/Jun [cited 2017 Mar 10]; 22(2):184-91. Available from: http://www.scielo.br/pdf/cadsc/v22n2/1414-462X-cadsc-22-02-00184.pdf
http://www.scielo.br/pdf/cadsc/v22n2/141...
-44 Silva BT, Santos SS, Silva MR, Sousa LD. [Perception of the elderly on the institutionalization: reflection on nursing care]. Rev Rene [Internet]. 2009 [cited 2017 Mar 10]; 10(4):118-25. Available from: http://www.revistarene.ufc.br/10.4/pdf/v10n4a13.pdf
http://www.revistarene.ufc.br/10.4/pdf/v...

The study points out that institutional nursing care for the elderly constitutes a critical area in relation to the knowledge, development and delivery of nursing services. Population aging and the growing emphasis on long-term care indicate that an even larger number of older people may need nursing care in LTCI in the future.11 Schumacher KL, Marren J. Home care nursing for older adults: state of the science. Nurs Clin North Am [Internet]. 2004 Sep [cited 2017 Mar 10]; 39(3):443-71. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15331297
http://www.ncbi.nlm.nih.gov/pubmed/15331...
Profile studies can demonstrate the fragile health and environmental conditions they are in.33 Carvalho VL. [Profile of long-stay institutions for the elderly located in a capital of Northeast]. Cad Saúde Colet [Internet]. 2014 Abr/Jun [cited 2017 Mar 10]; 22(2):184-91. Available from: http://www.scielo.br/pdf/cadsc/v22n2/1414-462X-cadsc-22-02-00184.pdf
http://www.scielo.br/pdf/cadsc/v22n2/141...
-44 Silva BT, Santos SS, Silva MR, Sousa LD. [Perception of the elderly on the institutionalization: reflection on nursing care]. Rev Rene [Internet]. 2009 [cited 2017 Mar 10]; 10(4):118-25. Available from: http://www.revistarene.ufc.br/10.4/pdf/v10n4a13.pdf
http://www.revistarene.ufc.br/10.4/pdf/v...

The number of existing institutions in Brazil and the number of elderly people living there are unknown. The Institute of Research and Applied Statistics (IPEA) carries out a national census of the LTCI which, until date, has only been concluded in the North, Central-West and South of the country. In this census, 1,421 LTCI were registered, more than 300 of which could not be located due to the lack of registration of these services in the competent entities.33 Carvalho VL. [Profile of long-stay institutions for the elderly located in a capital of Northeast]. Cad Saúde Colet [Internet]. 2014 Abr/Jun [cited 2017 Mar 10]; 22(2):184-91. Available from: http://www.scielo.br/pdf/cadsc/v22n2/1414-462X-cadsc-22-02-00184.pdf
http://www.scielo.br/pdf/cadsc/v22n2/141...
-44 Silva BT, Santos SS, Silva MR, Sousa LD. [Perception of the elderly on the institutionalization: reflection on nursing care]. Rev Rene [Internet]. 2009 [cited 2017 Mar 10]; 10(4):118-25. Available from: http://www.revistarene.ufc.br/10.4/pdf/v10n4a13.pdf
http://www.revistarene.ufc.br/10.4/pdf/v...

LTCI are considered as institutions for comprehensive institutional care, whose target public consists of people aged 60 years or older, dependent or independent, who are in no conditions to remain with the family or at home.22 Ministério da Saúde (BR). Agência Nacional de Vigilância Sanitária (ANVISA). Resolução RDC n. 283 de 26 de setembro de 2005. Regulamento Técnico que define normas de funcionamento para as Instituições de Longa Permanência para Idosos [Internet]. 2005 Sep [cited 2017 Mar 10]. Available from: http://bvsms.saude.gov.br/bvs/saudelegis/anvisa/2005/res0283_26_09_2005.html
http://bvsms.saude.gov.br/bvs/saudelegis...

The LTCI are not part of the annual elective inspection plan of the Federal Nursing Council and the Regional Councils (Cofen/Corens), as they are registered in the National Council of Social Assistance (CNAS), and not in the National Registry of Health Establishments (CNES). The lack of direct access to an updated register containing information pertinent to social welfare institutions significantly hinders their inclusion in the annual monitoring plan. For this reason, LTCI inspections are mostly carried out by means of official letters issued by the Public Prosecutor’s Office, which generate a demand for inspections by the Nursing Council.

The relevance of the recognition problem of LTCI as a space of solely social action is re-emphasized, in view of the historical framework of the creation of retirement homes, to shelter the elderly excluded from society. Nowadays, however, with the increasing aging, high dependence on long-term care and family insufficiency of the elderly, LTCIs have become social and health care spaces. They are mixed and referred to more correctly as socio-sanitary - and, if considered as such, require 24-hour nursing service.55 Portella MR, Dias RF, Dias PS. Desafios e perspectivas da enfermagem gerontológica: o olhar das enfermeiras.Rev Bras Cien do Env Humano. 2013 Mai-Ago; 9(2):226-37.

Studies on professional ethics are still scarce, also considering the short history of the professional category’s legal status, which occurred in the mid-1970’s. Most of them deal with nursing ethics in undergraduate education or professional ethics in general, but no study was found that discussed professional nursing ethics in LTCI. Regarding the scientific production on ILPI, the models of social assistance for the elderly are focused on, describing it as a place of shelter for the poor and needy elderly, a population mainly characterized by dependence and multiple morbidities.66 Camarano AA, Kanso S. As instituições de longa permanência para idosos no Brasil. R Bras Est Pop [Internet]. 2010 Jan/Jun [cited 2017 Mar 10]; 27(1):232-5: Available from: http://www.scielo.br/pdf/rbepop/v27n1/14.pdf
http://www.scielo.br/pdf/rbepop/v27n1/14...

Thus, LTCI constitute a peculiar niche for professional nursing practice. In history, these institutions have been preponderantly associated with philanthropy without health organization; with the exercise of lay care actions; and with laws for the LTCI that disregard those described in the Nursing Council. This, in a way, is in contrast to current LTCI models proposed in other countries, which have a long-term care philosophy with emphasis on promoting the quality of care and the quality of life of the elderly residents.44 Silva BT, Santos SS, Silva MR, Sousa LD. [Perception of the elderly on the institutionalization: reflection on nursing care]. Rev Rene [Internet]. 2009 [cited 2017 Mar 10]; 10(4):118-25. Available from: http://www.revistarene.ufc.br/10.4/pdf/v10n4a13.pdf
http://www.revistarene.ufc.br/10.4/pdf/v...
,77 Castle NG, Sonon KE. A culture of patient safety in nursing homes Qual Saf Health Care [Internet]. 2006 Dec [cited 2017 Mar 10]; 15(6):405-8. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2464891/
https://www.ncbi.nlm.nih.gov/pmc/article...

8 Lee HY, Shin JH, Harrington C. Comparing the nurse staffing in Korean and US nursing homes. Nurs Outlook [Internet]. 2015 Mar-Apr [cited 2017 Mar 10]; 63(2):137-43. Available from: http://www.nursingoutlook.org/article/S0029-6554(14)00158-4/pdf
http://www.nursingoutlook.org/article/S0...
-99 Camarano AA. Cuidado de longa duração para a população idosa: um novo risco social a ser assumido? Rio de Janeiro: IPEA; 2010.

The objective of this study was to evaluate the results of the ethical-professional nursing inspection in LTCI.

METHOD

This is an observational, retrospective documentary analysis study with a quantitative approach.

The place of study was the Inspection Department (DEFIS) of the Rio de Janeiro Regional Nursing Council (Coren-RJ). The Department employed 35 inspectors and five administrative officers to inspect the 92 cities of the State of Rio de Janeiro. The period of the study was between January 2010 and December 2013. This period was chosen because, as from 2010, DEFIS started to adopt a standardized model for the elaboration of detailed reports, to instruct fiscal administrative processes and to support the legal sector. This standardization took place in four pillars, which are: Legal Practice of the Profession; Staffing; Systematization of Nursing Care (SAE) and Legislations Related to the Professional Practice. Similarly, the guiding elements of the data collection instrument were whether or not there was a change in these requirements between the first and last inspection.

During the period delimited for the survey, 2,650 inspection inspections were carried out and 1,895 administrative inspection procedures were established. Of these, 159 (6%) were related to LTCI.

For inclusion in the study, the following criteria were applied: administrative processes drawn up at the LTCI with more than one inspection, and two detailed reports standardized by the inspectors. Administrative processes drawn up at the LTCI without data to permit comparison between the first and last inspection. The final sample consisted of 51 administrative processes. Figure 1 demonstrates the operation of the data collection.

Figure 1
Operation of study development phases. Niterói (RJ), 2015. LTCIs: Long-Term Care Institutions for the Elderly; PADS: administrative processes; DEFIS: Inspection Department.

The descriptive and inferential statistical analysis of the database was developed using computer resources from Statistical Package for the Social Sciences (SPSS) version 23.0 and Microsoft Excel 2007. The significance analysis of the differences between the averages of the quantitative variables of the first and final inspections was done by paired Student’s t test when the variables presented normal distribution. Otherwise, the two inspections were compared using the Wilcoxon test. The normality of the distributions of the quantitative variables was investigated by means of the Kolmogorov-Smirnov test and the Shapiro-Wilk test. It was considered that the distribution of the variable under analysis was normal when both tests did not reject the null hypothesis of normality. Significance tests were performed considering the maximum significance level of 5% (0.05).

The principles of Resolution 590/16 on research involving human beings were used and the proposal was submitted to the Research Ethics Committee of Universidade Federal Fluminense (UFF), with favorable opinion 606.995 on April 4th, 2014.

RESULTS

Of the 51 sample institutions, 23 (45.1%) were located in the city of São Gonçalo, ten (19.6%) in Rio de Janeiro, five (9.8%) in Petrópolis, four (7.8%) in Niterói and two (3.9%) in Campos. The sample also had an institution in each of the following cities: Natividade, Nova Friburgo, Paraíba do Sul, Rio Bonito, São Fidélis, São João da Barra and Teresópolis. Regarding the nature of the institution, 41 (80.4%) were private institutions and eight (15.6%) were philanthropic. Only one (2.0%) institution was public and one (2.0%) mixed (private and philanthropic). The main reason that led to the inspection of the LTCI was compliance with orders issued by the Public Prosecution (29, 56.9%); there were also requests for Certificates of Technical Responsibilities (CRT) in ten cases (19.6%) and denunciations in nine (17.6%).

In Table 1, the magnitude between the bad occupancy rate and the hiring of nursing professionals and caregivers in LTCI is highlighted.

Table 1
Bad occupancy rate, nursing professional and caregivers. Niterói, RJ, Brazil, 2015. (n=51)

According to the p-values, there were no significant differences between the averages of the variables in the first and last inspection. Although the caregiver is not part of the nursing team, the number of caregivers stands out, being higher at some institutions than the number of auxiliary nurses.

In Table 2, when possible, the McNemar test was applied to check for a statistically significant difference between the first and last inspection.

Table 2
Factors evaluated concerning the legal status of professional practice and nursing staffing. Niterói, RJ, Brazil, 2015. (n=51)

Significant improvement was found between the first and final evaluation concerning the legal status of professional practice. Nevertheless, what the proposed minimum staffing of nursing professionals is concerned, no changes were found.

Table 3 displays the items needed for the implementation of the SAE.

Table 3
Factors evaluated and related to Sistematização da Assistência em Enfermagem (SAE). Niterói, RJ, Brazil, 2015. (n=51)

Although the improvement in the items necessary for the implementation of the SAE is highlighted, it was not fully achieved due to the fragmentation in the essential requisites, mainly concerning the method, instruments and staff.

In Table 4, the items of the laws related to nursing care for institutionalized elderly are displayed, either direct or indirectly.

Table 4
Factors evaluated concerning laws related to care for institutionalized elderly. Niterói, RJ, Brazil, 2015 (n=51)

No differences were observed in the assessment of the factors related to the laws concerning elderly care, probably because these were prerogatives of other inspection departments but, when inappropriate, they affect the nursing work process.

DISCUSSION

The data show that, between the first and second inspections, there was a significant improvement (around 80%) in the legal status of professional nursing practice in the LTCI, guaranteeing safety for civil society regarding the legal practice of nursing. This result is due to the compliance with Federal Law 5.905/73, the Law of Professional Practice 7.498/86 and regulatory decree 9.4406/87.1010 Conselho Federal de Enfermagem (Cofen). Lei Federal n. 5.905/73, de 12 de julho de 1973. Dispõe sobre a criação dos Conselhos Federal e Regionais de Enfermagem e dá outras providências [Internet]. Brasília, DF: Cofen; 1973 [cited 2017 Mar 10]. Available from: http://www.cofen.gov.br/lei-n-590573-de-12-de-julho-de-1973_4162.html
http://www.cofen.gov.br/lei-n-590573-de-...
-1111 Conselho Federal de Enfermagem (Cofen). Lei 7.498/86, de 25 de junho de 1986. Dispõe sobre a regulamentação do exercício da enfermagem e dá outras providências [Internet]. Brasília, DF: Cofen; 1986 [cited 2017 Mar 10]. Available from: http://www.cofen.gov.br/lei-n-749886-de-25-de-junho-de-1986_4161.html
http://www.cofen.gov.br/lei-n-749886-de-...
This prerogative considers that, in addition to the technical capacity, the degrees have to be duly registered and the professionals should be duly registered in the disciplinary committee of the profession.1212 Przenyczka RA, Kalinowski LC, Lacerda MR, Wall ML. Conflitos éticos da enfermagem na atenção primária à saúde e estratégias de enfrentamento. Ciência, Cuidado e Saúde [Internet]. 2011 [cited 2017 Mar 10];10(2);330-7. Available from: http://www.periodicos.uem.br/ojs/index.php/CiencCuidSaude/article/view/12849
http://www.periodicos.uem.br/ojs/index.p...

The significant index of 88.02% of institutions that have technical nursing activities without the supervision of the nurse is an arbitrariness in the Law of Professional Practice and the rights of the elderly to comprehensive care by the nursing team. The Law of Professional Practice in Nursing is emphatic when, in Article 15, it emphasizes that all activities carried out by nursing technicians and auxiliary nurses, in public and private health institutions and in health programs, can only be performed under the guidance and supervision of nurses. All LTCI should have 100% of nurses, both in the first and last evaluation, because they offer the nursing service during the 24 hours of operation.1010 Conselho Federal de Enfermagem (Cofen). Lei Federal n. 5.905/73, de 12 de julho de 1973. Dispõe sobre a criação dos Conselhos Federal e Regionais de Enfermagem e dá outras providências [Internet]. Brasília, DF: Cofen; 1973 [cited 2017 Mar 10]. Available from: http://www.cofen.gov.br/lei-n-590573-de-12-de-julho-de-1973_4162.html
http://www.cofen.gov.br/lei-n-590573-de-...
-1111 Conselho Federal de Enfermagem (Cofen). Lei 7.498/86, de 25 de junho de 1986. Dispõe sobre a regulamentação do exercício da enfermagem e dá outras providências [Internet]. Brasília, DF: Cofen; 1986 [cited 2017 Mar 10]. Available from: http://www.cofen.gov.br/lei-n-749886-de-25-de-junho-de-1986_4161.html
http://www.cofen.gov.br/lei-n-749886-de-...

Another relevant factor that was expected to have improved at repeated inspections was the presence of nurses in the institution with a Technical Responsibility Certificate (CRT). In the final evaluation, 86.3% of the LTCI still did not have the technically responsible nurse. This demonstrates the shortage of professionals and the obstacles for the implementation of the SAE. The failure to comply with this infraction is believed to be due to the low salaries offered to the professionals, to the form of hiring and to the nurses’ lack of knowledge on their actual assignments when they are appointed as technical responsible for the nursing service of an LTCI.

When the nurse is notified of the need for the CRT, according to Cofen Resolution 509/2016, the professional receives orientations on all responsibilities developed at the institution, such as planning, organizing, directing, coordinating, executing and evaluating nursing services.1313 Conselho Federal de Enfermagem (Cofen). Resolução Cofen No 0509/2016. Atualiza a norma técnica para Anotação de Responsabilidade Técnica pelo Serviço de Enfermagem e define as atribuições do enfermeiro Responsável Técnico [Internet]. Brasília, DF: Cofen; 2016 [cited 2017 Mar 10]. Available from http://www.cofen.gov.br/resolucao-cofen-no-05092016-2_39205.html
http://www.cofen.gov.br/resolucao-cofen-...
When they formally discover these assignments, most nurses give up the CRT issue, requesting dismissal from the LTCI.1313 Conselho Federal de Enfermagem (Cofen). Resolução Cofen No 0509/2016. Atualiza a norma técnica para Anotação de Responsabilidade Técnica pelo Serviço de Enfermagem e define as atribuições do enfermeiro Responsável Técnico [Internet]. Brasília, DF: Cofen; 2016 [cited 2017 Mar 10]. Available from http://www.cofen.gov.br/resolucao-cofen-no-05092016-2_39205.html
http://www.cofen.gov.br/resolucao-cofen-...

With regard to the SAE, the administrative management and the nursing team itself still need to commit so that the basic organizational principles for the implementation of the SAE and Nursing Process in the LTCI can be met. The method, instruments and minimum and appropriate staffing need to be made feasible. In the absence of one of these items, the implantation of SAE is not feasible.1414 Conselho Federal de Enfermagem (Cofen). Resolução Cofen-358/2009. Dispõe sobre a Sistematização da Assistência de Enfermagem e a implementação do Processo de Enfermagem em ambientes, públicos ou privados, em que ocorre o cuidado profissional de enfermagem [Internet]. Brasília (DF): Cofen; 2009 [cited 2017 Mar 10]. Available from: http://www.cofen.gov.br/resoluo-cofen-3582009_4384.html
http://www.cofen.gov.br/resoluo-cofen-35...

Nurses need knowledge about the nursing theories, so that the actions originating from the SAE are based on theoretical concepts already consolidated in nursing and gerontology, and they are able to choose the action that best meets the needs of the context of the elderly residents, with focus on maintaining the functional capacity.1212 Przenyczka RA, Kalinowski LC, Lacerda MR, Wall ML. Conflitos éticos da enfermagem na atenção primária à saúde e estratégias de enfrentamento. Ciência, Cuidado e Saúde [Internet]. 2011 [cited 2017 Mar 10];10(2);330-7. Available from: http://www.periodicos.uem.br/ojs/index.php/CiencCuidSaude/article/view/12849
http://www.periodicos.uem.br/ojs/index.p...
,1414 Conselho Federal de Enfermagem (Cofen). Resolução Cofen-358/2009. Dispõe sobre a Sistematização da Assistência de Enfermagem e a implementação do Processo de Enfermagem em ambientes, públicos ou privados, em que ocorre o cuidado profissional de enfermagem [Internet]. Brasília (DF): Cofen; 2009 [cited 2017 Mar 10]. Available from: http://www.cofen.gov.br/resoluo-cofen-3582009_4384.html
http://www.cofen.gov.br/resoluo-cofen-35...
Knowing the profile of the nursing diagnoses can also enable nurses to plan nursing care in an individualized manner.1515 Garbaccio JL, Ferreira AD. Diagnósticos de enfermagem em uma instituição de longa permanência para idosos. Rev Enferm Cent O Min [Internet]. 2012 Set/Dez [cited 2017 Mar 10]; 2(3):303-13. Available from: http://www.seer.ufsj.edu.br/index.php/recom/article/view/218/345
http://www.seer.ufsj.edu.br/index.php/re...

Regarding the preparation of medical records, the literature recommends that nurses prioritize care for the elderly, focusing on the use of the multidimensional assessment of the elderly, which combine priority aspects of the aging process, although there are structural, organizational, economic and labor shortages that limit this elaboration of medical records by the nurses.1616 Santos SS, Lopes RS, Silva BT, Barros EJ. Silva ME, Hammerschimidt KS, et al. Pesquisa-ação na elaboração de Manual de Normas, Rotinas e Técnicas de enfermagem. Rev Enferm UFPE [Internet]. 2011 Mar/Abr [cited 2017 Mar 10]; 5(spe):426-34. Available from: http://repositorio.furg.br/handle/1/1135
http://repositorio.furg.br/handle/1/1135...

LTCIs have scarce infrastructure and human resources, which is a problem frequently observed on the political-scientific agenda in the area of geriatrics and gerontology. The number of professionals is reduced and they are subject to an overload of activities; therefore, the care to the elderly and the workers’ health are compromised.55 Portella MR, Dias RF, Dias PS. Desafios e perspectivas da enfermagem gerontológica: o olhar das enfermeiras.Rev Bras Cien do Env Humano. 2013 Mai-Ago; 9(2):226-37.,1717 Zúñiga F, Ausserhofer D, Hamers JP, Engberg S, Simon M, Schwendimann R. The relationship of staffing and work environment with implicit rationing of nursing care in Swiss nursing homes - A cross-sectional study. Int J Nurs Stud [Internet]. 2015 Sep [cited 2017 Mar 10]; 52(9):1463-74. Available from: http://www.journalofnursingstudies.com/article/S0020-7489(15)00165-0/abstract
http://www.journalofnursingstudies.com/a...
-1818 Umpiérrez AF, Fort FZ, Tomás VC. Adverse events in health and nursing care: patient safety from the standpoint of the professional's experience. Text Context Nursing [Internet]. 2015 Apr/June [cited 2017 Mar 10]; 24(2):310-5. Available from: http://www.scielo.br/pdf/tce/v24n2/0104-0707-tce-24-02-00310.pdf
http://www.scielo.br/pdf/tce/v24n2/0104-...
In addition, caregivers are part of the nursing service scales, being mistakenly described as nursing staff.1616 Santos SS, Lopes RS, Silva BT, Barros EJ. Silva ME, Hammerschimidt KS, et al. Pesquisa-ação na elaboração de Manual de Normas, Rotinas e Técnicas de enfermagem. Rev Enferm UFPE [Internet]. 2011 Mar/Abr [cited 2017 Mar 10]; 5(spe):426-34. Available from: http://repositorio.furg.br/handle/1/1135
http://repositorio.furg.br/handle/1/1135...

The act of delegating does not mean being exempt from liability though, which is non-transferable. The nurse maintains her responsibility in the face of possible harm done by the caregiver, as it is her duty to supervise the activities of the members of the nursing team under her leadership.1212 Przenyczka RA, Kalinowski LC, Lacerda MR, Wall ML. Conflitos éticos da enfermagem na atenção primária à saúde e estratégias de enfrentamento. Ciência, Cuidado e Saúde [Internet]. 2011 [cited 2017 Mar 10];10(2);330-7. Available from: http://www.periodicos.uem.br/ojs/index.php/CiencCuidSaude/article/view/12849
http://www.periodicos.uem.br/ojs/index.p...

Despite the importance of LTCI as care alternatives worldwide, in Brazil, there is still no valid and reliable instrument to monitor their quality. There are two quality assessment instruments in these institutions today: one is based on ANVISA’s RDC 283/2005, which defines minimum operating conditions for LTCI. Quality indicators related to care for the elderly (falls, pressure ulcers, hospitalizations, diarrhea, malnutrition and containment) are hardly used at the LTCI, differently from the recommendations of the Brazilian Health Surveillance Agency’s (ANVISA) Collegiate Board Resolution (RDC) 283/05.22 Ministério da Saúde (BR). Agência Nacional de Vigilância Sanitária (ANVISA). Resolução RDC n. 283 de 26 de setembro de 2005. Regulamento Técnico que define normas de funcionamento para as Instituições de Longa Permanência para Idosos [Internet]. 2005 Sep [cited 2017 Mar 10]. Available from: http://bvsms.saude.gov.br/bvs/saudelegis/anvisa/2005/res0283_26_09_2005.html
http://bvsms.saude.gov.br/bvs/saudelegis...

Another instrument used was an evaluation tool based on the regulations of Coren-RS and RDC 283/2005. In addition to the lack of validation, both are limited by a considerable specificity, as they mainly include indicators of structure or the exclusive orientation to nurses in a complex and multiprofessional context of LTCI.1919 Nakrem S, Vinsnes AG, Harkless GE, Paulsen B, Seim A. Nursing sensitive quality indicators for nursing home care: international review of literature, policy and practice. Int J Nurs Stud [Internet]. 2009 Jun [cited 2017 Mar 10]; 46(6):848-57. Available from: http://www.journalofnursingstudies.com/article/S0020-7489(08)00339-8/pdf
http://www.journalofnursingstudies.com/a...
-2020 Oliveira WI, Hernández PJ, Sousa KM, Pluvezam G, Gama ZA. Semantic and conceptual equivalence of the observable indicators of Nursing Home Care Quality Instrument. Ciênc Saúde Coletiva [Internet]. 2016 [cited 2017 Mar 10]; 21(7):2243-56. Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1413-81232016000702243
http://www.scielo.br/scielo.php?script=s...

With regard to compliance with laws related to the care of the institutionalized elderly in the LTCI, Coren-RJ does not notify the legal entity, but elaborates a detailed report suggesting functional adjustments, which are sent to the competent authorities, in cases that interfere directly or indirectly in the care. Accordingly, there was no change in any of the items between the first and last evaluation.

A relevant factor in the laws related to the elderly is the prescription of medicines, which has improved, but not significantly from a statistical point of view. In the last evaluation, an average 72.5% of the LTCI still presented problems related to medical prescriptions. These items, although linked to the nursing team (it is the nurse who schedules the medicines for the technicians and auxiliary nurses to administer), are part of the legislation related to care for the elderly.

The nursing team is not responsible for evaluating or validating prescription drugs, and is responsible for administering the drugs within the validity period of the medical prescription. The physician is responsible for prescribing medicines with a proper validity period, while the pharmacist is responsible for guarding and protecting them, according to the Ordinance of the Ministry of Health and the Secretariat of Health Surveillance 344/98.2121 Brasil. Portaria N. 344/98, de 12 de maio de 1998. Aprova o Regulamento Técnico sobre substâncias e medicamentos sujeitos a controle especial [Internet]. Brasília, DF: Diário Oficial da União: 1998 [cited 2017 Mar 10]. Available from: http://bvsms.saude.gov.br/bvs/saudelegis/svs/1998/prt0344_12_05_1998_rep.html
http://bvsms.saude.gov.br/bvs/saudelegis...

Notwithstanding the complexity of the matter, Cofen uses Resolution 487/15, which states that it is prohibited for nursing professionals to comply with the medical prescription at a distance or by any other means, if they do not include the stamp and signature of the physician, as well as the execution of overdue medical prescriptions.2222 Conselho Federal de Enfermagem (Cofen). Resolução Cofen N. 487/2015. Veda aos profissionais de Enfermagem o cumprimento da prescrição médica a distância e a execução da prescrição médica fora da validade [Internet]. Brasília (DF): Cofen; 2015. [cited 2017 Mar 10]. Available from: http://www.cofen.gov.br/resolucao-cofen-no-4872015_33939.html
http://www.cofen.gov.br/resolucao-cofen-...

Resolution 487/15 clarifies that nursing professionals who are required to perform medical prescriptions that are outdated or without a date have to refrain from doing so, as well as report the fact and those involved to Coren within their jurisdiction, which should, in safeguarding the public interest, take the necessary measures.2222 Conselho Federal de Enfermagem (Cofen). Resolução Cofen N. 487/2015. Veda aos profissionais de Enfermagem o cumprimento da prescrição médica a distância e a execução da prescrição médica fora da validade [Internet]. Brasília (DF): Cofen; 2015. [cited 2017 Mar 10]. Available from: http://www.cofen.gov.br/resolucao-cofen-no-4872015_33939.html
http://www.cofen.gov.br/resolucao-cofen-...

A medication administration error can occur in any stage of the medication use process. In addition, they are associated with medication errors if the incident has the potential to harm a patient and if it is a critical medication dose (for example, an intravenous antibiotic that is not given is considered both a medication error and a potential adverse medication event).

In case of emergencies with the elderly, few LTCI activate the Mobile Emergency System (SAMU), as treated in decree 2048/02. Most legal representatives responsible for LTCI transport the elderly by their own means, not taking into account the risks they are exposed to.

Interventions should be implemented to ensure a secure system of assistance. This is based on the initiatives that each service can start to implement from daily management, contributing to the quality of care concerning patient safety, satisfaction of the elderly and family, and inclusion of the ILPI in the social sphere.1818 Umpiérrez AF, Fort FZ, Tomás VC. Adverse events in health and nursing care: patient safety from the standpoint of the professional's experience. Text Context Nursing [Internet]. 2015 Apr/June [cited 2017 Mar 10]; 24(2):310-5. Available from: http://www.scielo.br/pdf/tce/v24n2/0104-0707-tce-24-02-00310.pdf
http://www.scielo.br/pdf/tce/v24n2/0104-...
,2525 Villar F, Serrat, R. Changing the culture of long-term care through narrative care: Individual, interpersonal, and institutional dimensions. J. aging stud., 40: 44-48, 2017. Availabre from: http://doi.org/10.1016/j.jaging.2016.12.007
http://doi.org/10.1016/j.jaging.2016.12....
-2626 Dantas CM, Bello FA, Barreto KL, Lima LS. [Functional ability of elderly with chronic diseases living in Long-Stay Institutions]. Rev Bras Enferm [Internet]. 2013 [cited 2017 Mar 10]; 66(6):914-20. Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0034-71672013000600016
http://www.scielo.br/scielo.php?script=s...

Although the methodological limitation intrinsic to documentary studies is admitted, with data being collected retrospectively, the reliability and validity of the data were confirmed by the original characteristics of the place of study, by the uniform qualification of the inspectors and by the definition of the universal pillars for the registration of the inspection report. These characteristics contributed to the robustness of the data, which allowed the comparison of the selected findings as a sample, that is, which contained at least two inspections. The sample number could be higher, however, if there were reports with more than one visit or if the services were included in the annual planning of health services for supervision, such as hospital units or health centers. In the LTCI, because they are considered and regulated like in the social sphere, most inspections still center on requests for CRT or denunciations, which may have influenced data with hypothetically precarious institutions or with non-conformities.

CONCLUSION

The results presented in the last inspection evaluation were sensitive to the inspections when translating parameters of advances in the quality of the services offered to the institutionalized residents and also in the integral nursing care. This study is an original research related to the work process of the inspection of the Rio de Janeiro Federal and Regional Nursing Councils in the activity niche of the Long-Term Care Institutions for the Elderly. Because nursing is the largest professional category that works during the 24 hours of operation of Long-Term Care Facilities for the Elderly, through this research, we intend to sensitize the competent entities (in particular the Public Prosecution and the National Health Surveillance Agency) to tighten the partnerships in joint inspections, permitting the achievement of better results and the inclusion of these institutions in the social-health sphere.

  • 1
    Paper taken from the thesis - Results of ethical-professional nursing surveillance in long-term care institutions for the elderly: retrospective study, presented to the Professional Master’s Program in Clinical Nursing at Universidade Federal Fluminense (UFF), in 2015.

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    » http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0034-71672013000600016

Publication Dates

  • Publication in this collection
    2018

History

  • Received
    07 June 2016
  • Accepted
    08 June 2017
Universidade Federal de Santa Catarina, Programa de Pós Graduação em Enfermagem Campus Universitário Trindade, 88040-970 Florianópolis - Santa Catarina - Brasil, Tel.: (55 48) 3721-4915 / (55 48) 3721-9043 - Florianópolis - SC - Brazil
E-mail: textoecontexto@contato.ufsc.br