NURSES’ ATTITUDINAL AND NORMATIVE BELIEFS CONCERNING HEMODYNAMIC ASSESSEMENT BY PULMONARY ARTERY CATHETERIZATION

The objective of this study was to identify, by using the Theory of Reasoned Action/Theory of Planned Behavior, the attitude and normative beliefs that influence the behavioral intention of the nurse to perform a hemodynamic assessment using the pulmonary artery catheterization. Data were collected through semistructured interviews involving 23 nurses from three hospitals in the city of Campinas, São Paulo. The data were analyzed according to a qualitative methodology. Among the Attitude Beliefs, affective beliefs and those related to the advantages and disadvantages of performing the behavior stand out. Among the Normative Beliefs social referents were identified for the behavior, as well as the behavior-stimulating factors and the factors that discourage the performance of the behavior.

The objective of this study was to identify, by using the Theory of Reasoned Action/Theory of Planned Behavior, the attitude and normative beliefs that influence the behavioral intention of the nurse to perform a hemodynamic assessment using the pulmonary artery catheterization.Data were collected through semistructured interviews involving 23 nurses from three hospitals in the city of Campinas, São Paulo.The data were analyzed according to a qualitative methodology.Among the Attitude Beliefs, affective beliefs and those related to the advantages and disadvantages of performing the behavior stand out.Among the Normative Beliefs social referents were identified for the behavior, as well as the behavior-stimulating factors and the factors that discourage the performance of the behavior.DESCRIPTORS: nursing care; intensive care; catheterization, Swan-Ganz; behavior

CREENCIAS NORMATIVAS Y DE ACTITUD DE LOS ENFERMEROS SOBRE EL ESTUDIO HEMODINÁMICO POR MEDIO DEL CATÉTER DE ARTERIA PULMONAR
El objetivo de este estudio fue identificar, por medio de la Teoría del Comportamiento Planificado, las creencias normativas y de actitud que contribuyen para la formación de la intención de comportamiento del enfermero en realizar el estudio hemodinámico (EH) por medio del catéter de la arteria pulmonar.Los datos fueron obtenidos atraves de entrevista semi estructurada de 23 enfermeros de unidades de  However, at the end of the 1980's, the first inquiries were raised about its use, as studies (1)(2) reported higher mortality rates among patients monitored with the catheter, leading to recommendations to suspend PAC use (3) .The lack of randomized research in this area made scientific societies and specialists recommend randomized studies to prove PAC efficacy (4) .
Recent studies at evidence level I were inconclusive about PAC efficacy (5)(6) .Nevertheless, literature reports that health professionals' limited knowledge on PAC management (7)(8)(9) has impaired catheter efficacy assessment.Hence, educational programs have been recommended to train these professionals in order to interpret the hemodynamic variables provided by the PAC (9)(10) .
Critical care nurses frequently mention difficulties to carry out hemodynamic studies (HS) using PAC, as well as the underutilization of obtained data in nursing care planning.
Studies have been realized to identify nurses' technical and conceptual knowledge about the PAC (7- 8) , but there are no reports on what conditions and knowledge they consider necessary to perform HS.
As health behaviors do not exclusively depend on knowledge, it is important to get to know what factors contribute to the formation of nurses' behavioral intent to perform HS.
Among theories that study behavior, the Theory of Reasoned Action (11) (TRA) stands out.According to these frameworks, the intention to realize a certain behavior is a function of the following factors:

Place of study
Data were collected at adult Intensive Care Units (ICUs) of two public and one private hospital located in Campinas, a large urban center with about one million inhabitants in the Southeast of Brazil.

Subjects
Participants were 23 nurse clinicians who had delivered care to at least three PAC patients in the last four months and agreed to participate by signing the.Professionals on health leave or any other leave of absence were excluded.The sampling process was intentional, using the saturation criterion to determine sample size (12) .

Data collection
Data were collected through semistructured interviews, using an instrument structured according to TRA premises and submitted to content validation (12)   .Seven experts with renowned knowledge

Data analysis
Data were analysed using a qualitative approach (13) , according to the following steps:

RESULTS
The The beliefs related to HS performance behavior are presented according to the two Central Thematic Units, which were a priori established according to TRA elements and their respective Central Theme Categories (Table 1).

Advantages of realizing HS
The analysis of answers about the advantages evidenced the subcategories: Advantages for patients, Advantages for Physicians and Advantages for nurses.
In relation to the patients, the analysis revealed that one of the advantages of PAC is the possibility of guiding treatment with precision, as PAC use permits obtaining accurate hemodynamic data.This contributes to define the diagnosis, guide therapeutical conduct and medication use.As to the Advantages for physicians subcategory, we observed that the same units of meanings as in Advantages for patients were reproduced.Among the few Advantages for nurses, contribution to nursing care and to professional learning stood out.The physician's trust in nurses' work was considered a behavior-stimulating factor because it causes the feeling of satisfaction.Greater knowledge about HS, obtained by practicing the behavior periodically, also revealed to stimulate the behavior.

Factors stimulating the behavior
These two subcategories were associated with the optimization of nursing care quality.
For some subjects, there is nothing stimulating the behavior, since they believe that the nurse only performs HS at the doctor's request.This indeed contributes to her considering the realization of the behavior as "obligatory".

DISCUSSION
This study revealed the existence of beliefs that permeate the behavior of performing HS, both in terms of the subject's attitude towards the behavior and the social referents that stimulate or discourage its realization.However, this acknowledgement occurs amidst many disadvantages nurses associate with HS.These observations strengthen the premises of the adopted theoretical reference framework (11)   , according to which attitudinal beliefs are formed from positive and negative meanings people attach to the realization of a behavior.
Moreover, in the assessment individuals make before performing the behavior, negative beliefs tend to exert a stronger impact that positive beliefs, and the latter tend to exercise greater influence on long-term decisions, while the former are more predominant in short-term decisions (14) .
When considering the decision to perform HS a shortterm resolution, the high prevalence of negative The subjective norm suggests greater possibilities that a subject will execute a behavior when he beliefs that important people expect him to perform the behavior (15) .In this study, the physician emerged as an important positive social The health team's inadequate use of hemodynamic data has aroused the interest of international scientific societies, as the knowledge deficit reflated to PAC handling is one of the main factors difficulting catheter efficacy assessment, which has led to recommendations to improve these professionals' knowledge and, mainly, to review and modify training and permanent education methods (10) .
Training and permanent education methods need to change, considering that education programs to improve technical-scientific knowledge have not been satisfactory in retaining and/or expaning professionals' knowledge (16) .The identification of in critical patient care evaluated the instrument by.A pretest was performed with three nurse clinicians from adult ITUs to assess the interviewees' understanding of the instrument.Interviews were held individually, protecting subjects' privacy, taperecorded and later transcribed.All subjects enrolled signed the Free and Informed Consent Term and the study was approved by the local Research Ethics Committee.

Figure 1 -
Figure 1 -Central theme category: Disadvantages of the behavior

Figure 3 -
Figure 3 -Central theme category: Factors stimulating the behavior

Figure 4 -
Figure 4 -Central theme category: Factors discouraging the behavior Among positive attitudinal beliefs, the advantages of using PAC in critical patients stood out, especially with respect to their contribution to the outlining of patient interventions.HS' positive contribution to patient treatment, in turn, was associated with a positive affect in relation to the behavior, resulting in tranquility in patient care.These findings point towards the acknowledgement of the importance of PAC use in patient treatment.
referent and was acknowledged as the professional who teaches and trusts nurses' work, contributing to their learning.The unit of meaning -physician's requestwas the most salient in the interviewees' discourse as a stimulus to perform HS.This information evidences that nurses realize HS on the basis of the physician's assessment and at his request.For some participants, this was one of the only factors stimulating the behavior.It seems incongruent that nurses indicate the doctor's request as a stimulus to perform HS, as nurses possess autonomy to realize HS and they are expected to interpret the collected data in order to support nursing interventions.On the other hand, the physician was also considered as a negative social referent, who discourages the realization of HS, mainly in the absence of a link with multiprofessional work and/or when he does not know or does not use data obtained through the PAC to guide critical patient treatment.Although the importance of the social referent should be acknowledged to perform certain behaviors, frequent references to the physician as a stimulus/ discouragement or even mediating affective beliefs about the performance of HS seem to contribute to remove nurses' focus from their responsibility to perform and interpret HS.Lack of knowledge and skills in PAC patient care were beliefs that permeated the disadvantages of the behavior, as well as negative affection with HS.These points towards the relevance of nurses' scientific recycling, if not as a determinant factor of behavior, then as a factor that contributes to training the behavior, as well as to motivation to perform it through the development of positive affection.In this context, the function of permanent education services must be emphasized, which should be especially important in nurses' recycling.However, our data showed that permanent education service professionals and nurse heads have also been considered as referents discouraging the realization of HS, particularly due to their inefficiency in helping nurses to acquire and improve PAC handling knowledge and skills.
beliefs and factors influencing adherence to the behavior is essential to guide the development of intervention programs that could be effective in optimizing and guaranteeing the accomplishment of important procedures or techniques in professional practice(15-17)   .Hence, the results of this study allow us to infer that the teaching methods permanent education services use about PAC management need to be reasesssed and restructured.Thus, it seems adequate to recommend that educational programs make an effort to provide technical-scientific contents but, also, that the elaboration of such programs considers factors motivating, permiting and strengthening the nurses' behaviors to adopt a specific behavior.It is important for this recycling to be directed at the development of clinical reasoning, making nurses self-confident about their competence and, therefore, able to participate in decision-making processes about critical patient care, together with their peers and the interdisciplinary team, in an equalitarian and autonomous way.In a future study, these data will contribute to the construction of a psychometric scale to assess the magnitude of each set of beliefs in the determination of this behavior.Identifying the most intense beliefs will permit the design of educative interventions aimed at strengthening positive beliefs and transforming beliefs in a positive sense for the behavior.

Table 1 -
Synoptic table of central thematic units: Attitudinal and normative beliefs and their respective central

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was associated with lack of PAC handling skills and with nurses' lack of knowledge about PAC.The feeling of disappointment was linked with the physician's not using HS data to guide therapeutic conduct.Among positive beliefs, satisfaction about performing the data, physicians and patients were indicated as positive social referents.Nurses were considered as positive social referents because they are interested in hemodynamic variables to elaborate their care plan.performance of HS: the discouragement comes... from supervision, because...I wasn't trained /.../ There's very little for nursing, so if we want something, we have to go for it, ask and generally it's to the doctor (E5).