Adolescent nursing consultation: an important excerpt from care provided by nurses in a Brazilian state

Abstract Objective: the care of adolescents with or without a chronic disease must complete, standardized and focused on individual demands and the transition process to adult care and adherence to treatment. This study aimed to characterize the care provided by nurses from the state of São Paulo who work with adolescents. Method: this is a cross-sectional and descriptive study on the care provided to adolescents by nurses in São Paulo, based on the answers to a self-administered questionnaire, available in the REDCap tool between August 2018 and October 2019. Results: participants answered 1632 questionnaires. Only 38% of nurses work with adolescents, 11.2% exclusively. Professionals were divided according to the median length of professional experience in groups A and B (≤5 years and >5 years). Drug addiction (p=0.01) and working with a multidisciplinary team (p=0.04) were significantly more reported in group B. Routine follow-up (p=0.02) and questioning about sexual or physical violence (p=0.03) were significantly more performed by professionals from group A. Conclusion: this study identified the need for a care protocol that can be replicated on a large scale and that includes the treatment and the particularities of adolescents to improve adherence and the transition into adult care.


Introduction
Comprehensive care specific to adolescent health must consider biological, psychological, and social changes that take place during this developmental period. The transition to adulthood includes complex life characteristics and factors such as structural and functional maturation of the brain, doubts about sexual identity, pregnancy, body image and self-care responsibilities, violence, and bullying must be considered during the nursing consultation (1)(2) .
Organizations need to train their professionals using participatory education and driven by social pressures, such as increased education, level of information of people and technological innovations, as well as motivation and expectation of people to participate in decisions, results, and future of the company (3) .
Adolescent medicine has recently been adopted as a specialty in high-income countries, which explains why many health professionals lack sufficient training and skills to properly work with adolescents. In lowand middle-income countries, debates regarding the training requirements for physicians and public health professionals remain incipient (4) .
Nurses are important to the health system when considering, for example, the implementation and maintenance of health policies, since these professionals play an awareness-raising role in the health system, given their intense contact with the community, contributing, directly or indirectly, to improve the quality of life of individuals (5) .
Given this scenario, the care provided by nurses and the availability of tools to be used in daily clinical practice and treatments must be characterized; regarding tools, they may be different when it comes to adolescent care, and are yet to be systematically evaluated in nurses working with this population in the state of São Paulo. The state is the richest and most populous of Brazil, having a diverse population with a large number of immigrants. São Paulo is a health reference in Brazil, providing care for a considerable percentage of patients from other statesconsidering the rate of adolescents (aged 10 to 19 years) in São Paulo of 5,570,389 individuals (6) . Therefore, this study aimed to characterize the care provided by nurses from São Paulo who work with adolescents.

Type of study
This is a descriptive and observational cross-sectional study, which analyzed, based on the answers to a self-administered questionnaire, the care provided by nurses from São Paulo to adolescents.

Study location
The state of São Paulo because it has the largest population contingent, corresponding to 21.7% of the country's total population, and with the largest number of registered nurses among the regional nursing councils (7)(8) .

Data collection tool
The self-administered questionnaire consisted of 40 questions to characterize the profile of the participants, evaluating their experience in managing adolescents, consisting of multiple-choice or dichotomous questions (yes and no). The questionnaire's ninth question ("Do you work with adolescents?") functioned as an exclusion criterion, that is, if the professional answered "No," their participation ended at that moment. The estimated length of response was approximately 15 minutes.

Data collection
Data collection was carried out via the application of the self-administered questionnaire between August 2018 and October 2019. The electronic survey included questions related to the following topics: 1) Demographic data of professionals (gender, years of practice, country), location of professional practice (public university, private university, public clinical practice and/or private clinical practice).
2) Employment of professionals (part-time or full-time).

Study population
The study population consisted of a convenience sample that included nurses from services that provide

Recruitment strategies
In 2018, COREN-SP sent the questionnaire twice, in a period of thirty days, to 100,000 e-mails from professionals registered on the Council's website, of which it is not possible to know how many returned because they were wrong or outdated. At the time of the request, the Council reported that the participation rate is usually low (1 to 5%), in a universe of more than 100,000 professionals. SOBEP made available the mailing list with 1,541 e-mails, but more than a thousand e-mails returned because they were outdated or wrong, and each professional is responsible for updating their address.
Participants received an e-mail presenting the survey, stating that their responses would be confidential, and the response link would be sent in an individual e-mail.
No incentives were offered. Reminder emails were sent periodically between August 2018 and October 2019, at fortnightly intervals.
Participants were also approached individually by the researcher at a Nursing Congress and the study objectives were explained. Then, the printed version of the questionnaire was given to professionals who claimed to work in the state of São Paulo and agreed to participate.
After filling out the questionnaires, they were collected by the researcher and the answers were added to the REDCAP system. As the questionnaire does not require name or e-mail identification, data were added without compromising the study and the participants.

Sample size
Sample calculation was impossible since the survey was sent via e-mail and adherence was voluntary, and the answers depended on the professionals. However, statistical validation for sample relevance was conducted: for a 0.05 alpha error, with a sample of 1,617 individuals, and a 38.7% proportion (percentage of those who work with adolescents), the margin of error varied between 4.4% (for 95% power) and 3.4% (for 80% power). The exact ratio difference test for a two-tailed constant was used on the G*power software version 3.1.9.3.

Statistical analysis
Results are presented as median (range) or mean ± standard deviation for continuous variables and number (%) for categorical variables. Nurses working with adolescents were divided into two groups based on the median length of experience working with adolescents: group A ≤ 5 years and group B > 5 years.
Data in the two groups were compared using Pearson's chi-square test or Fisher's exact test. In all statistical tests, the significance level of the independent variable was set at 5% (p < 0.05). Analyses were performed using the statistical software SPSS v.18 for Windows.
The variables with incomplete answers were identified in each table.

Ethical aspects
This study was approved by the Ethics Committee of Hospital das Clínicas de São Paulo under opinion number 2,296,748, and all participants signed a consent form prior to data collection.

Results
In total, 1,632 participants answered, with a predominance of female professionals (89%), Brazilian (99%), with part-time work hours (69%), and a balance of professionals working in public or private service. Only 632 (38%) of the nurses attended to adolescents ( Table 1).
The support treatment available and the characterization of the care provided by nurses are described in Table 2. www.eerp.usp.br/rlae 4 Rev. Latino-Am. Enfermagem 2022;30(spe):e3801.  (21) More than 100 patients 73 (12) Results are presented in n (%) Results are presented in n (%); *CRAFFT tool The main issues diagnosed in clinical practice for adolescents, despite being extremely relevant in this population, were mentioned by less than a quarter of professionals (Table 3). Afterwards, professionals who work with adolescents were divided into two groups according to professional experience to find possible differences in the provision of care related to the experience.
The median experience of professionals was 58 (0-1500) months, and the groups were named Group A (≤60 months of experience) and Group B (>60 months of experience), as shown in Table 4.  The nursing consultation, a mandatory work tool for carrying out the nursing process, aimed at adolescents, was reported by only 58.5% of professionals. This is relevant both are private activities of nurses carried out to contribute to the quality of patient care. Nursing consultation is a problem-solving action that requires technical, cognitive, and interpersonal skills, with systematized and interrelated actions aimed at compensating the basic needs of the patient/family/community (11) .
The nursing consultation also allows the professional Monitoring medication adherence is available in only 12.7% of services and is in line with a recent study carried out in Latin America (12) , where adherence to treatment and pregnancy are shown as major challenges in this population. Another study carried out with patients with pediatric autoimmune chronic rheumatic diseases describes the low adherence to medical treatment in 8/33 of the patients (24%) and shows a trend towards a correlation between socioeconomic factors and low adherence (13) . However, these studies did not use any scale to assess medication adherence, which can be very useful for nurses in diagnosing problems subject to intervention and, therefore, used in nursing consultations.
Available studies on treatment and the importance of adherence do not focus on the role of nurses and on the use of instruments that help to verify adherence, quality of life, disease acceptance, adolescent and family relationships and problems inherent to adolescence.
Adherence to drug treatment can be verified using instruments available in clinical practice, such as the Morisky and Green Test (TMG), composed of four questions that identify patients' attitudes and behaviors regarding drug intake. The instrument has quick application and allows a simple diagnosis (14) .
In this study, 70% of professionals are not aware of the existence of the CRAFFT tool, which assesses the risk of alcohol and drug use by adolescents, helps to detect the misuse of these substances and provide targeted treatment (9,15)  corroborating the worldwide concern about this public health problem (16) .
Questions aimed at the current Brazilian context should also be considered in the care provided to adolescents, such as the use of melee weapons or  (19)(20)(21)(22)(23)(24) . In the absence of such program established in the institution, nurses should be aware of their existence to adapt some activities, whenever possible, and assist in this extremely important process.
Additional analyses did not reveal statistically

Conclusion
The relevance of this study is justified by the We identified the need for a care protocol that can be replicated and that addresses the treatment and the particularities of adolescents, ways to improve adherence and the transition process to adult care.