Participated observation of nursing child health consultation

Abstracts

Diagnóstico de situação utilizando metodologia científica de natureza exploratória e descritiva (observação participada com tratamento estatístico descritivo) com objectivo de identificar as práticas de enfermagem na área da promoção de saúde durante uma consulta de enfermagem de saúde infantil. Das 31 consultas observadas (n=31) a maioria das observações ocorreu em crianças com idade inferior a 2 anos sendo os temas mais abordados a alimentação com utilização predominante de metodologia expositiva. Verificou-se ainda pouca utilização de suporte informacional e quando são utilizados reportam-se aos temas segurança e alimentação. A maioria dos prestadores de cuidados colocou questões e houve um reduzido registo da interacção prestador/criança existindo um dispêndio médio de 23 minutos por consulta. Face aos resultados e reflexão sobre os mesmos destaca-se como intervenção a elaboração de um manual de promoção de saúde com integração de aspectos teóricos e evidência científica de boas práticas nesta área.

Promoção da Saúde; Criança; Enfermagem pediátrica; Observação

ORIGINAL ARTICLE

Participated observation of nursing child health consultation

Observación participante de la consulta de enfermería para la salud infantil

Fernanda Manuela Loureiro^I; José António Neto Ferreira da Silva^II; Margarida Maria de Sousa Lourenço Quitério^III; Zaida Borges Charepe^IV

^IRN, graduated at Centro Hospitalar de Setúbal EPE Hospital de São Bernardo, Pediatrics Emergency Unit. Nursing doctoral student at the Health Sciences Institute of the Portuguese Catholic University. Setubal, [e-mail]

^IIRN Specialist in Child Health Nursing and Pediatrics. Licentiate in Nursing. Nurse specialist at Amora Health Center. Lisboa, Portugal. [e-mail]

^IIIDoctoral student in Nursing at the Portuguese Catholic University. Adjunct Professor of the Health Sciences Institute of the Portuguese Catholic University. Lisbon, Portugal. [e-mail]

^IVDoctorin Nursing at the Portuguese Catholic University. Assistant Professor of the Health Sciences Institute of the Portuguese Catholic University. Lisbon, Portugal. [e-mail]

^{Correspondence}

ABSTRACT

Situation diagnosis using exploratory and descriptive scientific methodology (participant observation with descriptive statistical treatment) in order to identify nursing' practices in the area of health promotion during a nursing child health consultation. The 31 consultations observed (n = 31) showed that the majority of observations occurred in children younger than 2 years being the most discussed topic feed with predominant use of expository methodology. There was also little use of informational support and when used relate to the themes of security and nutrition. Most providers raised questions and there was limited registration of the interaction between provider and child with an expenditure averaging of 23 minutes per consultation. Given the results and reflecting about them stands out as intervention the construction of a health promotion manual with the integration of theory and evidence of good practice in this area.

Descriptors: Health Promotion; Child; Pediatric nursing; Observation

RESUMEN

Diagnóstico de situación con una metodología científica de carácter exploratorio y descriptivo (observación participante con tratamiento estadístico descriptivo) con el fin de identificar las prácticas de enfermería en el ámbito de la promoción de la salud durante la consulta de enfermería para la salud infantil. De las 31 consultas observadas (n = 31) se mostró que la mayoría de las observaciones se produjeron en niños menores de 2 años siendo que el tema más discutido és alimentación con el uso predominante de la metodología expositiva. Se verificó poca utilización de apoyo informativo y cuando se utilizan se refieren a temas de seguridad y nutrición. La mayoría de los proveedores ha hecho preguntas y se verifico reducido registro de la interacción proveedores/niños con un expendio promedio de 23 minutos por consulta. Teniendo en cuenta los resultados y reflectando en ellos se destaca como intervención la elaboración de un manual para la promoción de la salud con la integración de la teoría y la evidencia de las buenas prácticas en este ámbito.

Descriptores: Promoción de la Salud; Niño; Enfermería pediátrica; Observación

INTRODUCTION

Health promotion is an area that has been gradually gaining interest among health professionals, not only for its vast importance and reference in guiding documents at national and international levels, but also because it is a broad subject. At the nursing level there is a greater concern in understanding its relevance and, above all, the role of nurses in this area. Nursing care occurs in multiple areas; however, it is at the level of primary health care that health promotion is most important.

Thus, in a course unit towards a master's degree in nursing in the specialized area of children's health and pediatrics, with the aim of identifying strategies used by nurses in the area of health promotion, participatory observation was performed of nursing consultations in children's health at a Health Center.

Promotion of health in pediatric nursing

The importance of health promotion as an area in need of attention harkens back to international conferences held in Ottawa (1986), Adelaide (1988), Sunsdalle (1991), Bogota (1992) and Jakarta (1997). These conferences stimulated the incentive to use the resources and knowledge of individuals in adopting healthy life styles. There have been ample references to this theme in national documents, such as the Law on Health in Portugal⁽¹⁾, which in subparagraph A of No. 1, Chapter I, base II states that health promotion and disease prevention are priorities in planning the State's activities. Further examples include the document Quality Standards for Nursing Care from the Order of Nurses⁽²⁾, which defines the promotion of health, stating that in the permanent search for excellence in professional practice, the nurse helps clients achieve maximum health potential. In addition, the Professional Development Model⁽³⁾ describes the specialization area - Child and Youth Health- as directed towards health projects involving children and youth experiencing health / illness, aiming at the promotion of health, prevention and treatment of disease, functional readaptation and social reinsertion in all contexts of life.

Health promotion aims at raising the health status of individuals and communities, enabling them (to empower) to gain control over those aspects of life that affect their health. These two elements (improving health and gaining control over it) are fundamental to the objectives and processes of health promotion⁽⁴⁾. The World Health Organization⁽⁵⁾ defines health promotion in a broad sense as a process that allows people to increase control over their life and improve it. The concepts of health education, health promotion and prevention of disease are often referred to synonymously⁽⁶⁾, but also as separate entities⁽⁷⁾; more generally, health promotion does not always concern itself with education. On the other hand, some aspects related to health behavior require interventions that are not consistent with an educational philosophy and methodology⁽⁸⁾.

In the context of children's health, family plays a leading role. Family can be understood as a dynamic system that includes subsystems - individuals (mother, father, child) and dyads (mother-father, mother - child and father-child) within the global family system⁽⁹⁾, in that the target group of care - the child or youngster- is located in the age group from birth up to 19 years of age, as defined by the World Health Organization. Nursing intervention at the level of primary health care is expressed in nursing consultations and child health surveillance, although it can be seen in other areas, such as vaccination clinics or school health programs.

METHOD

Observation is an investigation technique that can be defined as the systematic use of the senses in search of data needed to solve an investigative problem⁽¹⁰⁾. It should be performed in several stages: identify the situation to be observed, investigate objects of observation, set the registration mode, observe carefully and critically, record the observed data, analyze and interpret the data and draw conclusions. In this case, participatory observation was the best choice, because

in most situations the investigator should explicitly assume his role as a scholar within the observed population, combining it with other social roles whose position allows him a good observation position⁽¹¹⁾.

The observation referred to the work developed by nurses regardless of the structural characteristics, although the latter are also important⁽¹²⁾. Out of the twelve individuals that make up the nursing team of the Health Center where the resulting participatory observation was performed, consultations performed by seven individuals aged between 26 and 52 years were included, divided between professional categories including nurses (3), graduate nurses (3) and specialist nurses (1).

The activity that is presented in this study resulted from the context of an integrated internship within a master's course, previously authorized by the management of the health center. To perform the observations, authorization from the head of the nursing staff was requested, as well as from each of the parties being observed. Universal ethical principles were adhered to, including the principles of autonomy, beneficence, non-malfeasance and justice. Since no ethical issues emerged during the course of the study that risked compromising the integrity and dignity of those involved in the study, the study was not submitted to the Ethics Committee. We met in this context either within the specific context of the stage of study already authorized, or within the confines of the usual procedures adhered to in Portugal for courses of this nature. However, all measures were taken in order to respect and ensure the ethical principles mentioned previously. The nature, scope and purpose of the observation was clarified with the involved nurses, and confidentiality and anonymity was assured, both during the process of data collection and in the dissemination of results. Formal consent was requested through their signature on a consent form of each of the participants. The observations took place in the period between May 3rd and May 28th of 2010, and a total of 31 consults by nurses (n=31) were observed. No consultations in which there was an interruption for any reason were included. Following data collection, data were recorded immediately on a computer readable format Microsoft Office - Excel ® table and subjected to statistical description treatment.

In order to make the observations more systematized and targeted towards descriptive statistical treatment, an observation scale was built based on the existing instruments and literature in the field. Since there were few scientific references found regarding this particular subject, the observations made were of an exploratory and descriptive nature since, in these situations, one intends to recognize a given reality that has been poorly studied and raise hypotheses in order to understand this reality⁽¹¹⁾. Then, the methodology of participatory observation was applied, utilizing the definitions of the seven observation items that are described below.

Item 1 - Age group: the age of the child who took part in the child health consultation was recorded. To provide structure, we used the key ages recommended by the General Directors of Health⁽¹³⁾ for performance-type programs in child and teen health: 1st week of life, 1 month, 2 months, 4 months, 6 months, 9 months, 12 months, 15 months, 18 months, 2 years, 3 years, 4 years, 5-6 years, 8 years, 11-13 years, 15 years and 18 years.

Item 2 – Theme: to structure this item, we grouped anticipatory care that could be foreseen in the same performance-type program referred to above⁽¹³⁾, as well as documentation of nursing registration in use in the context of the health center. The following themes were established: growth and development, feeding, sleep and rest, elimination, recreation, vaccinations, clothing, social adaptation, affection, vaccinations, childhood diseases, hygiene and safety.

Item 3 - Methodology: for this item we considered the classification of teaching methods ⁽¹⁴⁾ , utilizing the following titles: expository method, demonstrative method, interrogative method and active method.

Item 4 - Use of informational support: the use of informational support is referenced extensively in the literature as a useful strategy⁽¹⁵⁾. In this regard, we considered whether or not this strategy was used; whenever it was used, we pointed out the type of supported delivered as a result of the existing informational support available (feeding, safety, vaccination and child behavior).

Item 5 - Request from the provider: it was also recorded if the caregiver accompanying the child to the consultation had raised issues or not.

Item 6 - Child/provider interaction: record of existing interaction between the child and caregiver present during the consultation.

Item 7 - Duration time: Finally, we considered the time spent in consultation.

The items were structured in the format of a grid to facilitate data recording, as can be seen in Table 1.

RESULTS

For item 1 – age range – it was found that 87% (n=27) of the observations involved children aged below 2 years old, as can be seen in Figure 1.

With regard to item 2, it was noted that the most commonly addressed themes were feeding (97%; n=30), safety (94%; n=29) and growth and development (90%; n=28). As less commonly addressed themes we highlight social adaptation (19%; n=6), childhood diseases (19%; n=6) and affection (23%; n=7), as can be seen in Figure 2.

Regarding item 3, it was verified that the expositive methodology was predominantly used (100%, n=31), whereas the other methodologies - demonstrative (19.4%, n=6), active (3.2%, n=1) and interrogative (9.7; n=3) were seldom used. In item 4 it was found that in 61% (n=19) of the consultations there was no use of informational support, while this type of support was utilized in 38.7% (n=12) of the consultations. Among the observations in which informational support was used, it was found that the ones most commonly utilized related to safety (36%, n=11) and feeding (16%, n=5).

Regarding item 5 it was found that in 77% (n=24) of the observations there were questions asked by the providers, while in 22.6% (n=7) of the observations no questions were asked.

With respect to observations of child / provider interaction (item 6) it was found that in 61% (n=19) of the consultations no information was recorded, while information was noted in 39%.

Regarding time spent in consultation (item 7), there was an average of 23 minutes spent, with a 10 minute minimum and 32 minute maximum, as can be seen in Figure 3.

In conclusion, 87% (n=27) of the observations involved children younger than 2 years old, with the most commonly addressed themes being feeding (97%, n=30), safety (94%, n=29) and child growth and development (90%; n=28). The less frequently addressed themes were social adaptation (19%; n=6), childhood diseases (19%; n=6) and affection (23%; n=7). There is a prevailing use of expositive methodology (100%; n=31). It is also noted that there is little use of informational support (61%; n=19 does not use) and when used, it refers to safety themes (36%; n=11) and feeding (16%; n=5). Most of the providers ask questions (77%; n=24) and there is a lack of recording in terms of provider/child interaction (58%; n=18 was not recorded). There is an average expenditure of time of 23 minutes per consultation.

DISCUSSION

In most of the consultations observed, the children were less than two years of age, which was expected since it corresponds to the period of childhood in which consultations take place at more frequent intervals⁽¹³⁾. As to the topics addressed, it is noted that the issues that are most often addressed are feeding, safety and child growth and development. In relation to food, this was also an expected result since it is early in life that the introduction of food takes place, and therefore food is a topic more frequently discussed during the consultations. As regards the safety theme, it is noted that accidents are one of the major causes of infant mortality and it is understood to be a subject that is also addressed frequently. According to the National Institute of Statistics⁽¹⁶⁾ external causes of mortality are most common at younger ages (accounting for 44.7% of deaths in the age group spanning one to nineteen years). Thus, the importance of accidents is highlighted, as in 2005 more than 50% of deaths in children were a result of external factors. The issues of child development come up in association with the two previous ones because, in the context of interventions, it is necessary to address the gains made by children in their growth and development. Regarding themes less often addressed (social adaptation, childhood diseases and affection) no similar studies were found in the literature that might explain these results. However, it can be assumed that, in relation to social adaptation and affection, these areas are inherent to caring for a child, and the basic functioning of the family which might lead nurses to address these issues are focused on less often due to time constraints. Regarding childhood diseases, this area is one less commonly addressed in healthy children, thus this result was not unexpected.

The predominant methodology is the expository one, a fact that is also found in national studies addressing nursing in the hospital setting ^(17-18). It is noted that the parents ask questions during the consultation, which reflects concern regarding the child's development, an aspect which is inherent to the role of parent⁽¹⁹⁾. We did not note the existence of notes focusing on the interaction between the provider and child, which is consistent with the little importance attributed to the issues of affection and social interaction. The mean duration time of the consultation (23 minutes) is consistent with the time recommended in the General Health Direction⁽¹³⁾.

CONCLUSION

Considering our results, since they are contextualized within a training path, the results were presented to the nursing staff and joint reflection allowed us to propose several interventions, namely:

• Awareness of nursing staff regarding the importance of the relational aspects of evaluation;

• Construction of a health kit promotion with integration of objects used in child care as a way to encourage the use of other methodologies beyond the expository one;

• Introduction of therapeutic letters as a way to provide positive reinforcement to parents in relation to care rendered to the child;

• Development of a manual of health promotion with the integration of theoretical aspects and scientific evidence of good practice in this area;

• Conduction of a similar study after implementation of interventions to assess their effectiveness.

REFERENCES

Received: 09/01/2011

Approved: 04/06/2012

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Correspondence addressed to:

Fernanda Manuela Loureiro

Rua Dr. Henrique Chancerelle Machete, n.º 5, 5º A

2910-779 - Setúbal, Portugal

Publication Dates

• Publication in this collection
  30 Jan 2013
• Date of issue
  Dec 2012

History

• Received
  01 Sept 2011
• Accepted
  06 Apr 2012