Nursing focuses and interventions that promote the autonomy of the elderly

Enfoques e intervenciones de enfermería promotoras de la autonomía del anciano

ABSTRACT

Objectives:

To describe the meaning attributed to the experiences of the clinical experience of specialist nurses in the implementation of nursing care focuses and respective interventions that promote the autonomy of the elderly.

Method:

Qualitative study based on Giorgi's method. Eighteen specialist nurses were interviewed, recruited for convenience in two hospitals in the northern region of Portugal, between March and December 2018.

Results:

In the clinical experience of specialist nurses, regarding the nursing process, three themes emerged: focuses of nursing care; implementation of nursing interventions and hindering factors.

Conclusions:

The specialist nurses, most of whom are rehabilitation specialists, essentially promote the physical capacity of the elderly, within the scope of autonomy, revealing that working conditions, such as lack of time and information systems, are the limiting factor of their promotion.

Keywords:
Patient care; Nursing care; Personal autonomy; Working conditions; Qualitative research

RESUMEN

Objetivos:

Describir el significado atribuido a las vivencias de la experiencia clínica de enfermeros especialistas en la implementación de los enfoques de atención de enfermería y las respectivas intervenciones que promueven la autonomía del anciano.

Método:

Estudio cualitativo basado en el método de Giorgi. Se entrevistaron dieciocho enfermeras especializadas, reclutadas por conveniencia en dos hospitales de la región norte de Portugal, entre marzo y diciembre de 2018.

Resultados:

En la experiencia clínica de los enfermeros especialistas, en relación con el proceso de enfermería, surgieron tres temas: focos de atención de enfermería; implementación de intervenciones de enfermería y factores obstaculizadores.

Conclusiones:

Los enfermeros especialistas, en su mayoría especialistas en rehabilitación, promueven fundamentalmente la capacidad física de las personas mayores, en el ámbito de la autonomía, revelando que las condiciones laborales, como la falta de tiempo y sistemas de información, son el fator limitante para su promoción.

Palabras clave:
Atención al paciente; Atención de enfermería; Autonomía personal; Condiciones de trabajo; Investigación cualitativa

RESUMO

Objetivos:

Descrever o significado atribuído às vivências da experiência clínica dos enfermeiros especialistas na implementação de focos do cuidado de enfermagem e respetivas intervenções promotoras da autonomia dos idosos.

Método:

Estudo qualitativo com base no método de Giorgi. Foram entrevistados 18 enfermeiros especialistas, recrutados por conveniência em dois hospitais da região a norte de Portugal, entre março e dezembro de 2018.

Resultados:

Na experiência clínica dos enfermeiros especialistas, quanto ao processo de enfermagem, emergiram três temas: focos do cuidado de enfermagem; implementação de intervenções de enfermagem e fatores dificultadores.

Conclusões:

Os enfermeiros especialistas, em sua maioria em reabilitação, promovem essencialmente a capacidade física dos idosos, no âmbito da autonomia, revelando que as condições de trabalho, como a falta de tempo e os sistemas de informação, constituem o fator limitador da sua promoção.

Palavras-chave:
Assistência ao paciente; Cuidados de enfermagem; Autonomia pessoal; Condições de trabalho; Pesquisa qualitativa

INTRODUCTION

The therapeutic relationship between health professionals and the person must be based on principles such as assertiveness and respect. With regard to the concept of autonomy, respect for the person implies the duty to respect their decision-making capacity and involves two aspects that fully complement each other: the recognition of the person’s ability to make their own decisions and the promotion of conditions that protect the exercise of this autonomy1.

The promotion of autonomy, through the right to self-determination, allows people to master their own being, their destiny, their life and their behavior, enabling freedom of choice and control of their actions, conditions that are essential for quality and dignity of life2. Such recognition is achieved through clinical interviews and systematic observation. Through these techniques, nurses are able to define the problems or potential problems of the person they care for and, thus, to elect the focuses of nursing care and respective nursing interventions3.

Demographic aging is a worldwide phenomenon that increases the responsibility of health professionals, given the challenge of maintaining quality of life, even in the face of disease circumstances. The aging rate between 2015 and 2080 is expected to double from 147 to 317 per 100 young people. Thus, the participation of the active population in the total population will considerably decrease4.

Despite the increase in longevity, elderly people are accompanied by multiple chronic diseases that arise associated with disability, functional decline and all the consequences resulting from this incapacity. The immobility processes resulting from incapacity reduce the quality of life of the elderly and considerably increase health care costs, including increasing the risk of hospitalization5.

Prevention at all levels is particularly important for the elderly person, and the intervention of specialist nurses is essential to maintain or promote their autonomy. Nurses, through the nursing process, must implement interventions that respond to these needs, because, as the authors point out3 the correct identification of the focuses of nursing care is an essential step to identify the specific need of the person, allowing to plan an appropriate response. Thus, through nursing care and its interventions adjusted with a view to training the elderly person, nurses are the professionals of excellence, given their skills in promoting/maintaining the autonomy of the elderly.

Through the speeches of nursing professionals, it can be observed inaccuracies in the concepts of autonomy and independence. In the implemented nursing processes, it appears that in promoting the autonomy of the elderly, nurses direct their care towards physical independence, especially for basic activities of daily living, designating these interventions as promoters of autonomy6. To improve the quality of nursing care, it is important to know both and distinguish them from each other. Autonomy is a broad concept that involves competences such as: physical capacity, cognitive capacity, social integration and emotional intelligence; independence, on the other hand, involves only physical competence7.

Given the above, the question was: What is the meaning of the clinical experience of specialist nurses regarding the implementation of nursing care focuses and respective interventions that promote the autonomy of the elderly? The objective of this study was to describe the meaning attributed to the experiences of the clinical experience of specialist nurses in the implementation of nursing care focuses and respective interventions that promote the autonomy of the elderly.

METHOD

This is a qualitative study, using the principles of Giorgi’s descriptive phenomenological methodology8, to understand the structure of the phenomenon and the meaning of the experiences lived by specialist nurses in their care practice. Giorgi’s method8, deals with descriptions of interviews about lived experiences in relation to a given phenomenon according to four steps: 1. reading all the transcriptions several times to know the whole experience; 2. reread the transcriptions in order to determine meaning units; 3. the meaning units must be transformed into a language suitable for the phenomenon under study and grouped into themes and sub-themes; 4. synthesize all meaning units into a consistent and descriptive statement about the participants’ experiences.

Data collection was conducted in two hospital institutions located in the north of Portugal, one large and one medium-sized; the first in the district of Porto and the second in the district of Viana do Castelo. The large hospital has 1105 beds, serves a population of 3.7 million users and is a university hospital, with specialties compatible with its size. The medium-sized hospital, on the other hand, has 411 beds, serves a population of 85 thousand users, has admissions for Internal Medicine, Surgery, Orthopedics, Pediatrics, Obstetrics, Neurology and Psychiatry. It also has outpatient, urgent and emergency services, gastroenterology, and day inpatient unit.

Inclusion criteria were: working for at least 6 months with the elderly and holding the title of specialist nurse (Rehabilitation Nursing and/or Medical-Surgical Nursing and/or Mental Health Nursing and Psychiatry and/or Community Nursing). The following were excluded: generalist nurses, specialist nurses in Child Care Nursing and Pediatrics, and Maternal and Obstetric Care, in addition to those on leave during the data collection period.

The participants were identified with the help of nurse managers. One of the authors made the invitation and all accepted to participate in the study. Eighteen specialist nurses participated, 10 of whom worked in clinical medicine units, 2 in surgical and 6 in orthopedics.

The data collection instrument consisted of two parts: the first included a sociodemographic questionnaire to characterize the participants and the second a semi-structured interview with the following question: Given your experience, how is the promotion of autonomy for the elderly expressed in the nursing care plan? In order to obtain a better understanding of the participants’ experience, other questions were asked: Can you describe this experience in greater detail?

Data collection took place between March and December 2018. The interviews were conducted by the first author and were audio-recorded and transcribed in full by the same author who conducted them. The average length of the interviews was 30 minutes. The end of data collection followed the data saturation criterion, since the data obtained started to present a certain redundancy/repetition, with no new data or new facts9. All interviews were audio-recorded and transcribed in full by the same author who conducted them.

For data analysis, it was used the Atlas.ti software version 8.4. Data were interpreted based on Giorgi’s method, through four steps: 1. getting the sense of the whole: repeated reading of the transcriptions in order to obtain a general idea of the lived experience; 2. description of the meaning units: the transcribed interviews were reread in detail, and when a transition of meaning was identified in the transcripts, these were distinguished as relevant aspects of the phenomenon under study; 3. transformation of the common language of the meaning units into scientific language: the meaning units were rewritten in a language suitable for the phenomenon under investigation, keeping the meanings expressed by the participants faithful; and 4. synthesis of the transformed meaning units, in a descriptive structure of the experience lived by the participants8.

This study complies with the Consolidated criteria form Reporting Qualitative Research (COREQ) guidelines. The research followed the current ethical guidelines in the country, all participants signed the Free and Informed Consent Form. The research was approved by the Ethics Committees of the two Institutions (Opinions no. 324/17 and no. 11/18). To ensure anonymity, the participants were identified with the initial letters referring to their profession and the interview number in the order of its realization: nurse (N1, N2, N3).

RESULTS AND DISCUSSION

From the 18 specialist nurses who participated in this study, most are female (n=17), the average age is 39.6 years, working on average for 16.3 years and are specialist nurses, on average for 5.9 years, most are specialist nurses in rehabilitation nursing (n=14), followed by medical-surgical nursing (n=2) and community nursing (n=2). It is noteworthy that rehabilitation nursing is the specialty with the highest number of specialists in both districts, where data were collected10.

From the data analysis, three themes emerged that reflect the essence of the specialist nurses’ experiences, in the promotion/maintenance of the elderly’s autonomy, through the identification of nursing care focuses and the implementation of nursing interventions that are articulated with autonomy. From this analysis, the theme of working conditions also emerges, and these nurses recognize that this theme is a limiting issue for the promotion of autonomy for the elderly. In short, three themes emerged from the analysis, namely: focuses of nursing care; implementation of nursing interventions; hindering factors, as shown in Figure 1.

Figure 1 -
Empirical Structure of the Phenomenon Analysis

Focuses of nursing care

The results show that from the speeches of the participants in this study, the theme focuses of nursing care emerged as: self-care, self-esteem, and management of the therapeutic regimen.

The identification of nursing care focuses is a fundamental step in identifying a problem or a specific need of the person, for the elaboration of a diagnosis that allows planning an appropriate response3. As the concept of autonomy is very broad, this implies, in clinical practice, the orientation of nurses’ attention to care focuses, which include: cognitive capacity, emotional management, physical capacity and social integration7. All of them oriented towards its promotion or even maintenance.

In “self-care” and “management of the therapeutic regimen”, excerpts from the discourses stand out:

[...] self-care, the management of the therapeutic regimen (N1).

091;...] self-care... hygiene, clothing, eating... with autonomy... the issue of the therapeutic management... transferring oneself is also reflected in autonomy (N6).

In fact, self-care is at the center of nurses’ attention when they intend to promote the autonomy of the elderly. Among these, dressing up, dressing/undressing, eating, hygiene, mobility in bed, moving, going to the toilet and walking stand out, corroborating these results in the study of the authors3, which aimed to describe the nurses’ perception about the priorities of the focuses of nursing care directed to the elderly person hospitalized in acute phase.

In the participants’ discourse, still about the focuses of nursing care, the sub-theme emerges: “management of the therapeutic regimen”, due to the importance it assumes, with regard to the person’s or their caregiver’s capacity to manage the therapeutic indications, providing essential tools for this management, through empowerment and health literacy. As other authors point out11, although they do not refer in their study to focuses of nursing care, they emphasize the importance of nurses investing in health education sessions, and, in order to put these interventions into practice, they need to link them to some focus of nursing care.

Regarding self-esteem, the participants’ discourse shows that:

[...] the self-esteem is linked to autonomy (N2).

[...] the sick patient may have altered self-esteem (N5).

Self-esteem is a psychological phenomenon that has a very intimate relationship with the emotional and cognitive dimensions of the person, so it directly influences autonomy and quality of life, as the authors point out12, corroborating the data in the present study since specialist nurses refer to the focus of nursing care: “self-esteem” as a promoter of autonomy of the elderly.

The identification of the elderly person’s needs, through the focuses of nursing care, is essential in many aspects related to the promotion/acquisition of competences necessary to maintain the autonomy of the person, including self-care3. However, one cannot forget other essential components that the concept of autonomy involves7, especially in the elderly person, who, given specific characteristics, require greater attention from nurses. In clinical practice, important areas such as cognition, psychological processes and social integration are often neglected, such as the analysis of the concept of autonomy describes7.

Implementation of nursing interventions

Regarding the implementation of nursing interventions, from the speeches of specialist nurses, it is perceived that they promote the autonomy of the elderly through: cognitive training, physical training, social training, rehabilitation interventions, respect for autonomy, giving time to the patient, teaching/instructing and training self-care, teaching informal caregivers, performing self-care and health literacy. Despite the fact that some of these professionals mention that autonomy is: little worked, disrespect for autonomy and it is not worked.

Regarding cognitive training, specialist nurses emphasize in their discourses:

The more I work on daily activities with the sick patient, the more he will become autonomous... we work on daily life activities and at the same time cognition (N14).

Autonomy for me is the ability that people have to make their own life, so they have to be independent...both physically and mentally... and the nurse has to work on these two components (N18).

Therefore, they emphasize that physical and cognitive training are inseparable. A study5, concluded that confusion is a neuropsychiatric problem that interferes with attention and cognition. However, when the person is subjected to a rehabilitation program, it can contribute to the improvement of the confusional state, corroborating the results of the present study.

Through the experiences shared by the specialist nurses, it appears that physical training is one of the most worked areas in their clinical practice:

[...] we go to the bathroom, if there is the possibility of walking, don't use a chair, if you have the possibility to collaborate, collaborate and also do exercises to perceive the best way to then be enough for yourself (N15).

This training is done during the performance of nursing interventions aimed at self-care, giving the person the opportunity to work on muscle strength, balance and joint movement, through self-care.

Social training is considered in the discourses as:

The physical part turns out to be easy to work [...] but the social part too (N5).

Namely the interaction between people, especially through facilitating the presence of family and friends. These professionals recognize that autonomy involves several dimensions, including the social dimension and the way the person integrates, as other authors defend 13 .

In the participants’ speeches, the importance to give the patient time also emerges:

[...] the elderly can be slower than adults, but they end up doing the tasks (N7).

Although this is not specifically a nursing intervention, it affects the quality of care provided and health gains. It is assumed that this aspect is considered in the guide to good nursing practices, and it is therefore not necessary that it be considered in the nursing process, as highlighted by other authors14. For the provision of care, the participants highlighted this aspect, due to the fact that the working conditions, in most cases, do not allow the patient to be given time to perform tasks, especially basic activities of daily living.

Specialist nurses highlight that:

[...] active, active-assisted and passive mobilizations are made, and we take the opportunity to do this also during self-care (N4).

[...] mobilizations are made and work muscle strength (N15).

The gains in health, with the implementation of rehabilitation programs, have been widely spread. The authors15 through the implementation of a rehabilitation program, obtained not only gains in functional independence, but also in the confusional state of the elderly.

In his discourse, it also emerges that autonomy involves:

[...] the ideal is to be able to adapt your habits to the service routine. The ideal is to maintain patient autonomy as much as possible (N14).

As well as give the patient time, respect for autonomy should not be considered in the nursing process, as it is part of the good practices manual14. However, and according to the nurses’ perception, the sick patients’ opinion is not considered in the care process, and their decision-making, an essential component for the satisfaction of autonomy, is disregarded7.

Within the scope of their competences, specialist nurses have as intervention teaching/instructing and training self-care; they show these competences in their discourses:

[...] it has to do with intensive training in important activities and giving them knowledge of the theoretical resources that can support their own practice (N2).

Through the study14, the actions “teach” and “instruct”, refer to the transmission of relevant information and to the respective demonstration, and these actions are associated with diagnoses in the dimension of “knowledge”. On the other hand, “train” is associated with diagnoses in the “skills” dimension. Although specialist nurses do not show this association in their discourses, they identify the need to implement these actions to promote autonomy with regard to self-care.

In their experiences, specialist nurses report that autonomy is little worked, when they report:

[...] nurses do not have a lot of time to work on people's autonomy, including the elderly (N1).

[...] we work very little on autonomy (N2).

Adding to that they implement few interventions that promote autonomy, since working conditions are limiting factors in this promotion and consequently generate dissatisfaction and burnout in nurses, as highlighted by other authors16.

Through their lived experience, specialist nurses mention that sometimes there is disrespect for autonomy:

[...] we are going to take care of a patient, we are the ones who select the pajamas, when the right thing would be to ask the patient: is there this... what do you decide to wear?” (N2).

[...] he must decide. This is autonomy. And we don't do that (N2).

[...] in day-to-day care, we do not ask the patient what... what he wants... what he likes (N4).

[...] it's us, together with the family, that make the decisions, and often they have the capacity to make decisions (N7).

Once again, good nursing practices are called into question. In fact, not putting before the person's decision, giving it time, among other actions, does not need to be explicit in the nursing process; but it must necessarily be included in the provision of care, especially when it comes to the quality of care and health gains14.

It is also performed teaching to informal caregivers to promote the autonomy of the elderly, which can be seen by the discourse:

[...] what I try to do with the family is to try to instill in them that at home they should encourage the patient to be as autonomous as possible and never replace the patient, but rather help... complement the sick patient in what is not able to achieve (N8).

In Portugal, family members, as a form of affection, end up replacing the elderly, initially in instrumental activities of daily living and later in basic activities of daily living, this in the normal aging process. In disease processes, the replacement of these two groups of activities appears simultaneously.

As far as performing self-care is concerned, it emerges from the participants’ discourses:

[...] we direct care a lot towards performing self-care [...] which in itself refers to transference, bathing, dressing, hygiene, using the toilet... we work a lot (N4).

[...] we basically work... food, hygiene, using the toilet and walking (N10).

[...] or me, my focus is on self-care... I'm not interested in intervening... in mobilizing a patient without being minimally clean (N14).

Actions of type “perform” are actions that reward the replacement of the person14, which in the context of promoting the autonomy of the elderly does not have a place.

Participants report the importance of health literacy in their discourses:

[...] providing them with adequate information to know about... and that they increase their capacity and autonomy (N2).

As already mentioned, health literacy and the empowerment of the person or caregivers is currently of crucial importance, both in the prevention and control of pathologies11, assuming equal importance regarding all dimensions that autonomy encloses.

According to the specialist nurses, autonomy is not worked, as can be seen:

[...] there is a professional culture in us, of not working on autonomy, because the time you spend doing one thing or another is exactly the same (N2).

[...] s we don't have much time to wait, we ended up doing it for them (N3).

[...] no, we don't give the patient time... to reflect on what we are doing at all. Daily life does not allow [...] (N5).

Thus, in these discourses, we realize that both the routinization and the lack of working conditions, turn out to be limiting factors in the promotion of the elderly’s autonomy. These findings are corroborated by other authors16.

D From the discourses emerge that no teachings are not performed, when they mention:

[...] Currently, the vast majority of our sick patients go to the continuing care units and, therefore, we end up not teaching (N1).

[...] I confess that it really is a gap, I try to work, but I have the notion that I don't do it in the most efficient and appropriate way, since it also seems to me that caregivers are more and more carefree with the elderly (N4).

Dissatisfaction associated with physical and intellectual fatigue, condition the practice of care16, guiding them to habits and routines, which are harmful to the individuality of care.

They also reveal the importance of not replacing the person:

[...] as a nurse specialist in rehabilitation, I never replace the elderly person, when they have the ability to do things alone (N1).

[...] always in the aspect of not replacing the person, of letting them do what they can (N16).

In the context of a rehabilitation process, the person should be encouraged to perform the activities, as their replacement could be a setback in this process. As highlighted, giving time to the person in a rehabilitation process, despite not being a nursing action, is essential for its success, so specialist nurses must attend to this aspect in the provision of care15.

Hindering factors

In addition to the individual competences of each nurse and the competences of the nursing team, working conditions are essential for the quality of care provided16.

From the experiences shared by the participants, the sub-theme of working with working conditions emerged, allowing this to develop the care that permeates quality:

[...] here at the stroke unit this work is facilitated, of course as long as we have the appropriate ratios and we usually do (N1).

The study17, states that the adequate number of nurses ensures the quality of nursing care, not only ensuring safety for the person, but also in achieving organizational goals.

Nurses recognize that there is a need for training on practices related to the promotion of autonomy:

[...] this is only accepted with a moment of sharing and reflection within the team, or by stimulating training in the area or about... information about information systems, because what happens is that people do not realize that there is a need to change behaviors (N2).

As highlighted in the study of other authors18, the recognition of errors, the strengthening of teamwork, through reflection on practices, instilling the discussion of opinions, as well as the encouragement of professionals for continuing training, constitute strategies of construction of patient safety.

Without working conditions, are the words mentioned by specialist nurses in their practices to promote autonomy:

[...] in my opinion, nurses do not have much time to work on people's autonomy, including elderly people (N1).

[...] no one cares about the degree of satisfaction, no one tries to realize that a patient may need half an hour for the professional to understand what he can do in self-care...because it seems that we are all afraid to assume that we do things running (N2).

The number of staff needed for nursing is essential for patient safety and also for the profession, as the patient, when feeling that he/she does not provide care within the parameters considered by the nursing discipline, experiences feelings of frustration and dissatisfaction16^,17.

The participants mention that the information technology system has many limitations, regarding planning and nursing records, regarding the promotion/maintenance of the elderly person. Emerged in the discourses: limited computing system:

[...] our computing system is very limited (N1).

[...] we only work on self-care... very sincerely, we raise the diagnoses that are on the computer... more than that, it's impossible (N3).

These findings do not corroborate the results obtained by authors19, who showed that the nursing information system makes information available in an easy and secure way, also consisting of important management support tools, as they allow access to indicators sensitive to nursing care.

The change in the culture of care is a challenge, as nurses recognize and demonstrate routines in certain practices, and it is necessary to implement measures and methodologies to accept and recognize practices that need improvement, especially in care aimed at promoting the autonomy of the elderly.

Other studies on the phenomenon of the autonomy of the elderly, especially on nursing care focuses and nursing interventions, should be conducted, in order to facilitate its promotion in the practice of care, since, in the context of care provision, the term autonomy is applied daily to the nurses’ discourses, meaning to refer to the physical and functional independence of the elderly20.

Regarding the limitations of the present study, we can highlight that the fact that there are few studies on the subject, hinders the qualitative analysis of the subject under study, also emphasizing the relevance of carrying out the same. Another limitation was the absence of specialist nurses in the field of mental and psychiatric health, and a greater number of specialist nurses in the areas of community nursing and medical-surgical nursing, allowing to have a uniform group of specialist nurses. Despite this, the study contributes to the debate on the role of nurses to promote the autonomy of the elderly.

CONCLUSION

With regard to the clinical experience of specialist nurses in promoting/maintaining the autonomy of the elderly, three themes emerged, namely: focuses of nursing care; implementation of nursing interventions; hindering factors, from the data obtained it can be seen that training is essentially physical and cognitive, being little worked on social training. Specialist nurses recognize that autonomy is little worked on in the practice of care, being the limiting factor of this promotion, information systems and lack of time.

As implications for practice, these results alert health professionals to the comprehensive concept of autonomy, to attend to its multidimensionality. As an implication for teaching, there is a need to deepen this concept, with a view to a more effective clinical practice.

This study encourages future nurses to be more aware and capable of promoting the autonomy of the elderly, through the implementation of nursing care focuses and nursing interventions that respond to the needs of the elderly.

In the future, more and more nurses will provide care for the elderly person. Recognizing such experiences is important because it encourages other health professionals, including hospital managers, to reflect on the challenges experienced by these nurses. The development of more studies on this topic will contribute to obtaining more evidence on the topic under study, which will have an impact on higher quality nursing care and respect for the autonomy of the elderly.

REFERENCES

• 1. Dzeng E. Habermasian communication pathologies in do-not-resuscitate discussions at the end of life: manipulation as an unintended consequence of an ideology of patient autonomy. Sociol Health Illn. 2019;41(2):325-42. doi: https://doi.org/10.1111/1467-9566.12825
  » https://doi.org/10.1111/1467-9566.12825
• 2. Reach G. Adherence challenges in chronic diseases. Med des Mal Metab. 2018;12(6):511-5. doi: http://doi.org/10.1016/S1957-2557(18)30135-4
  » http://doi.org/10.1016/S1957-2557(18)30135-4
• 3. Cruz AG, Gomes AMT, Parreira PMSD. Focos de atenção prioritários e ações de enfermagem dirigidos à pessoa idosa em contexto clínico agudo. Rev Enf Ref. 2017;Série IV(15):73-82. doi: https://doi.org/10.12707/RIV17048
  » https://doi.org/10.12707/RIV17048
• 4. Instituto Nacional de Estatística (PT). Projeções de população residente [Internet]. Lisboa: Instituto Nacional de Estatística; 2017 [cited 2021 Mar 01]. Available from: https://www.ine.pt/xportal/xmain?xpid=INE&xpgid=ine_destaques&DESTAQUESdest_boui=277695619&DESTAQUESmodo=2&xlang=pt
  » https://www.ine.pt/xportal/xmain?xpid=INE&xpgid=ine_destaques&DESTAQUESdest_boui=277695619&DESTAQUESmodo=2&xlang=pt
• 5. Lima AMN, Ferreira MSM, Martins MMPS, Fernandes CS, Moreira MTF, Rodrigues TMP. Independência funcional e o estado confusional de pessoas sujeitas a programa de reabilitação. J Health NPEPS. 2020;5(2):145-60. doi: http://doi.org/10.30681/252610104440
  » http://doi.org/10.30681/252610104440
• 6. Bennett L, Bergin M, Wells JSG. The social space of empowerment within epilepsy services: the map is not the terrain. Epilepsy Behav. 2016;56:139-48. doi: https://doi.org/10.1016/j.yebeh.2015.12.045
  » https://doi.org/10.1016/j.yebeh.2015.12.045
• 7. Lima A, Martins M, Ferreira S, Schoeller S, Parola V. O conceito multidimensional de autonomia: uma análise conceptual recorrendo a uma scoping review. Rev Enf Ref. 2021;5(7):e20113. doi: https://doi.org/10.12707/RV20113
  » https://doi.org/10.12707/RV20113
• 8. Giorgi A. An affirmation of the phenomenological psychological descriptive method: a response to Rennie (2012). Psychol Methods. 2014;19(4):542-51. doi: https://doi.org/10.1037/met0000015
  » https://doi.org/10.1037/met0000015
• 9. Ribeiro J, Souza FN, Lobão C. Saturação da análise na investigação qualitativa: quando parar de recolher dados? [editorial]. Rev Pesqui Qual. 2018 [cited 2021 Mar 01];6(10):iii-vii. Available from: https://editora.sepq.org.br/rpq/article/view/213/111
  » https://editora.sepq.org.br/rpq/article/view/213/111
• 10. Ordem dos Enfermeiros (PT). Membros activos especialistas [Internet]. Lisboa: Ordem dos Enfermeiros; 2018 [cited 2021 Mar 01]. Available from: https://www.ordemenfermeiros.pt/media/11137/c%C3%B3pia-de-2018_acumulado_dadosestatisticos_especialistas.pdf
  » https://www.ordemenfermeiros.pt/media/11137/c%C3%B3pia-de-2018_acumulado_dadosestatisticos_especialistas.pdf
• 11. Calha A. O desenvolvimento de competências de literacia em saúde em contextos informais: potencialidades da utilização da narrativa autobiográfica na educação para a saúde. In: Actas - 3º Congreso Ibero-Americano en Investigación Cualitativa; Badajoz, España; 2014 jul 14-16. p. 139-43.
• 12. Teixeira AC, Sampaio F. Desenvolvimento de um catálogo CIPE® para o foco de enfermagem “autoestima”: uma scoping review. Rev Port Enferm Saúde Mental. 2019;21:62-71. doi: http://doi.org/10.19131/rpesm.0239
  » http://doi.org/10.19131/rpesm.0239
• 13. Bouvet R. The primacy of the patient's wishes in the medical decision-making procedure established by French law. Eur J Health Law. 2018;25(4):426-40. doi: https://doi.org/10.1163/15718093-12540384
  » https://doi.org/10.1163/15718093-12540384
• 14. Paiva A, Cardoso A, Sequeira C, Morais EJ, Bastos F, Pereira F, et al. Análise da parametrização nacional do Sistema de Apoio à Prática de Enfermagem - SAPE [Internet]. Porto: Escola Superior de Enfermagem do Porto; 2014 [cited 2021 Mar 01]. Available from: https://www.esenf.pt/fotos/editor2/i_d/publicacoes/apn-978-989-98443-5-3.pdf
  » https://www.esenf.pt/fotos/editor2/i_d/publicacoes/apn-978-989-98443-5-3.pdf
• 15. Lima AMN, Ferreira MSM, Martins MMFPS, Fernandes CS. Influência dos cuidados de enfermagem de reabilitação na recuperação da independência funcional do paciente. J Health NPEPS. 2019;4(2):28-43. doi: http://doi.org/10.30681/252610104062
  » http://doi.org/10.30681/252610104062
• 16. Nogueira LS, Sousa RMC, Guedes ES, Santos MA, Turrini RNT, Cruz DALM. Burnout and nursing work environment in public health institutions. Rev Bras Enferm. 2018;71(2):336-42. doi: https://doi.org/10.1590/0034-7167-2016-0524
  » https://doi.org/10.1590/0034-7167-2016-0524
• 17. Poeira AF, Nunes L, Cerqueira AF, Silva A, Lopes N. Dotações seguras na qualidade dos cuidados de enfermagem: revisão sistemática. Riase. 2018 [cited 2021 Mar 01];4(3):1604-17. Available from: https://comum.rcaap.pt/bitstream/10400.26/28171/1/327-1262-1-PB.pdf
  » https://comum.rcaap.pt/bitstream/10400.26/28171/1/327-1262-1-PB.pdf
• 18. Wegner W, Silva SC, Kantorski KJC, Predebon CM, Sanches MO, Pedro ENR. Education for culture of patient safety: Implications to professional training. Esc Anna Nery. 2016;20(3):e20160068. doi: https://doi.org/10.5935/1414-8145.20160068
  » https://doi.org/10.5935/1414-8145.20160068
• 19. Fernandes S, Tareco E. Sistemas de informação como indicadores de qualidade na saúde. Uma revisão de níveis de abordagem. RISTI. 2016;(19):32-45. doi: https://doi.org/10.17013/risti.19.32-45
  » https://doi.org/10.17013/risti.19.32-45
• 20. Oberstadt MCF, Esser P, Classen J, Mehnert A. Alleviation of psychological distress and the improvement of quality of life in patients with amyotrophic lateral sclerosis: adaptation of a short-term psychotherapeutic intervention. Front Neurol. 2018;9:231. doi: https://doi.org/10.3389/fneur.2018.00231
  » https://doi.org/10.3389/fneur.2018.00231

Edited by

Associate editor:

Carlise Rigon Dalla Nora

Editor-in-chief:

Maria da Graça Oliveira Crossetti

Publication Dates

• Publication in this collection
  23 May 2022
• Date of issue
  2022

History

• Received
  03 May 2021
• Accepted
  01 Sept 2021