NSG 6440 Family Health Discussions

NSG 6440 Family Health Discussions

NSG 6440 Family Health Discussions

NSG 6440 Family Health Discussions Week 1 discussion

Discussion Questions

The discussion assignment provides a forum for discussing relevant topics for this week based on the course competencies covered.

For this assignment, post a response to one question in the Discussion Area by the due date assigned. You may respond to your classmates’ postings for either question.

To support your work, use your course and text readings and also use the South University Online Library. As in all assignments, cite your sources in your work and provide references for the citations in APA format.

Start reviewing and responding to the postings of your classmates as early in the week as possible. Respond to at least two of your classmates’ initial postings. Participate in the discussion by asking a question, providing a statement of clarification, providing a point of view with a rationale, challenging an aspect of the discussion, or indicating a relationship between two or more lines of reasoning in the discussion. Cite sources in your responses to other classmates. Complete your participation for this assignment by the end of the week.

You are a Family Nurse Practitioner working in a community health center. You are seeing a 14-year-old adolescent patent for an annual visit. The patient’s mother is also present during the visit and notes that the patient’s grades in school have been declining. Her son is also hanging out with a group of kids that she has concerns about. The mother has concerns for what is going on with her son. Answer the following questions using course resources (texts) and two other evidence-based sources (current guidelines and/or scholarly articles that are within a 3-5 year time frame).

What are the components of an annual exam for an adolescent patient?

Is the mother required to be present during your exam?

Describe 1 health promotion idea that you would discuss with your middle adolescence patient. Why is this idea important?

What are some screening tools that might be of importance in this situation? (hint: do you suspect drug or alcohol abuse here?)

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NSG 6440 Family Health Discussions Week 2 discussion

A fifteen-year-old female presents to your clinic complaining of shortness of breath and a nonproductive nocturnal cough. She states she used to feel this way only with extreme exercise, but lately, she has felt this way continuously. She denies any other upper respiratory symptoms, chest pain, gastrointestinal symptoms, or urinary tract symptoms. Her past medical history is significant only for seasonal allergies, for which she takes a nasal steroid spray but is otherwise on no other medications. She has had no surgeries. Her mother has allergies and eczema, and her father has high blood pressure. She is the only child. She denies smoking and illegal drug use. On examination, she is in no acute distress and her vital signs are: T 98.6, BP 120/80, pulse 80, and respirations 20. Her head, eyes, ears, nose, and throat examinations are essentially normal. Inspection of her anterior and posterior chest shows no abnormalities. On auscultation of her chest, there is decreased air movement and high-pitched whistling on expiration in all lobes. Percussion reveals resonant lungs.

What is the chief complaint?

Based on the subjective and objective information provided what are your 3 top differential diagnosis listing the presumptive final diagnosis first?

What treatment plan would you consider utilizing current evidence based practice guidelines?

NSG 6440 Family Health DiscussionsWeek 3 discussion

In week 3 you learned about other common adolescent health conditions. Review the following case study and answer the following questions:

An 18 year old white female presents to your clinic today with a 2 week history of intermittent abdominal pain. She also is positive for periodic cramping and diarrhea as well as low grade fever. She also notes reduced appetite. She notes that She admits smoking ½ PPD for the last 2 years. Denies any illegal drug or alcohol use. Does note a positive history of Crohn’s Disease. Based on the information provided answer the following questions:

What are the top 3 differentials you would consider with the presumptive final diagnosis listed first?

What focused physical exam findings would be beneficial to know?

What diagnostic testing needs completed if any to confirm diagnosis?

Using evidence based treatment guidelines note a treatment plan.

NSG 6440 Family Health Discussions Week 4 discussion

Discussion

This week’s content addressed common chronic diseases. Please review the case study below and answer the following questions:

A sixty-year-old baker presents to your clinic, complaining of increasing shortness of breath and nonproductive cough over the last month. She feels like she can’t do as much activity as she used to do without becoming tired. She even has to sleep upright in her recliner at night to be able to breathe comfortably. She denies any chest pain, nausea, or sweating. Her past medical history is significant for high blood pressure and coronary artery disease. She had a hysterectomy in her 40s for heavy vaginal bleeding. She is married and is retiring from the local bakery soon. She denies any tobacco, alcohol, or drug use. Her mother died of a stroke, and her father died from prostate cancer. She denies any recent upper respiratory illness, and she has had no other symptoms. On examination, she is in no acute distress. Her blood pressure is 160/100, and her pulse is 100. She is afebrile, and her respiratory rate is 16. With auscultation, she has distant air sounds and she has late inspiratory crackles in both lower lobes. On cardiac examination, the S1 and S2 are distant and an S3 is heard over the apex.

What is the chief complaint?

Based on the subjective and objective information provided what are your 3 top differential diagnosis listing the presumptive final diagnosis first?

What treatment plan would you consider utilizing current evidence based practice guidelines?

Week 5 discussion

Discussion Questions

The discussion assignment provides a forum for discussing relevant topics for this week based on the course competencies covered.

For this assignment, go to the Discussion Area and post a response to one question in the Discussion Area by the due date assigned. You may respond to your classmates’ posts for either question.

To support your work, use your course and text readings and also use the South University Online Library. As in all assignments, cite your sources in your work and provide references for the citations in APA format.

Start reviewing and responding to the postings of your classmates as early in the week as possible. Respond to at least two of your classmates’ initial postings. Participate in the discussion by asking a question, providing a statement of clarification, providing a point of view with a rationale, challenging an aspect of the discussion, or indicating a relationship between two or more lines of reasoning in the discussion. Cite sources in your responses to other classmates. Complete your participation for this assignment by the end of the week.

As a family nurse practitioner you are working in a rural health clinic. You are evaluating a 16-year-old adolescent patient who comes in complaining of having a difficulty concentrating in school. On exam you also note that the patient is very thin and frail in appearance and is asking you for diet pills.

What are some initial areas for concern? What screening tools can help lead you closer to your diagnosis?

Describe 1 health promotion strategy you can discuss with the patient.

Be sure to address the following in your plan of care: pharmacological and non-pharmacological (OTC) interventions, labs, follow-up, teaching, and referral/s.

Your work should integrate course resources (text/s) as well as a minimum of two (2) other evidence-based guidelines and/or articles published within 3-5 years.

NSG 6440 Family Health Discussions Week 6 discussion

This week’s content discussed common psychiatric disorders in the Adult and Older Adult client. Often times a secondary diagnosis is masked due to their psychiatric disorder. Review the following case study and answer the following questions.

Mr. White is a 72-year-old man, with a history of hypertension, COPD and moderate dementia, who presents with 4 days of increased confusion, nighttime restlessness, visual hallucinations, and urinary incontinence. His physical exam is unremarkable except for tachypnea, a mildly enlarged prostate, inattentiveness, and a worsening of his MMSE score from a baseline of 18 to 12 today.

Mr. White’s presentation is most consistent with an acute delirium (acute change in cognition, perceptual derangement, waxing and waning consciousness, and inattention).

What is the most likely diagnosis to frequently cause acute delirium in patients with dementia?

What additional testing should you consider if any?

What are treatment options to consider with this patient?

Week 7 discussion

Assignment 1: Discussion

This week’s content addressed common techniques and testing that can be prescribed by the Nurse Practitioner. Review ONE of the following videos and post for the class what you have learned this week:

Watch the following video on suturing

Suture Skills Course – Learn Best Suture Techniques

Watch the following video on EKG rhythms

Skillstat

Submission Details:

Post your response to the Discussion Area by the due date assigned. Respond to atleast two posts by the end of the week.

Week 8 discussion

Complete The Growth and Development APEA module. Pick one of the following topics that were reviewed: Newborn assessment, Nutrition, Child, Adolescent, or Immunization. Please choose on that has not been previously covered by a peer.

What is an area that you may have forgotten?

Explain the specific growth and development concept in detail and describe strategies that you will undertake to assist in retaining that information?

Submission Details:

Post your response to the Discussion Area by the due date assigned. Respond to atleast two posts by the end of the week.

NSG 6440 Family Health Discussions Week 9 discussion

This week’s content will focus on health literacy which is a common barrier towards achieving optimal health care. Please review the following information from the Agency for Healthcare Research and Quality website https://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/literacy-toolkit/index.html Evaluate these tools to discover ways that will help reduce the barriers that hinder healthcare literacy

What are your initial thoughts after reviewing the AHRQ website?

What are some strategies you can incorporate in everyday practice to assist with health literacy?

Week 10 discussion

Evidence-Based Clinical Intervention

By the due date assigned, submit your Evidence-Based Clinical Intervention to the Discussion Area.

Your Evidence-Based Clinical Intervention should be submitted in a Microsoft Word document following APA style and should include the following:

The medical problem/diagnosis/disease.

Typical presenting signs and symptoms including:

Onset, Characteristics, Location, Radiation, Timing, Setting, Aggravating factors, Alleviating factors, Associated symptoms, Course since onset, Usual age group affected

Concomitant disease states associated with the diagnosis

The pathophysiology of the problem.

Three differential diagnoses and the usual presenting signs and symptoms in priority sequence with rationales.

Reference to at least two current journal articles that show evidence-based practice as how to best treat this disorder related to the primary differential.

The expected outcomes of the intervention.

Algorithms if available.

A typical clinical note in SOAP format.

Respond to at least two of your classmates’ Evidence-Based Clinical Interventions using the lessons and vocabulary found in the reading. Support your answers with examples and research. Your responses should clarify your understanding of the topic. They should be your own, original, and free from plagiarism. Follow the APA format for writing style, spelling and grammar, and citation of sources.

NSG 6440 Family Health Discussions Week 2 project 2

SOAP Note and CORE Entries

Each week, you are required to enter your patient encounters into CORE. Your faculty will be checking to ensure you are seeing the right number and mix of patients for a good learning experience. You will also need to include a minimum of one complete SOAP note using this template . The SOAP note should be related to the content covered in this week, and the completed note should be submitted to the Submissions Area. When submitting your note, be sure to include the reference number from CORE.

Submission Details:

By the end of the week enter your patient encounters into CORE and complete at least one SOAP note in the template provided.

Name your SOAP note document SU_NSG 6440_W2_SOAPLastName_FirstInitial.doc.

Include the reference number from CORE in your document.

Submit your document to the Submissions Area by the due date assigned

Week 4 project 2

SOAP Note and eMedley Entries

Each week, you are required to enter your patient encounters into CORE. Your faculty will be checking to ensure you are seeing the right number and mix of patients for a good learning experience. You will also need to include a minimum of one complete SOAP note using this template . The SOAP note should be related to the content covered in this week, and the completed note should be submitted to the Submission Area. When submitting your note, be sure to include the reference number from CORE.

Submission Details:

By the end of the week, enter your patient encounters into CORE and complete at least one SOAP note in the template provided.

Name your SOAP note document SU_NSG 6440_W4_SOAPLastName_FirstInitial.doc.

Include the reference number from CORE in your document.

Submit your document to the Submissions Area by the due date assigned.

NSG 6440 Family Health Discussions Week 6 project 3

SOAP Note and eMedley Entries

Each week, you are required to enter your patient encounters into CORE. Your faculty will be checking to ensure you are seeing the right number and mix of patients for a good learning experience. You will also need to include a minimum of one complete SOAP note using this template . The SOAP note should be related to the content covered in this week, and the completed note should be submitted to the Submissions Area. When submitting your note, be sure to include the reference number from CORE.

Submission Details:

By the end of the week, enter your patient encounters into CORE and complete at least one SOAP note in the template provided.

Name your SOAP note document SU_NSG 6440_W6_SOAPLastName_FirstInitial.doc.

Include the reference number from CORE in your document.

Submit your document to the Submissions Area by the due date assigned.

Week 8 project 3

SOAP Note and eMedley Entries

Each week, you are required to enter your patient encounters into CORE. Your faculty will be checking to ensure you are seeing the right number and mix of patients for a good learning experience. You will also need to include a minimum of one complete SOAP note using this template. The SOAP note should be related to the content covered in this week, and the completed note should be submitted to the Submissions Area. When submitting your note, be sure to include the reference number from CORE.

Submission Details:

By the due date assigned, enter your patient encounters into CORE and complete at least one SOAP note in the template provided.

Name your SOAP note document SU_NSG 6440_W8_SOAPLastName_FirstInitial.doc.

Include the reference number from CORE in your document.

Submit your document to the Submissions Area by the due date assigned.

NSG 6440 Family Health Discussions Week 10 project 3

SOAP Note and eMedley Entries

Each week, you are required to enter your patient encounters into CORE. Your faculty will be checking to ensure you are seeing the right number and mix of patients for a good learning experience. You will also need to include a minimum of one complete SOAP note using this template. The SOAP note should be related to the content covered in this week, and the completed note should be submitted to the Submissions Area. When submitting your note, be sure to include the reference number from CORE.

Submission Details:

By the end of the week, enter your patient encounters into CORE and complete at least one SOAP note in the template provided.

Name your SOAP note document SU_NSG 6440_W10_SOAPLastName_FirstInitial.doc.

Include the reference number from CORE in your document.

Submit your document to the Submissions Area by the due date assigned.

NSG 6440 Family Health Discussions Week 3 Midweek Assignment

Aquifer Case Study #1

For this assignment, you will complete a Aquifer case study based on the course objectives and weekly content. Aquifer cases emphasize core learning objectives for an evidence-based primary care curriculum. Throughout your nurse practitioner program, you will use the Aquifer case studies to promote the development of clinical reasoning through the use of ongoing assessment and diagnostic skills and to develop patient care plans that are grounded in the latest clinical guidelines and evidence-based practice.

After you complete the Aquifer case study for the week, please print out the summary of your case session and submit as a PDF file to the Submissions Area. Note that the summary of your case session has your name on the top right hand corner. You need to submit this document as evidence that you have completed the case.

The Aquifer assignments are highly interactive and a dynamic way to enhance your learning. Material from the Aquifer cases will be present in the weekly quizzes, midterm, and final exam. You must have all Aquifer assignments completed in order to successfully pass the course.

Use this link for information on how to access and navigate Aquifer.

This week complete the case entitled “Case #22: 70-year-old male with new-onset unilateral weakness – Mr. Wright.”

Submission Details:

Name your document SU_NSG 6440_W3_MidWeekProject_LastName_FirstInitial.pdf.

Submit your document to the Submissions Area by the due date assigned.

NSG 6440 Family Health Discussions Week 6 Project: Aquifer Case Study

For this assignment, you will complete a Aquifer case study based on the course objectives and weekly content. Aquifer cases emphasize core learning objectives for an evidence-based primary care curriculum. Throughout your nurse practitioner program, you will use the Aquifer case studies to promote the development of clinical reasoning through the use of ongoing assessment and diagnostic skills and to develop patient care plans that are grounded in the latest clinical guidelines and evidence-based practice.

After you complete the Aquifer case study for the week, please print out the summary of your case session and submit as a PDF file to the Submissions Area. Note that the summary of your case session has your name in the top-right corner. You need to submit this document as evidence that you have completed the case.

The Aquifer assignments are highly interactive and a dynamic way to enhance your learning. Material from the Aquifer cases will be present in the weekly quizzes, the midterm exam, and the final exam. You must have all Aquifer assignments completed in order to successfully pass the course.

Use this link for information on how to access and navigate Aquifer.

This week, complete the case entitled “Case #26: 55-year-old male with fatigue – Mr. Cunha.”

Submission Details:

Name your document SU_NSG 6440_W6_Project1_LastName_FirstInitial.pdf.

Submit your document to the Submissions Area by the due date assigned.

Week 8 Project

NSG 6440 Family Health Discussions Aquifer Case Study

For this assignment, you will complete a Aquifer case study based on the course objectives and weekly content. Aquifer cases emphasize core learning objectives for an evidence-based primary care curriculum. Throughout your nurse practitioner program, you will use the Aquifer case studies to promote the development of clinical reasoning through the use of ongoing assessment and diagnostic skills and to develop patient care plans that are grounded in the latest clinical guidelines and evidence-based practice.

After you complete the Aquifer case study for the week, please print out the summary of your case session and submit as a PDF file to the Submissions Area. Note that the summary of your case session has your name in the top-right corner. You need to submit this document as evidence that you have completed the case.

The Aquifer assignments are highly interactive and a dynamic way to enhance your learning. Material from the Aquifer cases will be present in the weekly quizzes, the midterm exam, and the final exam. You must have all Aquifer assignments completed in order to successfully pass the course.

Use this link for information on how to access and navigate Aquifer.

This week, complete the case entitled “Case #18: 24-year-old female with headaches – Ms. Payne.”

Submission Details:

Name your document SU_NSG 6440_W8_Project1_LastName_FirstInitial.pdf.

Submit your document to the Submissions Area by the due date assigned. NSG 6440 Family Health Discussions

Professional exhaustion, quality and intentions among family health nurses

INTRODUCTION

This study is based on the theoretical framework of environments favorable to nursing practice, elaborated by the International Council of Nurses and characterized by innovative political frameworks centered on recruitment and retention of nurses, training and promotion strategies, adequate compensation for nurses, recognition programs for the work conducted, sufficient equipment and materials, and a safe work environment.

The working environment of family health nurses does not always offer favorable conditions for nursing practice. The association between two models of assistance in primary health care (APS), a traditional one focused on biomedicine, and the other with focus on the family health strategy (ESF), imposed the extension of the intellectual dimensions of work, polyvalence, and multifunctionality of the worker, exemplified by the development of different skills and competences for the assessment of health needs of the individual, the family, and of collectivity, negotiations and decision-making in shared form(1).

In this scenario occurs increased physical and mental workload(2), in which new risks to health and worker safety, such as psychosocial risks, are added to those already existing in the working environment, with the potential to increase the prevalence of professional exhaustion, also referred to as burnout(3). This is an emerging public health concern with repercussions in various areas of knowledge, such as: human resources management in health, health services management, workers’ health, and social security. Professional exhaustion is a syndrome characterized by an increased frequency of feelings of emotional exhaustion and depersonalization, or of personal accomplishment reduced due to work(34). NSG 6440 Family Health Discussions

The complex reality these nurses face nowadays encourages critical thinking in relation to the organization of health work, health care of nurses, and nursing human resources, and allows for an approximation of countries from Latin America and the Caribbean regarding environment problems and nursing working conditions. Investigating this subject is a priority of the National Agenda of Priorities in Health Research in Brazil, Latin America and the Caribbean, with regard to the restructuring of health work and human resources in health(5).

The hypotheses of this study are as follows: professional exhaustion is present among family health nurses; the nurses have intention of leaving current work and even nursing; and that professional exhaustion correlates with a decrease in professional quality of care, intention of leaving current work, and nursing.

OBJECTIVE

To analyze how family health nurses assess quality of care, check if they have any intention of leaving their current job and nursing, estimate the prevalence of professional exhaustion, and analyze potential correlations among variables.

METHOD

Ethical aspects

This study was approved by the Research Ethics Committee of the School of Medical Sciences of the State University of Campinas, having generated a Certificate of Presentation for Ethical Consideration. All participants read and signed two copies of the Informed Consent Form.

Design, study site and period

This is an observational, cross-sectional and correlational study, guided by the initiative Strengthening the Reporting of Observatinal Studies in Epidemiology (Strobe) with regard to the communication of the research(6).

The study was conducted in Campinas, a large municipality in Brazil, considered a full manager of its municipal health system, and absorbing part of the demand of the region. Data collection was conducted in the second half of 2012.

Population, inclusion and exclusion criteria

The study population was defined from a list of 287 primary health care nurses, and 266 professionals were found. The following was considered as inclusion criterion: exercising nurse professional activity in one of the family health units that have a family health team; and the following as exclusion criteria: being absent from work, or being on license or vacation at the time of data collection. According to the eligibility criteria, 198 nurses accepted participating in the voluntary survey.

Study protocol

The instrument for data collection used to characterize nurses consisted of two parts: the first with questions related to personal and professional data; and the second with questions for assessing general perceptions about quality of care, sufficiency in the number of professionals and resources available for work, and questions to assess the intentions of leaving current work(710) and leaving nursing(7,912).

The perception of quality of care was assessed using a question with Likert type scale and the following score: 1 (very bad), 2 (bad), 3 (good), and 4 (very good)(7). The sufficiency of professionals and material resources was evaluated by questions with dichotomous variables (yes, no).

Intention of leaving current work was examined by means of a question (“Put a mark along the line at the point that best describes your intention of leaving your current work in the next 12 months”), and the intention of leaving the nursing profession was examined by another question (“Put a mark along the line at the point that best describes your intention of leaving nursing in the next 12 months”). Both should be answered in visual analog scale from 0 (none) to 100 mm (a lot)(7). These variables were considered outcome variables(6) with regard to professional exhaustion in this research, as well as the quality of care.

The prevalence of professional exhaustion among professional nurses was assessed using the Maslach Burnout Inventory (MBI), a specific version for health professionals, validated in Brazil by Tamayo in 1997 and used among hospital nurses(7). The instrument measures the frequency of feelings expressing three dimensions of the syndrome: emotional exhaustion, depersonalization and reduction in personal accomplishment(4,7), considered predictors(6) of the intention of leaving current work and nursing, and of the quality of care in this research. Its measurement scale is of Likert type, with the following score: (1) never, (2) rarely, (3) sometimes, (4) frequently, and (5) always(7). The higher the score, the higher the frequency of feelings of emotional exhaustion, depersonalization or personal accomplishment(4).

Analysis of results and statistics

To decrease potential biases, of the 198 nurses who agreed to voluntarily participate in the survey, the instruments that were not completely filled with 30 professionals were excluded, which resulted in 168 eligible participants(6), composing the sample. This number was a calculation basis for the tertile of each of the MBI subscales. There is no consensus in the literature on the analysis and interpretation of the MBI. In this research, high levels of emotional exhaustion or depersonalization (third tertile), or low levels of professional accomplishment (first tertile), were considered professional exhaustion according to the criteria by Grunfeld et al(4). NSG 6440 Family Health Discussions

Not all survey respondents answered the questions corresponding to the variables: time since graduated, weekly work hours, intention of leaving current work, and intention of leaving nursing. The number of participants analyzed(6) for each of these variables is presented in Table 3. The participants refused to answer the items in the MBI and correlated variables were excluded from correlational analyses, and the number of respondents is shown in Table 5.

Table 1 Personal and professional characteristics of family health nurses, Campinas, São Paulo, Brazil, 2012 (N=198) 

Variable n* %
Sex
Female 175 88.38
Male 23 11.62
Marital status
Single 90 45.45
Married 84 42.42
Divorced or widowed 21 10.61
No information 3 1.52
Specialization Graduate Course
Public Health 117 59.10
Other fields 39 19.70
Does not have 41 20.70
No information 1 0.50
Graduated more than once
Yes 17 8.59
No 181 91.41
Employment Relationship
Under Public Workers’ Statue 191 96.46
Under CLT Regime 3 1.52
No information 4 2.02
Has another employment relationship
Yes 19 9.60
No 177 89.39
No information 2 1.01
Work shift
Morning, afternoon or night 109 55.05
Mixed 83 41.92
No information 6 3.03

Note:

*number of nurses;

Consolidation of Labor Laws.

Table 2 Perceptions of family health nurses, Campinas, São Paulo, Brazil, 2012 (N=198) 

Variable n* %
Perception of quality of care
Very bad 1 0.50
Bad 26 13.13
Good 154 77.78
Very good 14 7.07
No information 3 1.52
Adequate number of professionals
Yes 34 17.17
No 162 81.82
No information 2 1.01
Adequate resources
Yes 10 5.05
No 187 94.44
No information 1 0.51

Note:

*number of nurses.

Table 3 Descriptive measures of time since graduated, weekly work hours, intention of leaving current work, and intention of leaving nursing, among primary health care nurses, Campinas, São Paulo, Brazil, 2012 

Variable n* Mean Standard Deviation Minimum Median Maximum
Time since graduated (years) 165 10.61 9.11 2.00 6.00 35.00
Weekly working hours 191 38.27 7.97 30.00 36.00 88.00
Intention of leaving current job (mm) 186 28.40 33.30 0.00 10.50 100.00
Intention of leaving nursing (mm) 190 14.90 27.00 0.00 0.00 100.00

Note:

*number of nurses analyzed.

Table 4 Level ranges of the dimensions of burnout syndrome, according to the Maslach Burnout Inventory subscales, among nurses in primary health care, according to the cut-off points obtained from the tertile, Campinas, São Paulo, Brazil, 2012 (N=168) 

Maslach Burnout Inventory subscale Low Moderate High
Emotional exhaustion ≤22 23-27 ≥28
Depersonalization ≤7 8-10 ≥11
Personal accomplishment ≤29 30-32 ≥33

Table 5 Spearman’s correlation coefficient between the Maslach Burnout Inventory subscales and the variables: quality of care, intention of leaving current work and intention of leaving nursing among primary health care nurses, Campinas, São Paulo, Brazil, 2012 

Maslach Burnout Inventory subscales Quality of care (n*=165) Intention of leaving current job (n*=162) Intention of leaving nursing (n*=164)
Emotional exhaustion 0.13 0.34 0.28
Depersonalization 0.23 0.11 0.10
Personal accomplishment 0.32 0.17 0.12

Note:

*number of nurses analyzed;

p-value<0.05;

p-value<0.01

The data were typed in Excel spreadsheet, double checked, and imported into the software Statistical Analysis System (SAS) version 9.2 for analysis. Combined averages of the MBI subscales were obtained in order to be correlated with the average of the variables: quality of care, intention of leaving current work, and intention of leaving nursing, as conducted by other authors(7). For the correlation analysis between variables, we used Spearman’s rank correlation coefficient, and p≤0.05. The reliability of the MBI subscales were tested through the criterion of internal consistency, and measured using Cronbach’s alpha coefficient, where values higher than 0.60 were considered acceptable.

RESULTS

Table 1 presents personal and professional characteristics of the family health nurses. Most subjects in this research are women, single, with graduate studies in collective health, under the public workers’ statute, and concentrating their work in one shift (Table 1).

Table 2 presents the nurses’ perceptions on the quality of care and sufficiency of the amount of professionals and resources available for work. Most participants perceive quality of care as good and consider the number of professionals and resources available as inadequate (Table 2).

Table 3 presents descriptive measures of the variables: time since graduated, weekly work hours, intention of leaving current work, and intention of leaving nursing. The average weekly working hours is of 38.27, and there is intention of leaving current work and leaving nursing as well (Table 3).

In Table 4 are described the cut-off points obtained from the tertile, according to the distribution of scores attributed by the nurses to each of the MBI subscales. NSG 6440 Family Health Discussions

Considering the cut-off points obtained (Table 4), 28.0% of the family health nurses showed high scores for emotional exhaustion, 32.1% for depersonalization, and 38.7% showed low scores for personal accomplishment, which configures professional exhaustion. It was found that 37.5% of the nurses showed moderate scores for emotional exhaustion, 33.9% for depersonalization and 33.3% for personal accomplishment. It was found that 34.5% of the nurses showed low scores for emotional exhaustion, 33.9% for depersonalization, and 28% displayed high scores for personal accomplishment. In relation to the internal consistency of the MBI, Cronbach’s alpha coefficient resulted in 0.86 for emotional exhaustion, 0.66 for depersonalization and 0.72 for personal accomplishment.

The correlations between MBI subscales were analyzed by comparing them to the variables: quality of care, intention of leaving current work, and intention of leaving nursing. The correlations are presented in Table 5. It is worth highlighting the presence of five significant correlations, with moderate and low magnitudes (Table 5).

DISCUSSION

The equivalent proportion of nine female nurses for every male nurse (Table 1) highlighted the intense feminization of the profession(13). The predominance of singles in the sample (Table 1) probably decreased the impact of conflict experiences arising from professional responsibilities and reference to the collective in relation to economic and emotional responsibilities of married professionals who have children on the family group(1415).

Most participants were affiliated with the city prefecture by Public Workers’ Statute, having been approved by public sector recruitment on the basis of examinations and degrees for receiving a position, and also had access to a Specialization Graduate Course in the field of Public Health (Table 1). Interestingly, 8.6% of nurses were graduated in more than one field (Table 1), pointing to the duplicity of professional formation in part of the family health nurses. The average “time since graduated” of participants was of 10.6 years (Table 3), with variation from 2 to 35 years, which indicated the coexistence of different generations of nurses in the practice of nursing within the family health strategy.

In the municipality studied, the work shift could be mixed, with lunch break, but most nurses predominantly concentrated their daily journey in one shift (Table 1). Although it was observed that most participants had only one employment relationship (Table 1), which is desirable considering the construction of the bond with the collective and the recognition of the nursing work environment as stressful, it was found that the average weekly work hours, including other possible employment relationships, was superior to the 30 hours per week (Table 3) historically desired by nursing professionals.

One study showed that, in order to tolerate excess work hours over time, professionals often register their presence in the workplace without showing good performance during the whole period because they were emotionally exhausted and unmotivated, configuring presenteeism(16). As this phenomenon occurs, it impacts on quality of care and represents an important challenge for managers of health services and health human resources.

In this research, 86.15% of family health nurses assessed the quality of care as good or very good, and 13.84% assessed it as bad or very bad (Table 2). On the other hand, most of the family health nurses considered the number of professionals and resources available for conduction of care as inadequate (Table 2). It is important to consider that the perception of quality of care in primary health care brings with it an enormous degree of subjectivity and depends on the conception of the health care model in APS adopted in the municipality, which is limited by the structure of the health service and the financing available and managed at local level.

In relation to the care model, Mendes explains there are different decoding of APS to be considered: (1) as a selective primary care offered to poor people in poor regions, to whom is exclusively offered a set of low-cost technologies without the possibility of referrals and care levels of higher technological density; (2) as a primary level of access to the health system, emphasizing the way of organizing the entryway so that it meets the demands of the population for the most common health problems and minimizes economic costs; (3) as a an organization strategy of the health care system in the Health Care Network (RAS) and a way of organizing all of the system resources in order to satisfy the demands of the population(17).

Regarding the perception of quality of care, the expression is associated to security aspects of attendance, quantity and qualification of professionals, ambience wherein care is conducted. In this study, as most nurses assessed human and material resources as inadequate and still considered the quality of care as good and very good (Table 2), we can infer that assessment of the APS was based on the recognition of the model of primary care as selective, requiring fewer professionals and fewer resources(17). NSG 6440 Family Health Discussions

Although the new Brazilian National Primary Health Care Policy has established criteria for the organization of work processes in the APS with emphasis on ESF, according to Mendes, innovation is far from effectively being consolidated in practice, as structural conditions were not provided in order for that to happen, and cultural, technical and operational aspects from the conceptions of selective APS and APS as primary level of access still get merged with hazy distinctions(17). On the other hand, the achievements obtained in health are not cumulative nor permanent, since according to the political decisions adopted in the three levels of government, what was already achieved always has the risk of being lost.

This study witnessed intention of leaving the job among family health nurses, whose average obtained was of 28.40 mm in the visual analog scale from 0 to 100 mm (Table 3). This was higher than the average found among intensive therapy nurses(7). The compared result suggests that dissatisfaction with the professional practice environment is higher among ESF nurses than among nurses who work in intensive therapy environments. This evidence can be associated with the distribution of resources in the public health system, whose priority in a situation of insufficient funding is in general directed to tertiary health care, which includes intensive therapy services with focus on diagnostic technology and treatment of diseases, thereby reducing resources for primary health care.

Although there is a consensus that APS has the potential to solve 80% or more of the health problems of the population, this resolution is not effective in the conservative practice of primary care, and obscures its complexity in relation to care and management strategies for solving health problems(17), impairing the overcoming of selective APS practice.

To tolerate the risks of work situations, as in the case of a primary care environment turned precarious, professionals often use the strategy of denying or trivializing these risks due to fear of unemployment or being disqualified and having their professional development or functional trajectory harmed, compromising the moral integrity of these professionals(18). In this situation, when exposure to health risks and the uncertainty present in the working environment come to the mind of the nurse, the intention of leaving current work comes as well.

According to Fertonani et al., when considering the different understandings about the health care model, in reality persists the model focused on treating diseases, from biologic body care, in detriment of the model that emphasizes integrality(19). In addition, deficits in the formation of family health teams and the precariousness of the work relations and conditions(19) consolidate the practice of selective primary care(17). In this context, nurses’ frustation can intensify, increasing their negative perception of the professional environment, decreasing their professional performance and increasing their intention of leaving current work(9), this being considered a strong predictor of staff turnover(10).

A study with ESF professionals highlights employment turning precarious and poor working conditions as the main causes of turnover(9). Individually, turnover is harmful to workers’ health due to increased workload for those who continue exercising their professional practice in the institution, as they are usually forced to increase work-pace in order to maintain the previous productivity levels, adapt to longer week hours and, occasionally, being entrusted to the supervision of new workers(12).

In relation to the health team, turnover can result in loss of team cohesion and familiarity between its members and lead to episodes of intolerance and aggression against supervisors, subordinates and peers, where this deterioration in organizational environment may become a reason for future abandonment of the profession(11). High levels of staff turnover at institutional level generally implies reduction in the quality of healthcare service and involves problems of organization as well as direct and indirect costs(9), causing damage to the institution’s image(20), hindering the organization of the APS in RAS(17).

This study also highlighted the intention of leaving nursing (Table 3), with a value that is close to that found among intensive care nurses(7). The reason considered the most relevant for the intention of abandoning nursing is discontent with the working atmosphere(12). The studies cited and the findings of this research show that the negative perception of the professional practice environment is associated with dissatisfaction, future prospects of abandoning the profession, and can be considered an indicator that anticipates the leaving, as studied in countries that describe the shortage of professionals in the work market(8). NSG 6440 Family Health Discussions

Regarding MBI usage, Cronbach’s alpha values indicated that the three subscales showed internal consistency in the work locus of family health nurses. According to the criteria by Grunfeld et al., in this study, 28 to 38.7% of these nurses experienced professional exhaustion. The estimate of burnout prevalence deserves visibility and confrontation, and can contribute to the construction of indicators for quality of service and life of workers.

Significant correlation between emotional exhaustion and intention to leave the current job was witnessed, corroborating results already seen between primary care(20) and intensive care professionals(7). It was also evidenced significant correlation between emotional exhaustion and intention of leaving nursing. Hence, emotional exhaustion can be pointed as a predictor of intention of leaving nursing in this study. In the scenario of resistance and consolidation of SUS, researchers and managers must worry about ways to prevent nurses from abandoning their profession, as they are professionals with the skills and abilities that are desirable for conducting this health policy.

Two other significant correlations observed (Table 5) highlighted the reduction of personal accomplishment as a predictor of decreased quality of care and of the intention to leave the current job. Depersonalization was singled out as the only predictor of the intention of leaving the current job. Evidences of professional exhaustion among family health nurses help explain problems related to quality of care, the care model(17,19), presenteeism(16) and staff turnover(9).

It is advisable to perform permanent education and stimulate the recognition of existing health care models and care models that are to be constructed(19), in order to scale the number of professionals to the real population connected to the health unit. It is imperative that political participation of nurses be encouraged, in order to contribute for the identification and transformation of the structures that prevent SUS of being effectively conducted. Political omission can mean maintaining a non-desirable situation, the loss of what has already been achieved, and the impracticality of SUS to future generations. As recognizes the Brazilian Nursing Association (ABEn): health is democracy, and vice versa. Democracy requires political participation of all social groups, especially women.

Study limitations

Regarding study limitations, the absence of family health nurses not under Public Workers’ Statute, hired for a set time, with effective perspective of extinction of the work contract in the short-term, was considered a potential selection bias(6). It is noteworthy that data collection was conducted in a context of political instability in the municipality, which had successive depositions of mayors in 2012, which influenced negatively in the adhesion of these nurses to participating in the research.

Contributions to the field of Nursing

This research contributes to the science of nursing by providing information to support interventions in the environment of professional practice and for the construction of evaluation indicators of health services and human resources in nursing.

CONCLUSION

This study observed that the majority of family health nurses are female, assess the quality of work as good at the same time they recognize the inadequacy of human and material resources, pointing to the practice of a predominantly selective model of primary health care. Family health nurses experience the syndrome of professional exhaustion, which in this study was considered as a predictor of decreased quality of care, intention of leaving the current job, and intention of leaving nursing. Despite the limitations described, the hypotheses of this investigation were confirmed and the study denounces negative aspects of the work environment of family health nurses in the scenario studied, allowing comparison with other municipalities in similar situations, including other countries of Latin America and the Caribbean. NSG 6440 Family Health Discussions