quinta-feira, 11 de dezembro de 2008

Enfermeiro de Familia

Posted on 22:26 by oncare

Os Cuidados de Saúde Primários são uma área privilegiada para o exercício da autonomia dos
enfermeiros, e, por estarem mais perto da população podem promover mais facilmente a
visibilidade dos trabalho dos enfermeiros.


“Família refere-se a dois ou mais indivíduos, que dependem um do outro para dar apoio emocional, físico e económico. Os membros da família são autodefinidos”.

(HANSON, 2005)

Home visit protocol (more)

The home visits can be described as "systematic home visits to elderly people with health problems carried out by a home nurse". The 3 most important elements of the visits are to detect problems or risks, to give advice and to refer to other professional or community services. This brief description is applicable to all home visiting studies that have been carried out so far. However, there are large differences in the protocols that have been used in earlier studies, ranging from an interview to collect information on social and health conditions to a 'multidimensional geriatric assessment' in which medical, functional, psychosocial, and environmental evaluation of the problems and resources are assessed .Earlier studies did not show any clear relation between the structure of the visits and the effects. So far, the active components of the intervention are not known yet, but a number of elements seems to be of importance for the contents of the visits. We tried as much as possible to include these elements into the protocol: e.g., face-to-face assessment, good communication between the nurse and the elderly including an empathic attitude by the nurse, an individual plan, a client-centred approach, good compliance with the given advice and multiple visits .
The visits are carried out in a systematic way according to a nursing model that distinguishes 4 steps: diagnosis, planning of activities, carrying out the activities and evaluation.


Our starting-point is a client-centred approach. The elderly can indicate which problems they experience and which needs they have. The EasyCare Questionnaire an elderly assessment system, is used to detect further problems. Also, additional checklists are used on a variety of topics: e.g., vision, hearing and use of medication. A number of instruments are used for further diagnostic assessment: the get-up-and-go test the Geriatric Depression Scale [23] and the Mini Mental State .During the visits no physical examination takes place, as the home nurses are not qualified to do so. If necessary, the elderly are referred to their GPs.

Planning of activities.

An individual plan for each elderly person is set up. The activities are planned in agreement with the elderly, as this will improve compliance. We only included elderly with a poor (perceived) health, hence a broad range of problems can come forward, including physical, mental as well as social problems. Guidelines on a number of geriatric topics are used for advice and referral regarding problems and risks that are identified. A Handbook of Nursing Diagnosis is also used to set up goals and interventions. A maximum of three problems (and 2 interventions per problem) is being dealt with at one visit. Among the planned activities are referrals to professional or community services, and advice or information is given regarding, e.g., nutrition, social and physical activities and home aids.

Carrying out the activities.

The elderly are primarily themselves responsible to carry out the planned activities. The home nurse only supports the elderly. In order to improve compliance, the nurses contact the elderly by telephone 1 to 4 weeks after each visit, depending on the type of advice. They ask whether the advice has been followed, and if not, what the impediments are and if further assistance is necessary. The participants are offered consultation with the nurses by telephone each morning between 9.00 – 9.30 hours.


The evaluation of each home visit takes place at the next visit. The cycle is then repeated and new or old, but not solved, problems can be dealt with.
In the 3-months period before the start of the visits, the home nurses were actively involved in the development of the visiting protocol. They also received relevant training in communication skills and using assessment tools. They took courses on several subjects, e.g., relevant geriatric health topics, behaviour change and the usage of the Handbook of Nursing Diagnosis. Several pilot visits were carried out, in which different aspects of the protocol were trained, e.g., using assessment tools and measuring instruments.
Communication between the nurses and the GPs is according to the 'normal' communication lines between nurses of the home care organisations and the GPs. Before the start of the study all GPs received a list of eligible participants registered at their practice, to screen very ill persons. After randomisation a definite list of participants was sent to them, but no reference was made to which treatment group they belong. The allocation of the participants to the 2 groups was disclosed after conclusion of the first 3 home visits. The GPs then received an overview of all treated problems for each participant in the intervention group, including the accompanying recommendations and the results of the interventions. The GPs were asked for their comments or suggestions and in this way they could become involved, if they wanted to. A similar overview will be sent to them for visits 4–6 and 7–8.

Process evaluationAll elements of the intervention are monitored as part of a process evaluation.

This includes the registration of topics discussed at each visit, treated problems, advice given and referral to other services. The evaluation of each visit is registered at each next visit and includes the compliance with the given advice. Reasons for non-compliance are noted. The nurses' experiences with the visiting protocol, the role of the supervising public health nurse and the patient's experiences with the home visits will be assessed at the end of the intervention period by means of face-to-face-interviews.
Other aspects of the intervention process assessed are: the time spent on the visits, including the travelling and preparation time and the time spent on telephone contacts. Elements of the telephone conversation after each visit, most importantly whether the elderly complied with the given advice, are registered.
Detailed analyses of the intervention process and outcome data might help to identify which programme characteristics are related to possible favourable effects of the visits and may result in the development of more effective interventions. It might also provide additional information for the possible implementation of the visits in daily practice.
Outcome measuresThe primary health related outcome measures are: self-rated health, functional status, quality of life and changes in self-reported problems. In addition, a variety of other health measures (secondary outcome measures) will be assessed. Information will be obtained, among other things, on health complaints, medication use, and loneliness and mental health. The municipality will supply mortality data (secondary outcome measure) over the entire research period.
The use of services relates to the frequency and duration of care from the following services: domestic and community nursing care, GP, physiotherapy, day care in institutional care settings, hospital outpatient clinics, hospital, nursing home, home for the elderly, use of aids and modifications to the home. The primary outcomes for service use are specialist medical care and hospital (re-) admission. The health insurance companies will supply data on the use of services over the two-year research period. Additional data not covered by the health insurance companies, will be supplied by GPs, the hospital, the home care organisations, etc. Table 3 shows an overview of the outcome measures, their operationalisation and at which time points the measures are carried out.

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