Percepciones de los profesionales sobre la atención prestada, obstáculos y dilemas éticos relacionados con el final de la vida en hospitales, centros de Atención Primaria y residencias de ancianos / Perceptions of health care professionals about end-of-life care, obstacles and ethical dilemmas in hospitals, primary care and nursing homes

Fundamento: Este estudio compara la percepción de la práctica profesional, los obstáculos percibidos y los dilemas éticos de profesionales de medicina y enfermería en la atención al final de la vida en atención primaria (AP), atención hospitalaria (AH) y residencias de ancianos (RA). Material y Métodos: Estudio descriptivo, transversal y multicéntrico. Se realizó un muestreo intencional de profesionales de medicina y enfermería con más de cuatro meses de antigüedad de cuatro hospitales, cinco centros de AP y veintinueve RA de Granada. Se recogieron mediante un cuestionario ad hoc: la percepción de la práctica profesional en ocho dimensiones (estructura y procesos, aspectos físicos, psicológicos, sociales, espirituales, culturales, éticos y cuidados del moribundo), la frecuencia percibida de dilemas éticos, y los obstáculos para el cuidado. Se compararon las puntuaciones de los distintos contextos con la prueba ANOVA y análisis post hoc. Resultados: Participaron 378 profesionales, 215 (56,9%) de AH, 97 (25,7%) de AP y 66 (17,5%) de RA. En comparación a los profesionales de AP y AH, los de RA fueron significativamente (p <0,01) más jóvenes y con mayor experiencia profesional, y puntuaron significativamente mejor (p <0,01) tanto su propia práctica profesional como la de la institución en relación a las dimensiones de estructura y procesos de atención, aspectos físicos, psicológicos, sociales, espirituales, culturales y atención al moribundo. Los aspectos psicológicos y éticos fueron los peor valorados en todos los contextos, no encontrándose diferencias respecto a estos últimos. En comparación a los otros ámbitos estudiados, los profesionales de AP identificaron menos dilemas y los de RA percibieron mayores obstáculos. Conclusiones: Profesionales de AP y AH presentan resultados similares en la percepción de la atención al final de la vida, e inferiores a los de RA, pese a que en las RA se presentan más dilemas y obstáculos

Background: This study compares the perceptions of physicians and nurses regarding professional practice, perceived obstacles and ethical dilemmas in end-of-life care in primary care (PC), hospitals and nursing homes (NH). Methods: Descriptive, cross-sectional and multicentre study. Intentional sampling of physicians and nurses with more than four months professional practice from four hospitals, five PC centres and twenty-nine NH in Granada was carried out. An ad hoc questionnaire was developed to assess perception of professional practice in eight dimensions (structure and processes of care, physical, psychological, social, spiritual, cultural, ethical aspects and care for the dying), frequency of ethical dilemmas, and obstacles to optimum care. Scores of different settings were compared using the ANOVA test and post hoc analysis. Results: A total of 378 professionals participated, 215 (56.9%) from hospitals, 97 (25.7%) from PC and 66 (17.5%) from NH. NH professionals were older and had more professional experience than those from PC and hospitals, and they also rated both the institution and their own professional practice significantly better (p<0.01) than other professionals with respect to the dimensions of structure and processes of care, physical, psychological, social, spiritual, cultural aspects and care for the dying. Psychological and ethical aspects were the worst valued in all settings, with no differences regarding ethical aspects. Fewer ethical dilemmas were identified by PC professionals, while NH professionals perceived greater obstacles to end-of-life care in relation to other settings. Conclusion: Primary care and hospitalization presented similar results on the perception of end-of-life care, and lower results than those of nursing homes, although in these centres more ethical dilemmas and more obstacles were identified

[Perceptions of health care professionals about end-of-life care, obstacles and ethical dilemmas in hospitals, primary care and nursing homes.] / Percepciones de los profesionales sobre la atención prestada, obstáculos y dilemas éticos relacionados con el final de la vida en hospitales, centros de Atención Primaria y residencias de ancianos.

BACKGROUND: This study compares the perceptions of physicians and nurses regarding professional practice, perceived obstacles and ethical dilemmas in end-of-life care in primary care (PC), hospitals and nursing homes (NH). METHODS: Descriptive, cross-sectional and multicentre study. Intentional sampling of physicians and nurses with more than four months professional practice from four hospitals, five PC centres and twenty-nine NH in Granada was carried out. An ad hoc questionnaire was developed to assess perception of professional practice in eight dimensions (structure and processes of care, physical, psychological, social, spiritual, cultural, ethical aspects and care for the dying), frequency of ethical dilemmas, and obstacles to optimum care. Scores of different settings were compared using the ANOVA test and post hoc analysis. RESULTS: A total of 378 professionals participated, 215 (56.9%) from hospitals, 97 (25.7%) from PC and 66 (17.5%) from NH. NH professionals were older and had more professional experience than those from PC and hospitals, and they also rated both the institution and their own professional practice significantly better (p<0.01) than other professionals with respect to the dimensions of structure and processes of care, physical, psychological, social, spiritual, cultural aspects and care for the dying. Psychological and ethical aspects were the worst valued in all settings, with no differences regarding ethical aspects. Fewer ethical dilemmas were identified by PC professionals, while NH professionals perceived greater obstacles to end-of-life care in relation to other settings. CONCLUSION: Primary care and hospitalization presented similar results on the perception of end-of-life care, and lower results than those of nursing homes, although in these centres more ethical dilemmas and more obstacles were identified.

Relación entre autoconcepto físico, ansiedad e IMC en estudiantes universitarios mexicanos / The relation of physical self-concept, anxiety, and BMI among Mexican university students

El propósito de la investigación es conocer y relacionar los resultados del autoconcepto físico, con diferentes tipos de ansiedad y el IMC en los estudiantes de enfermería y educación física dela península de Yucatán (México). La muestra estuvo formada por 264 participantes, de los cuales 91 eran varones y 173 mujeres, con edades comprendidas entre 18 y 25 años. Nuestros datos revelan que en el autoconcepto físico, los valores obtenidos por los estudiantes de educación física son superiores al de los estudiantes de enfermería. Los estudiantes de enfermería presentan mayores valores de ansiedad estado que los de educación física. La percepción que tienen los estudiantes de ciclos superiores en prácticamente todas las dimensiones del autoconcepto es superior a la del alumnado de ciclos inferiores. Los niveles de ansiedad disminuyen conforme pasan de ciclos inferiores a superiores (AU)

The purpose of this paper is to know and relate the results of the various dimensions formed by the physical self-concept with respect to the different types of anxiety and the BMI among nursing and physical education students in the area of the Yucatán peninsula in Mexico. The study is based on a sample of 264 people, being 91 men and 173 women between the ages of 18 and 25. The outcome shows that the values obtained by physical education students are higher than those obtained by nursing students regarding the physical self-concept. Nursing students present a higher level of anxiety compared to physical education students. The perception showed by junior and senior students with regard to almost all dimensions of self-concept is higher than that of freshmen and sophomore students. Anxiety level among students decreases throughout the years (AU)

Influencia del ámbito, rural o urbano, en la percepción de los apoyos y las necesidades de las personas cuidadoras en el hospital / Influence of environment, rural or urban, in the perception of the supports and needs of caregivers in hospitals

Fundamento. Tras implementar un Plan Funcional con medidas de apoyo a personas cuidadoras en dos hospitales de Granada, se analizan la eficacia y el efecto del medio en la percepción y las necesidades de la persona cuidadora. Material y método. Se realizó un estudio cualitativo, fenomenológico, a través de entrevistas semi-estructuradas. Participaron 45 personas cuidadoras incluidas en el Plan Funcional. Se midieron además apoyo social percibido, función familiar y nivel de ansiedad mediante los cuestionarios Duke-unc, Apgar familiar y Escala de Goldberg, respectivamente. El análisis de los datos cualitativos se llevó a cabo mediante codificación abierta, axial y selectiva, y los cuestionarios mediante estadística descriptiva .Resultado. Las personas cuidadoras del ámbito urbano valoraron más los apoyos que les facilitaban la vida en el hospital y los apoyos sociales para el domicilio y las del ámbito rural los apoyos hospitalarios orientados a educación en cuidados para cuando estuviesen en su domicilio, todos ellos vinculados a la personalización de cuidados. Las alteraciones personales por el cuidado están presentes en ambos ámbitos aunque difieren en las repercusiones psíquicas y en el tipo de fármacos y su consumo. Existen diferencias en cuanto a los apoyos necesarios y las dificultades encontradas. Conclusiones. El ámbito donde habitualmente viven las personas cuidadoras condiciona sus percepciones del cuidado y algunas de sus necesidades en el hospital. Se deberán revisar las medidas del Plan Funcional cuestionadas, redefinir algunas prioridades e incluir medidas adicionales en función de la situación familiar de las personas cuidadoras (AU)

Background. After the Functional Plan was implemented with support measures for caregivers in hospitals of Granada (Spain), the effectiveness and impact of environment on the perception and needs of caregivers was analysed. Materials and methods. A qualitative, phenomenological study was made through semi-structured interviews. A total of 45 caregivers included in the Functional Plan participated. In addition, perceived social support, family functioning, and the anxiety level was measured, respectively, through the Duke-UNC, Apgar Family, and Goldberg Scale questionnaires. The data were qualitatively analysed by open, axial, and selective coding, and the questionnaires by descriptive statistics. Results. The caregivers of the urban setting valued more the support that made their life easier in the hospital and the social support at home, while caregivers in rural settings valued the hospital support oriented towards education in care for life after returning home, all linked to the personalization of care. The personal disturbances due to care occurred in all the settings, although differences appeared in psychic repercussions and in the type of drugs and their consumption. There were differences in terms of support needed and the difficulties encountered. Conclusions. The setting where caregivers live determine their perceptions of the care and some of their needs in the hospital. The measures questioned in the Functional Plan should be reviewed and some priorities should be redefined, including additional measures, depending on the family situation of the caregivers (AU)

Suffering indicators in terminally ill children from the parental perspective.

PURPOSE: Suffering is a complex multifaceted phenomenon, which has received limited attention in relation to children with terminal illness. As part of a wider study we interviewed parents of children with terminal illness to elicit their perspectives on suffering, in order to provide initial understanding from which to develop observational indicators and further research. METHODS: Qualitative descriptive study with semi-structured interviews made "ad hoc". Selection through deliberate sampling of mothers and fathers of hospitalised children (0-16 years old) with a terminal illness in Granada (Spain). KEY RESULTS: 13 parents were interviewed. They described children's suffering as manifested through sadness, apathy, and anger towards their parents and the professionals. The isolation from their natural environment, the uncertainty towards the future, and the anticipation of pain caused suffering in children. The pain is experienced as an assault that their parents allow to occur. CONCLUSIONS: The analysis of the interview with the parents about their perception of their ill children's suffering at the end of their lives is a valuable source of information to consider supportive interventions for children and parents in health care settings. An outline summary of the assessed aspects of suffering, the indicators and aspects for health professional consideration is proposed.

[Influence of rural or urban environment on perception of the supports and needs of caregivers in hospitals]. / Influencia del ámbito, rural o urbano, en la percepción de los apoyos y las necesidades de las personas cuidadoras en el hospital.

BACKGROUND: After the Functional Plan was implemented with support measures for caregivers in hospitals of Granada (Spain), the effectiveness and impact of environment on the perception and needs of caregivers was analysed. MATERIALS AND METHODS: A qualitative, phenomenological study was made through semi-structured interviews. A total of 45 caregivers included in the Functional Plan took part. In addition, perceived social support, family functioning, and anxiety level were measured, respectively, through the Duke-UNC, Apgar Family, and Goldberg Scale questionnaires. The data were qualitatively analysed by open, axial, and selective coding, and the questionnaires by descriptive statistics. RESULTS: The caregivers of the urban setting valued the support that made their life easier in hospital and the social support received at home more highly, while caregivers in rural settings valued hospital support oriented towards education in care for life after returning home, all linked to the personalization of care. Personal disturbances due to care occurred in all settings, although differences appeared in psychic repercussions and in the type of drugs and their consumption. There were differences in terms of support needed and the difficulties encountered. CONCLUSIONS: The setting where caregivers live determines their perceptions of care and some of their needs in the hospital. The measures questioned in the Functional Plan should be reviewed and some priorities should be redefined, including additional measures, depending on the family situation of the caregivers.

Influencia de la comunicación del diagnóstico y el pronóstico en el sufrimiento del enfermo terminal / No disponible

Objetivo: describir las características diferenciales entre los pacientes informados del diagnóstico o pronóstico y los que no lo están y establecer diferencias en la percepción del sufrimiento, utilizando el indicador percepción subjetiva del tiempo. Métodos: estudio observacional descriptivo con pacientes terminales de una Unidad de Cuidados Paliativos en Granada (España). Se administró un cuestionario elaborado ad hoc a 33 sujetos. Para medir el sufrimiento se utilizó el instrumento de percepción subjetiva del tiempo. Los motivos de la percepción del tiempo se analizaron cualitativamente mediante teoría fundamentada. Se midieron también indicadores de dolor y otros síntomas, ansiedad percibida por el paciente en sí mismo y en su familia, y comunicación con la familia y los profesionales sanitarios. Para el análisis cuantitativo se usó la prueba de Kruskall-Wallis y el paquete estadístico SPSS 15.0. Resultados: el 24,2% de los pacientes de la muestra estaban completamente informados. No existe relación estadísticamente significativa entre conocer el diagnóstico y la percepción del paso del tiempo. No se han encontrado diferencias estadísticamente significativas entre los grupos respecto a la ansiedad personal y familiar, a la comunicación con la familia ni a la comunicación con los profesionales. Los pacientes completamente informados (CI) suelen estar menos nerviosos que los no informados (NI) y los parcialmente informados (PI), y además es en este grupo (CI) donde se da un mayor porcentaje de pacientes que mantienen una comunicación fluida con los profesionales. El paso del tiempo "muy lento" está relacionado con el dolor grave o muy grave (p = 0,026) y con la ansiedad percibida (p = 0,002). En el análisis cualitativo destaca el aburrimiento y el entretenimiento como una variable relevante en el estudio del sufrimiento (AU)

Objective: to describe the differences between patients informed of their diagnosis or prognosis, and those not informed about it, and to establish differences regarding how patients perceive suffering. In order to do so, an indicator of subjective time perception will be used. Methods: a descriptive observational study carried out with terminally iII patients at one Palliative Care Unit in Granada (Spain); 33 individuals were provided with an ad hoc questionnaire. ln order to measure suffering an instrument on subjective time perception was used. The different ways of perceiving time were analyzed qualitatively through theory. Other indicators of suffering and other symptoms, anxiety of the patient and their families, and communication with the family and health professionals were measured. In order to carry out the quantitative analysis, the Kruskall-Wallis test and SPSS 15.0 version software were used. Results: 24.2% of sample patients were fully informed about diagnosis or prognosis. There was no significant relation between knowing a diagnosis and time perception. No significant differences were identified regarding personal and family anxiety, communication with the family or professionals. Fully informed patients tend to be less anxious than those not informed or partially informed. Besides, it is in the group of full informed patients where there is a higher percentage of patients having a good communication with professionals. Perceiving time "slowly" is related to serious or very serious pain (p =0.026) and the anxiety perceived (p = 0.002). In the qualitative analysis boredom and entertainment are relevant variables in the study of suffering (AU)

[Terminal illness. Death... in the words of professionals. A qualitative study based on in-depth interviews with health professionals]. / Enfermedad terminal, muerte... en palabras de los profesionales (y II). Un estudio cualitativo de entrevistas en profundidad a profesionales de la salud.

This article is the second part of an interesting qualitative research project which presents and interprets opinions made by diverse medical and nursing professionals regarding care provided to terminal patients and relationships with patients' relatives.

Condicionamientos de la sobreactuación terapéutica. Papel de la familia / No disponible

Objetivos: identificar dificultades y obstáculos de los profesionales médicos y enfermeros en relación con la sobreactuación terapéutica; explorar la diversidad de experiencias. Método: estudio cualitativo de tipo fenomenológico basado en entrevistas individuales a profesionales médicos y enfermeros que trabajan con enfermos terminales y familia, en hospitales y centros de salud de zonas urbanas y rurales de Granada y provincia, grabadas y transcritas, y asistidos en el análisis de la información por el software Atlas.tí, con una muestra de 42 entrevistas (20 médicos, 21 enfermeros y 1 psicólogo) sobre 48, y 6 rechazadas por no cumplir criterios de triangulación de la información. Resultados: aunque los profesionales son contrarios a alargar la agonía de los enfermos admiten que la presión que soportan de las familias les lleva a intervenir. Aparecen diferencias de posicionamiento y matiz entre profesionales en hospitales y en centros de salud, y entre profesionales médicos y enfermeros, sin embargo, para todos ellos, el trabajo con la familia es un problema. Conclusiones: desde la perspectiva del profesional, las demandas familiares condicionan la presencia de sobreactuación. Ausente la consideración de los deseos y opiniones de los pacientes en la toma de decisiones. Dificultades para reconocer la situación de enfermedad terminal y para transmitirla, así como identificar enfermo terminal y enfermo agónico explican comportamientos sobreactuantes. El trabajo con los familiares para acordar y consensuar medidas terapéuticas requiere un entorno de relación terapéutica que no se puede improvisar en el último momento (AU)

Objetive: to identify the difficulties and obstacles that professional doctors and nurses face in relation to therapeutic obstinacy. To explore experience diversity. Method: qualitative phenomenological research based on individual interviews (recorded and transcribed) to doctors and nurses working with terminally ill patients and their families in hospitals and health centers in the suburbs and rural areas of Granada and its province. The analysis of data has been supported by the Atlas.tí software. The sample consists of 48 interviews, 42 of them to 20 doctors, 21 nurses, and 1 psychologist; the remaining 6 were rejected because of unmet criteria for information triangulation. Results: despite the fact that professionals are opposed to prolonging the agony of patients, they recognize that pressure from family demands eventually leads them to intervene. Attitudes and stance show differences between professionals in hospitals and health centers, and between doctors and nurses. Nevertheless, working with patient families is a problem. Conclusions: from a professional’s point of view, family requests condition the presence of therapeutic obstinacy. Patient wishes and opinions are not considered when a decision is to be made. There are difficulties in recognizing and reporting on illness status, as well as difficulties in identifying a terminally ill patient from an agonizing one. These difficulties explain obstinate behaviors. Working with families to arrange for therapeutic decisions requires a therapeutic relationship environment, which cannot be improvised at the last minute (AU)

Variables del comportamiento en la anorexia infantil: propuesta de una escala de valoración / Variables in the behaviour of infant anorexia: Proposal for a scale of evaluations

Objetivo: Determinar los factores asociados conla anorexia infantil y construir un instrumento de valoraciónde fácil aplicación para su discriminación.Material y método: Se estudiaron 220 niños deedades entre 2 y 4 años, 30 con trastorno grave dela conducta alimentaria, 40 con trastorno leve y 150sanos. Se elaboró una escala compuesta por 91items agrupados en 16 subescalas, valorándoseconducta alimentaria y factores del comportamientodel niño, actitud de los padres ante la alimentacióndel niño y aspectos relacionales y emocionales entreambos.Resultados: La consistencia interna de las subescalasosciló entre 0,63 y 0,90, con unas correlacionesentre clases de 0,95-0,99. El análisis factorialeliminó 12 items; los 79 items restantes quedarondistribuidos en 27 nuevas subescalas, las cuales establecíandiferencias entre los tres grupos. Mediantela discriminación lineal de Fisher la escala quedó reducidaa 22 items, consiguiéndose un nivel muy altode clasificaciones correctas.Conclusión: Se propone una escala de fácil aplicaciónpara detectar precozmente la anorexia infantil

Objetive: To determine de factors related to infantanorexia, to construct an instrument of evaluationseasy to apply and which would facilitate the discriminationthereof.Material and method: 220 children between 2and 4 years were examined, 30 of which had seriousdisorder of eating habits, 40 with slight disorder and150 were completely sane. A scale composed of 91items was produced and assembled into 16 subscales,in which the following was evaluated: eating habits,factors in the behaviour of the child, parents´actitude towards the nourishment of the child andthe emotional aspects and relationship betweenboth.Results: The internal consistency on the subscalesranged from 0,63 to 0,90, with correlations betweenclasses of 0,95-0,99. The factorial analysis eliminated12 items, the remaining 79 items were distributedinto 27 new subscales, which set up the differencesbetween the groups. By means of Fisher´slineal discrimination, the scale was reduced to 22items obtaining thus a high level of correct classifications.Conclusion: A scale which is easy to apply is hereproposed in order to detect infant anorexia at anearly stage (AU)

Adherencia terapéutica en hipertensos. Estudio cualitativo / Treatment adherence of hypertensive patients: a qualitative study

La prevalencia de la hipertensión en España se sitúa en torno al 25% de la población adulta. Los profesionales de la salud disponen de un amplio arsenal terapéutico y conocen los criterios higiénico-dietéticos que mantendrían los niveles arteriales dentro de la normalidad. La falta de observancia de la pauta terapéutica es común en todo proceso crónico. En el caso de la hipertensión arterial las cifras de no cumplidores alcanzan límites realmente preocupantes, cerca del 40% para el tratamiento farmacológico y entre el 60-90% en las medidas higiénico-dietéticas. Por ahora, se sabe poco sobre las opiniones y expectativas que los pacientes tienen sobre la hipertensión y su tratamiento. Para tratar esta cuestión, hemos diseñado un estudio cualitativo basado en la técnica de los grupos focales. El objetivo ha sido identificar desde la perspectiva de los usuarios las dificultades del cumplimiento, así como los factores relacionados con este fenómeno. Constatamos la dificultad a la hora de seguir las prescripciones médicas, en gran medida porque no se sienten tratados de forma individualizada para establecer el tratamiento, las medidas adecuadas y el modo de llevarlo a cabo. Consideramos que es fundamental optimizar la relación del profesional de la salud con el paciente

The prevalence of hypertension among adults in Spain reaches around 25%. Health professionals have many therapeutic means at their disposal and know all hygienic and dietetic measures needed to keep arterial levels within normality. Non-adherence to therapy is a common observable fact in all chronic processes. Concerning arterial hypertension, non-adherence percentages reach alarming levels: nearly 40% non-adherence to drug treatment and between 60-90% non-adherence to hygienic and dietetic measures. So far, little is known about patients' expectations and opinions about hypertension and its treatment. To deal with this subject, a qualitative study was designed based on the focal groups' technique. The aim was to identify adherence difficulties according to patients, as well as other factors related to this phenomenon. We have detected treatment adherence difficulties, mainly due to a lack of individual treatments, measures and application methods. We believe it is essential for health professionals to optimize their relations with their patients

[Nursing, family, and terminally ill patients]. / Enfermería, familia y paciente terminal.

The authors publish data which refer to a study carried out on a sample of 350 nursing professionals in the Granada hospital network, subdivided into two groups: a risk group (GR) and a non-risk group (NR). The authors analyze the results obtained relative to the presence of stress in situations of agony and death, as well as the family as an object for professional treatment in both study groups.