Promoção da saúde do trabalhador e humanização no trabalho: relato das atividades realizadas na atenção primária e secundária / Promotion of worker's health and humanization at work: report of activities performed in primary and secondary care

Os objetivos deste estudo são: relatar a experiência do desenvolvimento das atividades de sensibilização dos trabalhadores relacionadas à promoção da saúde no ambiente laboral e à humanização no trabalho realizadas em dois serviços de saúde de um município do estado de Minas Gerais e avaliar junto à equipe a realização dessas atividades. As atividades de alongamento, massagens, escalda-pés, dinâmica de grupo e oficina da beleza foram realizadas na atenção primária e secundária. Utilizou-se um questionário e as respostas foram apresentadas por estatística simples. Os trabalhadores avaliaram as atividades como "excelentes"; referiram melhorar o dia de trabalho; sentiram-se valorizados e mais dispostos para o trabalho, além de solicitarem a continuidade de ações de promoção da saúde e humanização no trabalho. Por mais simples que sejam, essas atividades proporcionaram momentos de reflexões e a pausa laboral, tendo em vista a saúde do trabalhador e melhor qualidade de vida no trabalho.

The objectives of this study are: to report the experience of developing awareness activities for workers related to health promotion and humanization at work, carried out in two health services in a municipality in the state of Minas Gerais; and assess with the team these activities. Stretching activities, group dynamics, massages, foot baths, beauty workshop and health promotion were carried out in primary and secondary care. A questionnaire was used and the answers were presented by simple statistics. The workers rated the activities as "excellent"; reported improving their working day; they felt valued and more willing to work, in addition to requesting the continuity of actions to promote health and humanization at work. As simple as they are, these activities provided moments of reflection and a break from work, with a view to the worker's health and better quality of life at work.

Clinicians' perspectives on decision making in lower limb amputee rehabilitation.

OBJECTIVE: Decision making within amputee rehabilitation includes the assessment of whether a patient is suitable for a prosthesis and if so, what components to provide. This study seeks to increase understanding about clinicians' perspectives on what factors influence these decisions. METHOD: One-to-one semi-structured interviews were completed with 23 experienced clinicians at their place of work at 4 UK amputee rehabilitation centres. Thematic analysis using a theoretical, semantic approach was used to identify key themes from the data. RESULTS: Four key themes were identified: estimating outcome; difficulties predicting outcome; patient choice and barriers to prescribing. There was variation in the importance placed on each theme between individual clinicians and services, with factors such as budget and risk aversion acting as barriers to prescribing. Only one of the 4 centres used formal prescribing guidelines. CONCLUSION: The results highlight the difficulties clinicians experience in estimating outcome and suggest inequity of prosthetic provision in the UK, with variation in the provision of high cost items. The development of national prescription guidelines is suggested to improve equality of prosthetic provision.

Transcutaneous electrical nerve stimulation for phantom pain and stump pain in adult amputees.

Following amputation, 50% to 90% of individuals experience phantom and/or stump pain. Transcutaneous electrical nerve stimulation (TENS) may prove to be a useful adjunct analgesic intervention, although a recent systematic review was unable to judge effectiveness owing to lack of quality evidence. The aim of this pilot study was to gather data on the effect of TENS on phantom pain and stump pain at rest and on movement. Ten individuals with a transtibial amputation and persistent moderate-to-severe phantom and/or stump pain were recruited. Inclusion criteria was a baseline pain score of ≥3 using 0 to 10 numerical rating scale (NRS). TENS was applied for 60 minutes to generate a strong but comfortable TENS sensation at the site of stump pain or projected into the site of phantom pain. Outcomes at rest and on movement before and during TENS at 30 minutes and 60 minutes were changes in the intensities of pain, nonpainful phantom sensation, and prosthesis embodiment. Mean (SD) pain intensity scores were reduced by 1.8 (1.6) at rest (P < 0.05) and 3.9 (1.9) on movement (P < 0.05) after 60 minutes of TENS. For five participants, it was possible to project TENS sensation into the phantom limb by placing the electrodes over transected afferent nerves. Nonpainful phantom sensations and prosthesis embodiment remained unchanged. This study has demonstrated that TENS has potential for reducing phantom pain and stump pain at rest and on movement. Projecting TENS sensation into the phantom limb might facilitate perceptual embodiment of prosthetic limbs. The findings support the delivery of a feasibility trial.

Can simple clinical tests predict walking ability after prosthetic rehabilitation?

OBJECTIVE: To investigate whether simple clinical measures can predict walking ability after lower limb prosthetic rehabilitation. DESIGN: Prospective observational study. SUBJECTS: Ninety five adults who were assessed as suitable for lower limb prosthetic rehabilitation by the multidisciplinary team. METHODS: Information regarding baseline clinical factors (amputation details, comorbidities, physical ability, mood and cognitive ability) was collected prior to provision of the prosthesis. Backward step linear regression was used to identify factors predictive of performance on the Timed Up and Go test following rehabilitation. RESULTS: Seventy one participants were able to complete this walking test and were included in the final analysis. The backward step regression model had an adjusted R2 of 0.588 and comprised 6 factors: age (p = 0.002), gender (p = 0.027), level of amputation (p = 0.000), presence of contracture (p = 0.088), ability to stand on one leg (p = 0.062) and Trail Making Tests A + B (p = 0.047), a test of cognitive flexibility. Cause of amputation (dysvascular or non-dysvascular) was not an independent predictor of walking outcome. CONCLUSION: These results indicate that simple clinical assessments completed prior to prosthetic provision can be used to predict mobility outcome. These findings need to be validated in a larger population across other amputee rehabilitation services and if confirmed could easily be incorporated into routine clinical practice.

Interdisciplinary team working in physical and rehabilitation medicine.

Effective team working plays a crucial role in Physical and Rehabilitation Medicine (PRM). As part of its role of optimizing and harmonizing clinical practice across Europe, the Professional Practice Committee of Union of European Medical Specialists (UEMS) Physical and Rehabilitation Medicine (PRM) Section reviewed patterns of team working and debated recommendations for good practice at a meeting of national UEMS delegates held in Riga, Latvia, in September 2008. This consensus statement is derived from that discussion and from a review of the literature concerning team working. Effective team working produces better patient outcomes (including better survival rates) in a range of disorders, notably following stroke. There is limited published evidence concerning what constitute the key components of successful teams in PRM programmes. However, the theoretical basis for good team working has been well-described in other settings and includes agreed aims, agreement and understanding on how best to achieve these, a multi-professional team with an appropriate range of knowledge and skills, mutual trust and respect, willingness to share knowledge and expertise and to speak openly. UEMS PRM Section strongly recommends this pattern of working. PRM specialists have an essential role to play in interdisciplinary teams; their training and specific expertise enable them to diagnose and assess severity of health problems, a prerequisite for safe intervention. Training spans 4-5 years in Europe, and includes knowledge and critical analysis of evidence-based rehabilitation strategies. PRM physicians are therefore well-placed to coordinate PRM programmes and to develop and evaluate new management strategies. Their broad training also means that they are able to take a holistic view of an individual patient's care.

Pharmacotherapy for treatment of attention deficits after non-progressive acquired brain injury. A systematic review.

OBJECTIVE: To systematically review the effectiveness of medications used to improve attention in people with non-progressive acquired brain injury. DESIGN: A systematic review. METHODS: MEDLINE, EMBASE, CINALH, PUBMED and PsychINFO databases were used to identify studies published between 1987 and 2008 meeting the following criteria: studies with subjects older than 18 years; diagnosis of new onset or previous acquired brain injury; medication given to improve attention and use of outcome to measure attention. Studies involving subjects in low arousal states or with neurogenerative conditions were excluded. The studies were categorized into three evidence levels: I - Randomized controlled trials; II - Prospective studies, controlled trials with methodological limitations; and III - Retrospective studies, clinical case series. RESULTS: Forty-seven articles were identified on initial search. Twenty-six met the pre-specified criteria. Five articles were assessed as meeting the level I evidence criteria, 12 were level II studies and 9 were level III studies. Methylphenidate can improve information processing speed but not all attention aspects in some people after traumatic brain injury. There is weak evidence for use of dopamine agonists to improve neglect/inattention after stroke. There is little evidence on the frequency of adverse effects and long-term functional benefits. CONCLUSION: Although there is lack of robust evidence to recommend the routine use of medication to improve attention after traumatic brain injury and stroke, the existing evidence indicates potential for benefit in some patents and therefore further research is warranted.

Predicting walking ability following lower limb amputation: a systematic review of the literature.

OBJECTIVE: To investigate factors that predict walking with a prosthesis after lower limb amputation. DESIGN: Systematic literature review. METHODS: A computer-aided literature search of MEDLINE, EMBASE, CINAHL and the Cochrane Library was performed to identify studies published up to August 2007 that investigated factors that predicted walking ability after lower limb amputation. RESULTS: A total of 57 studies were selected. Predictors of good walking ability following lower limb amputation include cognition, fitness, ability to stand on one leg, independence in activities of daily living and pre-operative mobility. Longer time from surgery to rehabilitation and stump problems are predictors of poor outcome. The impact of the cause of amputation on walking varies between studies. In general, unilateral and distal amputation levels, and younger age were predictive of better walking ability. Sex probably does not have a significant influence on walking ability. CONCLUSION: The heterogeneity of methods and outcome measures used in the identified studies make comparison difficult and, in part, explains conflicting conclusions in relation to predictive factors. Further investigation of predictive factors is needed to estimate walking potential more accurately and guide targeting of modifiable factors to optimize outcome after lower limb amputation.

Qualidade de vida no trabalho: percepções da equipe de enfermagem na organização hospitalar / Nurses' perceptions of quality of working life for the nursing team / Calidad de vida en el trabajo: percepción del equipo de enfermería en la organización hospitalaria

Com este estudo objetivou-se compreender o significado de qualidade de vida no trabalho sob a ótica da equipe de enfermagem no cotidiano do trabalho hospitalar. Trata-se de uma pesquisa qualitativa, com abordagem fenomenológica desenvolvido com 15 profissionais da equipe de enfermagem que trabalham em uma organização hospitalar situada na cidade de Teófilo Otoni-MG. Para a coleta das informações foi utilizada a entrevista aberta e os dados foram analisados sob os pressupostos dos momentos metodológicos citados por Martins (1992). Da análise dos dados emergiram três categorias das quais descrevemos apenas uma, a Qualidade de vida e condições de trabalho, por melhor atender aos objetivos deste estudo. Essa categoria envolveu três subcategorias: "A gente é ser humano também", "Qualidade de vida notrabalho e a realidade vivenciada","Qualidade de vida no trabalho e a realidade sonhada". Compreendemos que ter qualidade de vida no trabalho significa ter a oportunidade de ser ouvido pelos gestores e demais profissionais da equipe de saúde da organização hospitalar e poder expressar idéias e aspirações em relação às questões que envolvem o cotidiano de trabalho. Percebemos a carência de políticas que trabalhem a temática qualidade de vida no trabalho na organização hospitalar e sugerimos que a contemplação desta se dê mediante a realização de oficinas que envolvam outros profissionais da equipe de saúde e também os gestores.

This study aimed to understand the meaning of Quality of Working Life from the point of view the nursing team in the daily hospital activities. This is a qualitative research with phenomenological approach developed with 15 professionals of a team working at a hospital in the city of Teófilo Otoni, Minas Gerais. Information was collected in an open interview and data was studied under the principles of the methodological moments according to Martins (1992). From the data analysis three categories emerged. We describe only one due to the objectives of this study. The category "Quality life and working conditions"involved three categories:"We are also human beings","Quality of working life and reality","Quality of working life and the reality we dream of". We understand that Quality of Working Life means having the chance of being heard by managers and other health team professionals from the hospital, being allowed to show ideas and longings regarding the issues that involve the daily activities. We noticed lack of policies in working with Quality of Working Life in the hospital and we suggest it being considered with workshops involving other health team professionals as well as their managers.

Este estudio se llevó a cabo con el objetivo de comprender el significado de la calidad de vida en el trabajo desde el punto de vista del equipo de enfermería en el día a día del trabajo hospitalario. Se trata de una investigación cualitativa, con conocimiento de fenomenológica, realizado con 15 profesionales del equipo de enfermería de un hospital de la ciudad de Teófilo Otoni, Minas Gerais. La recogida de datos se llevó a cabo con entrevistas abiertas. Los datos se analizaron bajo los presupuestos de los momentos metodológicos citados por Martins (1992). A partir del análisis de datos se consideraron tres categorías de las cuales describiremos sólo una, debido a la limitación de esta publicación. La categoría "Calidad de vida y condiciones de trabajo"involucró tres sub-categorías: "También somos seres humanos", "Calidad de vida en el trabajo y realidad concreta", "Calidad de vida en el trabajo y realidad soñada". Comprendemos que la calidad de vida en el trabajo significa tener la oportunidad de ser escuchados por gestores y demás profesionales del equipo de salud al igual que poder expresar ideas y aspiraciones sobre lo que implica el trabajo cotidiano. Percibimos la carencia de políticas que trabajen este asunto y sugerimos que se tenga en cuenta realizando talleres que involucren otros profesionales del equipo de salud hospitalario y sus gestores.

Um olhar sobre as ações do enfermeiro no processo de acreditação hospitalar / A study of the actions of nurses in hospital accreditation processes / Una mirada a las acciones de la enfermera en el proceso de acreditación hospitalaria

Trata-se de uma pesquisa bibliográfica em que se propõe descrever ações do enfermeiro no processo de acreditação hospitalar. O estudo foi desenvolvido durante os meses de abril e maio de 2006 através de revisão de literatura sobre o tema escolhido, disponível nos bancos de dados BIREME, LILACS, SCIELO e BDENF. Os dados foram obtidos nas seguintes categorias: o processo de acreditação hospitalar e o enfermeiro no processo de acreditação hospitalar. Concluiu-se que a liderança, a comunicação, a habilidade técnico-científica, a organização do trabalho e os programas de educação continuada são estratégias que possibilitam ao enfermeiro implementar as mudanças requeridas às novas situações e ao trabalho interdisciplinar. Dessa forma esse profissional vem proporcionando melhoria na qualidade da assistência e contribuindo efetivamente para o alcance dos objetivos institucionais , ou seja,o êxito do processo de acreditação.

This paper is a bibliographic review aiming to describe the actions of nurses in the hospital accreditation process. A review of literature on this theme was undertaken between April and May 2006 using the BIREME, LILACS, SCIELO and BDENF databases. Data was collected on the hospital accreditation process, and nurses in the hospital accreditation process. We concluded that leadership, communication, technical and scientific knowledge, organization of work, and continuing education programs are strategies that enable nurses to implement changes required for the new situation and for interdisciplinary work. Nurses, therefore, can facilitate improvements in the quality of care and effectively support the institution as it seeks success in the accreditation process.

Se trata de una investigación bibliográfica que se propone describir acciones del enfermero en el proceso de acreditación hospitalaria. Este estudio se llevó a cabo durante abril y mayo de 2006 con revisión de literatura sobre el tema en pauta, disponible en las bases de datos BIREME, LILAS, SCIELO y BDENF. Los datos se obtuvieron en las siguientes categorías: el proceso de acreditación hospitalaria y el enfermero en el proceso de acreditación hospitalaria. Se concluyó que líderes, comunicación, habilidad técnico científica, organización del trabajo y programas de educación continua son estrategias que le permiten al enfermero implementar los cambios que requieren tanto las nuevas situaciones como el trabajo interdisciplinario. De tal manera, dichos profesionales vienen proporcionando mejoras en la calidad de la asistencia y contribuyendo efectivamente al alcance de los objetivos institucionales, es decir, al éxito del proceso de acreditación.

Screening for job loss: development of a work instability scale for traumatic brain injury.

OBJECTIVE: The objective of this study was to explore the concept of work instability (a mis-match between an individual's functional and cognitive abilities and the demands of their job) following traumatic brain injury (TBI) and develop a work instability scale specific to this population. METHOD: Work instability (WI) following TBI was explored through qualitative interviews which were then used to generate items for a work instability scale (WIS). Rasch analysis was used to examine the scaling properties of the TBI-WIS which was then validated against a gold standard of expert vocational assessment by occupational psychologists. RESULTS AND CONCLUSION: The resulting measure is a 36 item, self-administered scale which can be scored in three bands indicating low, medium and high risk of job retention problems. The scale meets modern psychometric requirements for measurement and presents an opportunity in routine clinical practice to take positive action to prevent job loss.

Construct validity and reliability of the Rivermead Post-Concussion Symptoms Questionnaire.

OBJECTIVES: To provide further evidence of reliability and internal and external construct validity of the Rivermead Post-Concussion Symptoms Questionnaire (RPQ), which measures severity of postconcussion symptoms following head injury. DESIGN AND SETTING: A cross-sectional study of consecutive patients presenting with a head injury in two urban teaching hospitals and a community trust. PATIENTS: Three hundred and sixty-nine patients returned a questionnaire from 1689 consecutive adult patients (18 years and above) referred to radiology for a skull X-ray following a head injury, and those who were currently under the care of a community-based multidisciplinary head injury team. METHOD: Internal construct validity tested by fit to the Rasch Measurement model; external construct validity tested by correlations with Rivermead Head Injury Follow-up Questionnaire (RHFUQ); test-retest reliability tested by correlations at two-week intervals. OUTCOME MEASURES: Rivermead Post-Concussion Symptoms Questionnaire and Rivermead Head Injury Follow-up Questionnaire. MAIN RESULTS: RPQ scores ranged from 0 to 64 (17.3% floor, 0.3% ceiling). Overall fit to the Rasch model was poor (item fit mean -0.416, SD = 1.989, chi-squared= 172.486, p<0.01) suggesting a lack of unidimensionality. The items headaches, dizziness and forgetful displayed misfitting residuals and the first two items also displayed significant item trait fit statistics (p < 0.0006). After removing the items headaches, dizziness and subsequently nausea the RPQ demonstrated good fit at overall and individual item levels, both for the remaining 13 items (RPQ-13) and the three items (RPQ-3) which now formed a subsidiary scale. All items functioned consistently across age and gender. The RPQ-13 and RPQ-3 scales showed test-retest reliability coefficients of 0.89 and 0.72 (both p-values < 0.01) and positive correlations with RHFUQ scores (0.83 for RPQ-13, 0.62 for RPQ-3, both p-values < 0.01). CONCLUSIONS: As currently used, the RPQ does not meet modern psychometric standards. Its 16 items do not tap into the same underlying construct and should not be summated in a single score. When the RPQ is split into two separate scales, the RPQ-13 and the RPQ-3, each set of items forms a unidimensional construct for people with head injury at three months post injury. These scales show good test-retest reliability and adequate external construct validity.

Assessing decision-making and capacity in minimally-aware patients.

The assessment of decision-making by minimally-aware patients represents an important challenge for medicine, science and the law. This paper seeks to assist the dialogue between these disciplines by discussing three aspects: the difficulties inherent in establishing a reliable means of communication with the patient; the difficulty of exploring understanding and decision-making once a means of communication has been determined; and the legal implications including problems that may arise with the 'balance of probabilities' legal standard of proof. These aspects are discussed using the example of patients who have very severe acquired brain damage or are in states which verge on the 'persistent vegetative state'. The discussion is informed by existing case law and by reference to clinical method and scientific theory including binomial theory.

The value of melatonin for sleep disorders occurring post-head injury: a pilot RCT.

PRIMARY OBJECTIVE: Whilst there is data to support the use of Melatonin in treating disorders of the sleep-wake cycle, so far there is little published evidence on the efficacy of Melatonin in treating the prevalent condition of post-TBI sleep disturbance. RESEARCH DESIGN: The present work used a randomized double-blind controlled cross-over trial to compare Melatonin (5 mg) and Amitriptyline (25 mg) in a small sample of TBI patients presenting with chronic sleep disturbance. MAIN OUTCOME AND RESULTS: No differences in sleep latency, duration, quality or daytime alertness were found for either drug compared to baseline using significance testing. However, effect sizes revealed some encouraging changes. Patients on Melatonin reported improved daytime alertness compared to baseline. On Amitriptyline, patients reported increased sleep duration compared to baseline. CONCLUSIONS: The study provides preliminary evidence for the value of Melatonin and Amitriptyline in treating sleep disorder post-TBI. There were no adverse drug effects. Suggestions are made for ongoing investigation for the treatment of this prevalent condition.

Treatment of longitudinal deficiency affecting the femur: comparing patient mobility and satisfaction outcomes of Syme amputation against extension prosthesis.

Patients with proximal focal femoral deficiency or longitudinal deficiency affecting the femur were selected from a large regional center. Twenty-eight such patients were identified and were divided into two groups depending on how their condition was managed. Group 1 had opted for the surgical approach of ankle disarticulation (Syme amputation) and the fitting of an above-the-knee prosthesis. The patients in group 2 had been managed in a nonsurgical fashion using an extension prosthesis. They were asked about their level of mobility using the recognized Locomotor Index and their overall satisfaction using self-designed questions. The two groups' scores were similar for mobility whether using their prosthesis or not, but group 1 had lower satisfaction scores than group 2. Current opinion advocates the use of surgery in the management of proximal focal femoral deficiency because it is believed to have better cosmetic and functional results, but in the authors' comparison similar scores for mobility were shown. The nonsurgical extension prosthesis was associated with fewer musculoskeletal and residual limb problems, fewer problems with public transport, and greater satisfaction than Syme amputation. Overall, this small study suggests that the nonsurgical approach is preferable.