REVIEW ARTICLE

Knowledge production in nursing about empowerment in chronic health conditions

Lina Márcia Miguéis Berardinelli^I; Nathália Aparecida Costa Guedes^II; Araci Carmen Clos^III; Juliana Pereira Ramos ^IV; Anna Carolina dos Santos Chaves^V; Clícia Vieira^VI

^I Nurse. Associate Professor, Department of Medical-Surgical Nursing and the Graduate Program of the School of Nursing at the State University of Rio de Janeiro. Scholarship from the Incentive Program for Production, Technical and Artistic (Prociência). Brazil. Email: l.m.b@uol.com.br
^II Nurse. Master's Student in the Graduate Program in Nursing at the School of Nursing at the State University of Rio de Janeiro, Brazil. Email: nathyyguedes@gmail.com
^III Nurse. Master's in Philosophy. Assistant Professor in the School of Nursing at the State University of Rio de Janeiro, Scientific Editor for the UERJ Nursing Journal. Brazil. Email: araciclos@yahoo.com.br
^IV Student of the 7th Period of the Undergraduate Program, Faculty of Nursing at the State University of Rio de Janeiro. Scientific Initiation Scholarship, National Council for Scientific and Technological Development. Rio de Janeiro, Brazil, Email: julianapereiraramos@gamil.com
^V Nurse. Master's Student in the Graduate Program in Nursing at the School of Nursing at the State University of Rio de Janeiro, Brazil. Email: carolchavesrj@gmail.com
^VI Nurse. Master's Student in the Graduate Program in Nursing at the School of Nursing at the State University of Rio de Janeiro, Brazil. Email: cliciavieira@gmail.com

DOI: http://dx.doi.org/10.12957/reuerj.2015.16799

ABSTRACT

This study aimed to analyze scientific production in the nursing field on the subject of empowerment in chronic health conditions. An integrative review was conducted to answer the question: What is the state of the nursing literature about empowering people with chronic health conditions? Data was collected in an integrated manner from the Public/Publish Medline (PubMed), Scientific Electronic Library Online (SciELO) and Virtual Health Library (BVS) databases in February and March 2015. The search for articles was conducted in those databases with the combined keywords 'empowerment', 'nursing' and 'chronic disease' in English, Portuguese and Spanish. Twelve complete publications from 2006 to 2015 were selected. Two categories emerged: empowerment in chronic health situations; and the concept of empowerment and professional training. The national and international scientific literature on the subject needs to be enlarged.

Keywords: Empowerment; chronic illness; nursing; professional training.

INTRODUCTION

The empowerment concept and reflection on its pedagogical significance assume a prominent role in the panorama of chronic non-communicable diseases (CNCDs). Chronic health situations have been challenging for the humanity, by reason of their growth on all continents, and with this demanding change in health care practice, to rethink new approaches and monitoring that exceed the prevailing biologistic and organic model that has been insufficient to meet the demands and the complexity involving the care of people with CNCD.

The epidemiological indicators of World Health Organization (OMG) demonstrate that the CNCD constitute a health problem of major proportions, therefore, has amounted to 72% of the causes of deaths. Currently, they are responsible for 60% of the global disease burden. In addition it warns that, in 2020, it will be responsible for 80% of the disease burden in developing countries ¹.

Similarly, the consequences of these disorders generated by CNCD are multiple, which bring harm to people's health by preventing them to live fully and to carry out a series of activities from a professional and social point of view. The estimates for the Brazil suggest that the loss of productivity at work and the reduction of the income generated by them will lead to a loss in the Brazilian economy $4.18 billion between 2006 and 2015 ^1,2.

Therefore, the Pan American Health Organization and WHO stressed that the possible interventions in the CNCD can be, for example, educational activities aimed at changing behavior as well as continuing care, long-term, planned prospectively, proactively and fundamentally supported in primary health care. The training of patients is fundamental in order to develop its accession, with the support of families, the care goals, as well as autonomy in problem solving and participation in clinical decision-making, always under the supervision of healthcare teams².

Confirming these ideas, the action lines of the Ottawa Charter and the Declaration of Alma Ata reaffirm the need to intensify the actions of health promotion strategies in the routine of services, promote independent living for people, individuals and professionals, so that together can understand health as a result of living conditions, providing a more equitable social development³.

Moreover, the targeted interventions to clients should invest in self-care actions, knowledge and access to information as needed for the decision-making; developing social skills, aiming at empowerment practices⁴.

The empowerment has assumed meanings that refer to potential for development, increase of information and perception, in order to promote real and symbolic interest, which enables democracy⁵.

Empowerment allows dialogical learning, development of critical consciousness, in which the individual finds direction for a healthy individual/autonomous/custom way of living. Only the information shared in educational processes alone will not change behavior in relation to the problem situation. Although knowledge is a necessary condition for the process of change in a practice or behavior, other variables like the attitude will have to be changed so that particular harmful behavior is modified⁶.

This work aims to contribute to the development of scientific knowledge production in nursing, on the empowerment of people suffering from chronic diseases, and for upgrading nurses, causing reflections to changes in health care, as well as leverage new objects of research. Therefore, the objective of this study was to analyze the scientific production in the area of nursing on the empowerment of people in chronic health situations.

METHODOLOGY

It is a study of integrative review, method relevant to nursing, because its professionals are constantly challenged to seek scientific knowledge, with the objective of promoting improvement in care. The evidence-based practice encourages the use of research results in health care provided, in different levels of attention, corroborating the importance of research in clinical practice ⁷.

The integrative review promotes critical presentation of scientific productions, easy to read by professionals who do not have the time to realize the full reading of the available material. Thus, by this method, it is possible to analyze the published studies that lead to general conclusions about a particular area of study⁸.

Thus, for the study design, the six methodological steps by Ganong were followed: selection of cases or issues for review; establish criteria for the selection of the sample; characteristic of the primary research; Data analysis; perform the interpretation of the results and finally reviewing the presentation⁹.

The first step was outlined by the issue for review: How is the literature in nursing about the empowerment of people with chronic health conditions? The following were established the criteria for the selection of studies, these being: full article available online , periodic qualified, results of research, experience reports, reviews, and news, in Portuguese, English or Spanish available in electronic media, the cut-off time of the last 10 years (2005-2015). The following were excluded from the study: publications not available in their entirety and that differed substantially from the theme proposed for the research.

The data collection was observed the following primary characteristics: the production of the data was carried out in February and March of 2015, from the databases Public/Publish Medline (PUBMED), Scientific Electronic Library Online (SCIELO) and Virtual Health Library (VHL) in an integrated manner with the databases: Nursing Database (BDENF), Latin American and Caribbean Health Sciences (LILACS), Medical Literature Analysis and Retrieval System Online (MEDLINE). The search for articles was processed with the keywords combined: empowerment, nursing and chronic disease in these databases and in English, Portuguese and Spanish.

The study of integrative review, as an instrument of evidence-based practice, is characterized as an approach that addresses both the clinical care and for the education based on knowledge and observation of clinical practice quality⁸.

The evidence are classified in hierarchical form for the evaluation of research or other sources of information, is based on the categorization of the Agency for Healthcare Research and Quality (AHRQ) of the United States of America. The classification covers six levels described below: Level 1 - meta-analysis of multiple controlled studies; Level 2 - individual study with experimental design; Level 3 - study of nearly experimental design to study without randomization with one group pre and post test, time series or case-control; Level 4 - study of non-experimental design as correlation descriptive and qualitative research or case studies; Level 5 - report cases or data obtained systematically, verifiable quality or program evaluation data; Level 6 - opinion of respected authorities based on clinical competence or opinion of expert committees, including information not interpretations based on research; regulatory or legal opinions⁸.

The data collection instrument consisted of the following items to record information extracted from articles: title, authors, journal published, and summary, type of research / methodology used main results and conclusion. The treatment of the data was applied to the collected material, on the basis of thematic analysis of Minayo, laying down the steps: pre-analysis with reading and re-reading the material, exploration of the material obtained and treatment of results with organization, interpretation and presentation of results in the form of categories ^10,11.

The results were discussed in the light of the relevant literature on the theme ^12-30.

RESULTS AND DISCUSSION

In SCIELO database, a scientific publication was found, from the association of the cited descriptors. In PUBMED 23 articles were located, only 10 were available and discussed the chosen theme. 12 Articles were identified in the database VHL, and only two of them were available in integrates and approached the chosen theme. Totaling, 12 articles ^12-23.

In this way, we could notice a reduced number of scientific articles published on the topic of empowerment in customers with CNCD, in the databases searched.

The articles found and their authors, journal, database, and search types are listed in Figure 1.

FIGURE 1 : Description of the studies included in the integrative review, according to title, author, journal (year, volume), database and study type. 2006-2014.

As far as the year of publication, there is a number of texts more in the years of 2014 and 2013, both with four studies each, followed by two in 2008, one in 2006 and one in 2010. There was no production on the subject in 2005. As to the authorship of the works published, one article was written by nurses and doctors and 11 only by nurses.

In relation to the methodological design of the study, in databases and virtual library consulted there is the predominance of quantitative surveys in six articles; followed by qualitative research, in four texts; a theoretical study; and one of actuality.

Outlines the research and their levels of evidence are shown in Figure 2.

FIGURE 2 : Description of the studies included in the integrative review according to the study type and level of evidence. 2006-2014.

The results generated show that research on empowerment in chronic diseases are few in number, possibly to be considered also a field to be explored.

Before the material selected, was held thematic analysis, after exhaustive reading of the articles. The analysis aimed to organize and summarize the data to respond to the problem proposed in this study. In addition, the interpretation sought to associate the described in articles with knowledge more extensive, already obtained on the subject ¹². From then on, the proximity between the articles and the repetition of themes among them, two categories emerged: The empowerment in chronic health situations and the concept of empowerment and training of professionals. These categories are discussed below.

Empowerment in chronic health situations

Empowerment in chronic health conditions was the most prominent theme among the works analyzed, keeping in mind throughout the time frame studied.

Empowerment is seen as a way to increase the commitment, self-management, improving the effectiveness and quality of life can reduce disability costs and care in disease. It is a process of empowerment with a focus on the ability to participate consciously in health care, in the decision-making process and is associated with an awareness of their strengths and skills development, self-esteem, well-being and self-capacity¹². This design values autonomy according to the literature ^23-30.

The articles described adults and elderly, in chronic health situations, as subjects of study, in which the empowerment was central object to enhance the potential of them for the learning and the use of the tools they need to live as independently as possible and to maintain/improve their own quality of life and their families ²⁰. To motivate this behavior for health, showed several strategies such as the use of technology - computer, internet, discussion groups, questionnaires^{12,15,16,18-20}.

It is also noticeable that the articles, according to this category, focused on the empowerment of children and families with chronic disease, whereas such intervention the best strategy to control the disease and its management by the children and their parents. In this process, the patients do not play a passive role in the course of the disease, instead, they are actively involved in the course of the treatment, assuming the responsibility of taking care of themselves, with the knowledge and skills appropriate to that respect and, consequently, reducing hospitalization and crises ^13,14. These behavioral changes reflect the principles of desired autonomy ^23-30.

The concept of empowerment and professional training

The interest and attraction to the concept of empowerment was stimulated, in mid-1980, in conjunction with the design of health promotion WHO, as a process of empowerment of the community to increase and improve skills for self-care and health maintenance ¹⁵. According to the articles, the concept of empowerment is linked to active participation, commitment to change, knowledge to problem solving, responsibility for self-care, customer competence and control of health or life^15,21,22. The empowerment in health promotes the ability to participate consciously of decisions and healthcare. It is the promotion of autonomy and citizenship ^23-30.

The role of health professionals is to facilitate the engagement of the patient toward the goals of health, using the best available methodology to motivate it¹⁷. The participation of health professionals, especially nurses, may influence the clinical decision-making, with the objective of obtaining appropriate treatment. To facilitate this participation, it is necessary to inform them of the self-care necessary, using strategies to involve them. It is necessary that the patient's preferences are taken into consideration in order to maintain them in the care process¹⁸.

Health professionals need to recognize the needs of patients, the level of knowledge about their disease and their expectations with the treatment and, from there, seeking a behavior modified and committed to their health and self-care.

FINAL CONSIDERATIONS

Before the initially proposed objective, it was found that the production on the empowerment theme in chronic health situations, in a temporal excerpt from 2006 to 2015 was reduced, totaling 12 work, grouped in two categories: Empowerment in chronic health situations and the concept of empowerment and the training of professionals. We emphasize the lack of works in Portuguese.

It is crucial that public policies meet the needs of this population, with incentives to health promotion programs that emphasize the empowerment of the individual, with the aim of improving their quality of life.

It is necessary that the national and international scientific production on the theme discussed is expanded.

REFERENCES

1.Ministério da Saúde (Br). Plano de ações estratégicas para o enfrentamento das doenças crônicas não transmissíveis (DCNT) no Brasil 2011-2022. 2011. [citado em 05 mar 2015]. Available at: portal.saude.gov.br/portal/arquivos/pdf/cartilha_plano.pdf

2.Organização Pan-Americana da Saúde; Organização Mundial da Saúde. Doenças crônicas não transmissíveis: estratégias de controle e desafios e para os sistemas de saúde. Brasília (DF) 2011. [citado em 05 mar 2015]. Disponível em: http://apsredes.org/site2012/wp-content/uploads/2012/06/Condicoes-Cronicas_flavio1.pdf

3.Teixeira MB. Empoderamento de idosos em grupos direcionados à promoção da saúde. [dissertação de mestrado] Rio de Janeiro: Escola Nacional de Saúde Pública; 2002. [citado em 05 mar 2015]. Disponível em: http://portalteses.icict.fiocruz.br/transf.php?id=000034&lng=pt&nrm=iso&script=thes_cover

4.Otero LM, Zanetti ML, Teixeira CRS. Características sociodemográficas e clínicas de portadores de diabetes em um serviço de atenção básica à saúde. Rev Latino-Am Enfermagem. 2007; [citado em 05 mar 2015] Disponível em: http://www.scielo.br/pdf/rlae/v15nspe/pt_08.pdf

5.Wendhausen ALP, Barbosa TM, Borba MC. Empoderamento e recursos para a participação em conselhos gestores. Rev Saúde Sociedade. 2006; [citado em 05 mar 2015]: 15(3) 131-144. Disponível em: http://www.scielo.br/scielo.php?pid=S010412902006000300011&script=sci_arttext.

6.Carvalho GS. Literácia para a saúde: um contributo para a redução das desigualdades em saúde. In: Leandro M, Araújo M, Costa M, organizadores. Saúde: as teias da discriminação social. Braga (PT): Universidade do Minho; 2002, 119-35.

7.Galvão CM, Sawada NO, Mendes IAC. A busca das melhores evidências. Rev esc enferm USP [Internet]. 2003; 37: 43-50. [citado em 02 fev 2015]. Disponível em: http://www.scielo.br/pdf/reeusp/v37n4/05.pdf

8.Souza MT, Silva MD, Carvalho, R. Revisão integrativa: o que é e como fazer [Internet]. 2010; [cited in 2015 02 fev] 8:102-6. Available from: http://apps.einstein.br/revista/arquivos/PDF /1134-Einsteinv8n1_p102106_port.pdf

9.Ganong LH. Integrative reviews of nursing research. Res Nurs Health. 1987; 10 (1):1- 11. Acess for EBSCO host ®.

10.Minayo MCS. O desafio do conhecimento - pesquisa qualitativa em saúde. 11^a ed. São Paulo: Hucitec; 2008.

11.Minayo MCS. Organizadora. Pesquisa social: teoria, método e criatividade. 20^a ed. Petrópolis (RJ): Vozes; 2002.

12.Fotoukian Z. Shahboulaghi FM, Khoshknab MF, Mohammadi E. Barriers to and factors facilitating empowerment in elderly with COPD. Med J Islam Repub Iran. 2014; 2015; 28:155 [cited in Feb 06]. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4322331/

13.Payrovee Z, Kashaninia Z, Alireza Mahdaviani S, Rezasoltani P. Effect of family empowerment on the quality of life of School-Aged Children with Asthma. Tanaffos. 2014; [cited in 2015 Feb 03] 13: 35-42. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4153273/

14.Ghazavi Z, Minooei MS, Abdeyazdan Z, Gheissari A. Effect of family empowerment model on quality of life in children with chronic kidney diseases. Iran J Nurs Midwifery Res. 2014; 19: 371-5. [cited in 2015 Feb 03]. 19 (4): 371-5. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4145491/

15.Fotoukian Z, Shahboulaghi FM, Khoshknab MF, Mohammadi E. Concept analysis of empowerment in old people with chronic diseases using a hybrid model. Asian Nurs Res (Korean Soc Nurs Sci). 2014; [cited in 2015 Feb 03] 8 (2): 118-127. Available from: http://www.asian-nursingresearch.com/article/S1976-1317(14)00021-8/abstract

16.Park C, Park YH. Validity and reliability of Korean version of health empowerment scale (K-HES) for older adults. Asian Nurs Res (Korean Soc Nurs Sci). 2013; [cited in 2015 Feb 03] 7 (3): 142-8. Available from: http://www.asian-nursingresearch.com/article/S1976-1317(13)00040-6/abstract

17.Smith LL, Lake NH, Simmons LA, Perlman A, Wroth S, Wolever RQ. Integrative health coach training: a model for shifting the paradigm toward patient-centricity and meeting new national prevention goals. Glob Adv Health Med 2013; [cited in 2015 Feb 03] 2(3): 66-74. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3833534/

18.Vestala H, Frisman GH. Can participation in documentation influence experiences of involvement in care decision-making? Open Nurs J 2013; [cited in 2015 Feb 03] 7: 66-72. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3680981/

19.Weinert C, Cudney S, Hill WG. Rural women, technology, and self-management of chronic illness. Can J Nurs Res. 2008; [cited in 2015 Feb 03] 40: 114-34. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18947095

20.St-Cyr Tribble D, Gallagher F, Bell L, Caron C, Godbout P, Leblanc J, et al. Empowerment interventions, knowledge translation and exchange: perspectives of home care professionals, clients and caregivers. BMC Health Serv Res. 2008; [cited in 2015 Feb 03] 8:177. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2528009/

21.Hill W, Weinert C, Cudney S. Influence of a computer intervention on the psychological status of chronically ill rural women: preliminary results. Nurs Res 2006; [cited in 2015 Feb 03] 55 (1): 34-42. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1484522/

22.Balduino AFA, Mantovani MF; Lacerda MR; Meier MJ. Análise conceitual de autogestão do indivíduo hipertenso. Rev Gaúcha Enferm 2013; [citado em 03 fev 2015] 34(4). Disponível em: http://dx.doi.org/10.1590/S1983-14472013000400005

23.Leite NSL, Cunha SR, Tavares MFL. Empowerment das famílias de crianças dependentes de tecnologia. Rev enferm UERJ. 2011; 19:152-6.

24.Vasconcelos EM. O poder que brota da dor e da opressão: empowerment, sua historia, teoria e estratégias. São Paulo: Paulus; 2011.

25.Carvalho SR. Os múltiplos sentidos da categoria empowerment no projeto de promoção da saúde. Cad Saúde Publica. 2004; [citado em 10 abr 2015] 20:1088-95. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0102-311X2004000400024

26.Ferreira MS, Castiel LD. Que empowerment, qual promoção da saúde? Convergências e divergências conceituais em práticas preventivas em saúde. Cad Saúde Publica. 2009; [citado em 10 abr 2015] 25: 68-76. Disponível em: http://www.scielo.br/scielo.php?pid=S0102-311X2009000100007&script=sci_arttext

27.Dunst CJ, Trivette CM, Deal AG. Enabling & empowering families: principles & guidelines for practice. Cambridge (MA): Brookline Books; 2010.

28.Labonte R. Health promotion and empowerment: reflections on professional practice. Health education guartely. 1994 [cited in 2015 Apr 10] 21: 253-68. Avaliable from: http://www.ncbi.nlm.nih.gov/pubmed/8021151

29.Freire P. Pedagogia da autonomia: saberes necessários à pratica educativa. 43^a ed. Rio de Janeiro: Paz e Terra; 2013.

30.Freire P. Pedagogia do oprimido. 17^a ed. Rio de Janeiro: Paz e Terra; 2011.