ORIGINAL RESEARCH

Meaning of educational actions in nursing consultations for chronic renal clients and relatives

Harlon França de Menezes^I; Ann Mary Machado Tinoco Feitosa Rosas^II; Alessandra Conceição Leite Funchal Camacho^III; Flávia Silva de Souza^IV; Benedita Maria Rêgo Deusdará Rodrigues^V; Richardson Augusto Rosendo da Silva^IV

^I Nurse. Universidade Federal Fluminense. Aurora de Afonso Costa School of Nursing. Academic Program in Health Care Sciences. Niterói, Rio de Janeiro, Brazil. E-mail: harlonmenezes@hotmail.com
^II Nurse. Associate Professor. Federal University of Rio de Janeiro. Anna Nery School of Nursing. Department of Nursing Methodology. Rio de Janeiro. Brazil. E-mail: annmaryrosas@hotmail.com
^III Nurse. Adjunct Professor. Universidade Federal Fluminense. Aurora de Afonso Costa School of Nursing. Department of Fundamentals of Nursing and Administration. Niterói, Rio de Janeiro, Brazil. E-mail: cicacamacho@gmail.com
^IV Nurse. Master in Nursing. Federal University of Rio de Janeiro. Clementino Fraga Filho University Hospital. Rio de janeiro Brazil. E-mail: sflaviashu@gmail.com
^V Nurse. Professor. State University of Rio de Janeiro. Department of Maternal and Child Nursing. Rio de Janeiro. Brazil. E-mail: benedeusdara@gmail.com
^VI Nurse. Associate Professor. Federal University of Rio Grande do Norte. Department of Nursing. Natal, Rio Grande do Norte, Brazil. E-mail: rirosendo@hotmail.com

DOI: http://dx.doi.org/10.12957/reuerj.2018.31921

ABSTRACT

Objective: to understand the meaning of educational actions in nursing consultations for chronic renal clients in conservative treatment and their relatives. Method: study guided by Social Phenomenology. Between November 2015 and April 2016, 12 chronic renal clients and their relatives were interviewed at a university hospital nephrology clinic in Rio de Janeiro State, Brazil, after approval by the research ethics committees of the proposing and co-participant institutions. The interviews were transcribed and submitted to analysis framed by the related literature. Results: two categories emerged: expectations when going to a nursing consultation and Caring for the other to face the adversities imposed by the disease. Conclusion: the study allowed us to understand that, in their daily lives, these individuals acquire the ability and practice to cope with their limitations. Their relationships afford contributions to recognition not only for the values of the clinic, but also for the value focused on by relational care.

Descriptors: Chronic renal failure; nursing in the office; health education; family.

INTRODUCTION

The increased prevalence of chronic diseases is one of the most important events that communities and health professionals have faced in this century. Health habits and behaviors can drastically affect the prevalence of these diseases, as they are associated with significant sociodemographic disparities, considering that, in general, racial/ethnic minorities and the poor population are often prone to have these diseases at an early age^1,2.

Chronic Kidney Disease (CKD) is an anomaly of renal structure or function, present for more than three months, with severe health implications. It is prolonged, usually coexisting with others, such as hypertension and diabetes. Consequently, the patient needs to make use of many tablets, for example, which imposes a high personal and monetary burden, extensively, on their families³.

CKD has grown dramatically in countries in the northern hemisphere^1,4. In Brazil, to date, there is no definitive epidemiological information. However, it is estimated that approximately three million Brazilians present this disease at an advanced stage, and the current report shows a trend towards an increase in the number of people on dialysis, incidence rates and prevalence of treatment, especially considering the last four years^5,6.

Faced with this reality, the prevention of CKD progression needs to be focused on risk factors, through specific guidelines that reach the reality of the patient's daily life, as well as of those who live and exchange decisions about the problem and treatment. In this sense, the health team plays a crucial and active role in directing and raising clients' awareness to achieve quality of life.

Nursing, through its main care activity, the nursing consultation, is responsible for preventive behavioral actions that are part of its daily routine and that can also assume the connotation of duty and responsibility towards the other. These actions are defined as interventions aimed at avoiding the onset of specific diseases, stimulating the improvement of their clinical, psychological and social conditions⁷.

Studies have emphasized the role of nursing in CKD, such as in blood pressure control, in the accepted risk factors for progression and in the need for preventive programs, considering that many sociodemographic aspects are associated with health disparities^8-10.

Thus, the support given in the consultation, even in the conservative treatment phase, may serve as a subsidy for health professionals to improve the outpatient follow-up of these individuals, with effective adherence to treatment, leading to considerable clinical outcomes and, consequently, quality of life. In this context, the clinical progression of the disease stabilizes and the client becomes able to act receptively.

Thus, the question that guided this study was: How the educational actions in the consultation influence for the chronic kidney disease client and his/her family caregiver? The objective was to understand the meaning of educational actions in the nursing consultation for chronic kidney disease clients in conservative treatment and for their family caregivers.

THEORETICAL FRAMEWORK

For the Social Phenomenology, the important thing is not to separate the subjects of the phenomenon, but to reunite them inseparably in the intentional structure of the experience. In this way, the purpose is to elucidate the meaningful structure, that is, the set of subjective meanings that constitute the world of life, based on the fact that every action that the subject develops has an intentional meaning and seeks to meet their expectations¹¹.

In this sense, the adherence of this framework to the study concerns health care that originates from the interaction between people (intersubjectivity) and is always endowed with intention (intentionality). Thus, the first experiences of care occur in the world of life (social world) and are acquired with family members and close people. Personal experiences and the knowledge transmitted by professionals on the health care (body of knowledge) are added to these experiences throughout life. The body of knowledge and the position of the actors in the social sphere (biographical situation) allow the establishment of common goals for social action¹².

For the framework, care is socially constructed and has its origin in the existential context, being driven by human actions. The reasons that relate to the future projects are called "reasons-for" and those based on the individual's body of knowledge and experience lived in the biopsychosocial scope are called "reasons-why"¹¹.

This study addresses intentionality, that is, the future projects of clients and their caregivers through the reasons-for.

METHODOLOGY

The region of inquiry was in the world of life of chronic renal clients and their caregivers who participate in the nursing consultation in a nephrology outpatient clinic of a university hospital, located in the city of Rio de Janeiro, Brazil.

Twelve chronic renal clients, older than 18 years, seen in the conservative treatment program, in stages III (pre-dialysis) to V (non-dialysis), and their 12 family caregivers, over 18 years of age, were included in this study. Thus, there were the inclusion criteria⁵. The reason for inserting clients into advanced stages of DRC was due to the fact that their experience is permeated by a clinical profile that influences health needs. We excluded clients who attended the consultation alone, as well as those who participated in the consultation for the first time because they had not 'experienced' the consultation yet.

Between November 2015 and April 2016, phenomenological interviews were conducted and recorded by the main researcher through a media device. The interviews lasted an average of 25 minutes in the treatment rooms, and the following questions were presented to the clients: What do you expect when you come to the nursing consultation at the nephrology clinic? And to caregivers: What do you expect from the nursing consultation at the nephrology outpatient clinic? What do you have in mind when you come with your family member with CKD and receive educational guidance during the nursing consultation to take care of them during the treatment?

The participants had been contacted in advance so that the date and time for the interviews were scheduled and, thus, they signed the Informed Consent Form that guaranteed anonymity. Participants are identified with the word Client and Caregiver, followed by the sequence number of the interview. New interviews were cancelled when the content of the responses of both groups regarding their reasons (reason-for) was repeated.

The statements were analyzed according to the steps of social phenomenology researchers: reading and re-reading of each speech, with the objective of identifying the relevant aspects regarding the context of the experience of clients and caregivers; identification and subsequent grouping of the significant aspects of the speeches into units of meaning; synthesis of units of meaning to later compose the categories. The discussion of the data was based on social phenomenology and related literature^13,14.

This research was approved by the Research Ethics Committees of the proposing and co-participating institution through the reports of numbers 1,045,709 and 1,067,955, respectively.

RESULTS

Of the clients interviewed, seven were men, aged between 21 and 81 years, six of whom were married, all with systemic arterial hypertension and seven with diabetes, with eight clients in stage IV of CKD. The average age of the caregivers between 31 and 72 years old, of whom 10 were female, and the main kinship were due to the conjugal and parental relationship.

The expectations, desires and goals through the face-to-face relationship, seized by the educational actions in the nursing consultation, were described in the natural attitude of the clients and their family members. Thus, the speeches converged into the categories described below.

Expectations when going to the nursing consultation

The clients showed that the consultation is a learning resource for the improvement of the quality of life through the educational actions. In this sense, they understand that the consultation with the nurse provides guidance to face and experience the CKD, since they understand the proposal of conservative treatment, from the clarification of doubts, and thus clarify the supposed beliefs, without ignoring the social relations that affect the world. The following statements depict this expectation.

Caring for the other to face the adversities imposed by the disease

Clients' caregivers understand that the consultation is an altruistic strategy for the population. Thus, the system of relevance, that is, the set of priorities and preferences of the subjects favors the control of the CKD, since they classify to receive "different" and pertinent guidelines, demonstrating that the consultation is satisfactory and allows support so that they can live well and face adversities with their being. The testimonies portray this perception.

DISCUSSION

The testimonies revealed that the clients and their caregivers have perceptions regarding the participation in the nursing consultation and its contribution during the conservative treatment. The educational actions in the consultation are aimed at providing understanding of the disease and a sharing strategy, in view of the need of interaction and support during the treatment.

The study points to the consultation as an instrument capable of not only encompassing specific needs but also as space for coping with other everyday demands, such as stigmas and barriers that permeate some diseases, revealing sociocultural aspects that also need to be addressed¹⁵ .

In this way, nurses must be able to develop their creativity and sensitivity in an active, systematic and continuous way so that they can identify the quantity and quality of their care. This allows that their actions, considered as a live work in acts, systematized and based on knowledge, as well as in previous experiences and in their own intuitive concepts, specific ways of seeing and describing the practice, turn to the care of individuals, providing them with the safety, comfort and well-being necessary to help the human being to experience the health-disease process ¹⁶.

In this sense, in CKD, clients assisted in the conservative treatment by a prepared and stimulated team need resolute actions that aim at their peculiarities, as well as those of their caregivers, that include plausible educational actions for this group and that encourage support and self-care. In this way, educational actions should be considered as priorities in policies for prevention, diagnosis and early treatment, allowing people to develop a critical awareness of the cause of their health problems¹⁶.

It is evident in the statements that the educational actions that they learn in the consultations are necessary and in line with the reality of each one of them, emphasizing the measures of protection and identification of possible problems and teaching how to overcome these problems in their daily life.

The educational approach aims to clarify relevant details about the disease and to teach the adoption of self-management practices in an accessible and dialogical way, with the participation of the patients, since they must know and understand the ways of caring for themselves without imposition of methods or difficulties, being active beings in their own treatment. It is relevant to attribute to the patient the profile of active agent and participant in the educational program, assisting them in the recovery and/or adaptation imposed by the CKD¹⁷.

International studies have shown that adjuvant support of nurses in nephrology is promising, as a reduction in the rate of progression of CKD and improvement of renal function has been demonstrated. The results have also showed measurable improvements in health behaviors, as well as a reduction in the length and number of hospital stay^9,18.

The studies also complement the relevance of the viability and the potential effectiveness of an integrated care model for CKD management, because during the course of interventions led by nurses there was improvement in the control of risk factors for CKD progression. Client adherence to medication and lifestyle counseling can be improved with integrated intervention, indicating that clients considered to be at high risk are sometimes willing to engage in lifestyle changes when they receive adequate support and education to manage their condition combined with empowerment by improving self-care skills^9,18.

Thus, the team will only promote behavioral changes if it understands that the uniqueness of the human being can only be understood when one has direct contact with it. The interest in the biography of each client enables professionals to know their universe, regardless of their configuration, and help building the model of care. This means that private interests may be in the same context as the interests of a group ¹².

Within the biographical context, it is relevant to address the individual's ability to obtain, process and understand basic health information and services necessary to make important decisions to one's own health and to medical care. It is necessary to consider that the stress resulting from the diagnosis of a serious illness and the overload of information to be followed contribute to inadequate learning and, consequently, trigger negative clinical outcomes. However, the client's understanding of information regarding his/her illness should be assessed at each consultation in an attempt to eliminate health disparities¹⁹.

Thus, educational actions need to meet not only the capacity of understanding of chronic renal clients, but even that of their caregivers, given the need to place them as actors in their stories. The experience in the outpatient clinic was therefore useful to refer clients and their caregivers to the nephrology service so that they could know the steps of a renal replacement therapy through hemodialysis and peritoneal dialysis and thus reveal the beliefs that permeated the daily life of these individuals.

Thus, a study conducted in southern Brazil revealed that when clients in advanced stages are prepared and referred earlier, emergency procedures can be avoided. For this purpose, they need to make the best treatment choice. Chronic renal patients on conservative treatment demonstrate to know the risks of complications in relation to the guidelines received and to be aware of their health condition and commitment to the requirements for the maintenance of the treatment²⁰.

So when the client decides how and where to go with their treatment, many of them have the support of their close caregivers, whether these individuals are linked as members of their own family or those brought together though social life. By the way, some participants in this study had the collaboration of people who, although not having a family relationship, acted in an active way in the life of the renal patient, participating in all decisions.

A study carried out in the interior of São Paulo that aimed to evaluate the social and emotional support of people undergoing hemodialysis revealed that the most frequent sources of support included support from the family, partners, spouse, girlfriend or boyfriend and friends²¹.

The results of this study are in line with a study conducted in São Paulo with hypertensive patients with and without renal disease, showing that the association of renal disease with marital status was significant, with predominance of individuals with a partner in this group. The authors also mentioned that living together as a couple has been an indication of family support, which would be related to better adherence to the treatment of chronic diseases and better health outcomes²².

Thus, the presence of the caregiver should be seen as essential in the process of coping and continuing with the treatment. The presence of the caregiver in the consultation is essential, since he/she can learn, ask questions, present his/her conditions and wishes, that is, be heard. Thus, when interacting with the caregiver, the nurse is able to unveil feelings and propose plausible health actions through intersubjective care.

This care is linked sociologically when it indicates that intersubjectivity is crucial to understanding human existence, seeking the subjective meanings of the acts and phenomena of the historical development constructed by man. Being inserted in the world also means communicating with it and, as communication presupposes intersubjectivity, these typifications sustain the whole social relation in which the individual was born¹².

In this context, it is already known that the experience with chronic disease is permeated by ways of coping and encouragement, especially when patients discover the disease and need support. The relationship of these patients with their caregivers has been highlighted in the researches, however, in the reality experienced, many face the anguish of how their beings will deal with the disease, and some go through these moments with enthusiasm.

A study with clients undergoing dialysis has revealed that the constructs of hope, spirituality and optimism need to be considered in the care provided by health professionals in order to assist patents in coping with the disease and the treatment of chronic kidney. Also, these professionals should be committed to considering the level of these constructs in health assessments²³.

The coping directed at the emotion or problem of clients in dialysis was characterized by strategies of attachment to religion/belief, seek of family support, denial and avoidance. Resilience emerged as a mode of acceptance and a new meaning to their experiences, seeking adherence to treatment and care in an attempt to minimize the problems caused by the disease²⁴.

The reaction in the face of the disease and the strategies used by the individuals seem to constitute important factors that need to be considered for the promotion of health and quality of life of these clients. Understanding the coping measures will allow the health team to offer adequate support in order to prevent attitudes of pessimism and discouragement in the face of illness²⁴.

It is clear that information and guidance on the illness need to be provided individually so that the linkages can be strengthened. Thus, it is necessary to pay attention to the issue of personalized and welcoming care as a promoter of autonomy in view of its importance the improvement of living conditions, as the disease progresses^7,25,26.

Thus, the nursing consultation must be intensified and strengthened by the health services, so that it is a possibility of an effective strategy of adherence to the treatment and that the professionals involved commit themselves to the care provided, considering that the dimensions of their actions turn to the growth of population.

CONCLUSION

The present study presented the daily life of the chronic renal clients and of their families, as well as the positive modification when they learn and acquire, through educational actions, abilities to deal with their limitations. In addition, the relationships they have allow them to recognize the values of their clinic, as a priority on the value focused on relational care, either with their relative or with the nurse.

This study has limitations characterized by the specificity of the studied population and for being in a local reality. As contributions, it points out the need to look at the care provided to people with CKD, and the research allows reflections that may impel changes in the prevention and management of chronic complications of the disease and subsidize new assessments in the area.

Thus, it enables constructing new health practices in the perspective of the perception of other ways of doing and taking care, given the meaning of daily suffering and confrontations in which clinical care recognizes these limits to break with the instituted way of intervening, thus enhancing health promotion actions.

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