ORIGINAL ARTICLE*

Nursing consultation: care from the perspective of the person with type 2 diabetes mellitus**

Consulta de enfermagem: o cuidado na perspectiva da pessoa com diabetes mellitus tipo 2

Consulta de enfermería: atención desde la perspectiva de la persona con diabetes mellitus tipo 2

Cortez, Daniel Nogueira[1]; Santos, Marine Tavares[2]; Lanza, Fernanda Moura[3]

ABSTRACT

Objective: to know the perception of the person with type 2 diabetes mellitus about the individual and collective nursing consultation carried out in the Family Health Strategy. Method: qualitative study based on the theory of symbolic interactionism with 15 users followed by a nursing consultation following an intervention protocol and behavior change, for six months in 2017. Data collected through a focus group and analyzed using the Content Analysis technique in thematic modality. Results: when the nursing consultation is instituted, the user begins to perceive the nurse as one of the actors involved in their care, in addition to referring to behavioral changes and benefits after being followed up. Conclusions: the nursing consultation has a positive impact on the daily life of people with diabetes mellitus, as it helps the user to recognize their chronic condition, demystifies fear, contributes to empowerment and increased self-care.

Descriptors: Nursing; Family health strategy; Nursing assessment; Nursing process; Diabetes mellitus, type 2

RESUMO

Objetivo: conhecer a percepção da pessoa com diabetes mellitus tipo 2 sobre a consulta de enfermagem, individual e coletiva, realizada na Estratégia Saúde da Família. Método: estudo qualitativo, fundamentado na teoria do interacionismo simbólico, com 15 usuários acompanhados por consulta de enfermagem, seguindo protocolo de intervenção e mudança de comportamento, por seis meses, em 2017. Dados coletados por meio de grupo focal e analisados mediante a técnica de Análise de Conteúdo na modalidade temática. Resultados: ao ser instituída a consulta de enfermagem, o usuário começa a perceber o Enfermeiro como um dos atores envolvidos em seu cuidado, além de referir mudanças de comportamento e os benefícios após serem acompanhados. Conclusões: a consulta de enfermagem tem impacto positivo no cotidiano da pessoa com diabetes mellitus, pois auxilia o usuário a reconhecer sua condição crônica, desmistifica o medo, contribui para o empoderamento e o aumento do autocuidado.

Descritores: Enfermagem; Estratégia saúde da família; Avaliação em enfermagem; Processo de Enfermagem; Diabetes mellitus tipo 2

RESUMEN

Objetivo: conocer la percepción de la persona con diabetes mellitus tipo 2 acerca de la consulta de enfermería individual y colectiva realizada en la Estrategia de Salud Familiar. Método: estudio cualitativo basado en la teoría del interaccionismo simbólico con 15 usuarios seguido de una consulta de enfermería siguiendo un protocolo de intervención y cambio de comportamiento, durante seis meses en 2017. Datos recopilados a través de un grupo focal y analizados utilizando la técnica de Análisis de Contenido en modalidad temática. Resultados: cuando se inicia la consulta de enfermería, el usuario comienza a percibir a la enfermera como uno de los actores involucrados en su atención, además de referirse a los cambios de comportamiento y los beneficios después de un seguimiento. Conclusiones: la consulta de enfermería ayuda al usuario a reconocer su condición crónica, desmitifica el miedo, contribuye al empoderamiento y al autocuidado.

Descriptores: Enfermería; Estrategia de salud familiar; Evaluación en enfermería; Proceso de enfermería; Diabetes mellitus tipo 2

INTRODUCTION

Diabetes Mellitus (DM) is regarded as a public health problem, with relevant epidemiological impact among chronic non-communicable diseases. In Brazil, in 2019, estimates were that 16.8 million people had DM, with a projection of 26 million in 2045. Regarding expenses, in 2019, Brazil was third among the countries that most spent on treating this condition, globally, after the United States and China.¹ In 2013, a study carried out by the National Health Survey identified the prevalence of DM in 6.2% of the adult Brazilian population.²

In view of the epidemiological situation associated with multiple factors (hereditary, individual and social) that interfere in managing controlling DM, care and treatment actions can be considered a challenge in the country.^3-4 Another trait of this chronic condition is that self-care practices account for by 98% of the treatment, thus requiring health professionals to provide support and facilitate care.^5-6 This type of self-care-based assistance transcends biomedical models, still  dominant in Brazil.^6-8

In this context, the Primary Health Care (PHC) directive is, preferably, to be the user’s gateway into the health system, and to act holistically in promoting health, preventing diseases and complications, providing treatment and health maintenance.⁸ PHC describes Family Health Strategy (FHS) as the main strategy for consolidating its guidelines, and places the nurse practitioner as a member of an interdisciplinary team.^7-8

As team members, nurses must accompany patients with chronic DM using a nursing consultation carried out by continuous data collection, by nursing diagnosis, implementing necessary requirements, and evaluating processes, based on clinical reasoning for decision making and care planning.^7,9 Studies have shown that nursing consultation and educational actions, once structured, have an impact on health self-management, increase incentives to self-care and contribute to behavioral changes.^4,10-11

However, nursing consultation is not yet an official practice in most health services in Brazil and, even when performed, it has gaps in implementation and execution.^3,11 Interest in this theme arose during Nurse Residency in Primary Care / Family Health, which pointed the following research problem: what is the perception of users with type 2 DM about individual nursing consultations and meetings held at the FHS?

Researching the chronic condition of DM in PHC is always a current and relevant theme, in view of the epidemiological magnitude and the impact on health systems; it is therefore an opportunity to discuss the role of nurses in this context. Thus, the goal of this study is to know the perception of people with type 2 DM about individual and collective nursing consultation carried out in the FHS.

METHOD

This is an exploratory descriptive study carried out through a qualitative approach, based on the theory of Symbolic Interactionism. Qualitative research seeks to understand human beings and the complexity of their relationships experienced in the environment they live, allowing for one to describe and explore both individual and collective subjectivity.¹² Symbolic Interactionism, on the other hand, is a theoretical perspective that seeks to understand reality and individual uniqueness based on the meaning experienced through social interactions.¹³

The study was developed at a Family Health team that opened in 1999, in a medium-sized municipality in the State of Minas Gerais, Brazil; it has 43 Primary Care Units, out of which 32 are FHS with coverage of 50.8% of the population, and 11 Traditional Units. The FHS set for this study has 2,689 people connected to it, 90 of whom were registered with a diagnosis of type 2 DM. It should be noted that, even though this FHS has been in activity for a long time, the then existing nursing consultation was not systematized, and occurred sporadically. When Family Health Residence was implemented at the unit, in 2016, the process of organizing this demand began.

In this perspective, for nurses to implement consultation, the 90 registered users diagnosed with type 2 DM were located and invited; Community Health Agents visited them, or called them personally, or yet approached them at the FHS, asking them to schedule an appointment, participate in health education groups, and be visited by nurses at home. This service also followed the Ministry of Health recommendations.⁷

For individual and collective nursing consultations, an intervention protocol was used in which a nurse or a Nursing Resident should accompany the user for at least six months, with at least two nursing consultations and two educational health activities during the period, carried out at home or at the unit itself.

For developing all activities, a “Behavioral Change Protocol” was defined as basis, which is valid for Brazil¹⁴, and consists of five stages: 1) problem definition; 2) addressing feelings and concerns; 3) setting goals; 4) ways of carrying them out and 5) assessing actions and results. This instrument directs professionals to act as facilitators, based on empowering practices where the user is led to reflect on their chronic condition and then change their behavior.¹⁵

The study included users with type 2 DM over 18 years of age with preserved cognitive ability, who performed daily activities and self-care independently, and who accepted to take part in all stages of the study. An Informed Consent Form was presented to each participant; it was read and, after consent, signed in two copies.

Considering user availability to participate in all activities provided for in the intervention protocol, for at least six months, the monitoring in the nursing consultation initially had 22 participants. During the estimated time, three users withdrew, claiming they worked at the times the unit carried out its activities, and four users changed their coverage area during the intervention, between September 2016 and June 2017.

The eligible participants were then 15 users who took part in all stages of the intervention protocol; they were invited, by telephone, to take part in the study on their perceptions regarding the nurse’s performance in both individual and collective nursing consultations.

A focus group was chosen for data collection. This technique allows for the emergence of elements that participants experience, by interaction and exchange during the group dialogue.¹⁶ The following questions were used: a) Describe what you have seen when you consulted with the nurse; b) How did you describe your self-care towards diabetes mellitus before and after the consulting with the nurse; c) What most caught your attention when consulting with the nurse?

Two focus groups were carried out, according to user availability. The guiding questions for the focus group were not previously tested, but it is noteworthy that the facilitator who conducted it is an expert in both DM and focus groups, and did not participate in any stage of the nursing care established in the intervention protocol, so that there would be no inhibition on the reports towards the collection script guiding questions.

Sessions took place in the health unit, the setting of this study, on the evening, and only the participants and the facilitator were present; they happened during May 2017; 11 people participated on the first one, and four on the second. Audio was recorded, with 70 and 60 minutes, respectively.

For data analysis, the thematic-categorical Content Analysis technique was chosen, allowing for the discovery of the meaning clusters that make up communication, and for performing its regrouping into empirical categories.¹² After collection, materials of the focus groups were organized and transcribed in full, and did not return to the study participants either for corrections or comments. To guarantee participant anonymity, groups were identified as G1 (Focus Group 1) and G2 (Focus Group 2). A content analysis was carried out by the main researcher, without using any qualitative data analysis software.

This study has no conflicts of interest and was developed based on the National Health Council Resolution #466 of December 2012. Data collection started after the project was approved by the Research Ethics Committee of the Universidade Federal de São João del-Rei (UFSJ), CAAE 58517416.5.0000.554. This article is based on a completion of residency research paper that is published on the UFSJ repository (https://ufsj.edu.br/portal2-repositorio/File/resenf/Marine%20TCC.pdf).

RESULTS

46.7% (7) of the 15 study participants were men with average 59.8 years of age (±6.2) and 53.3% (8) were women with an average 65 years of age (±10) ,9). Regarding education, 6.7% (1) were illiterate, 66.7% (10) had 1 to 8 years of education, and 26.6% (4) had 9 to 12 years. Regarding professions, 60% (9) were retired, 20% (3) declared themselves to be home homemakers, 13.3% (2) worked informally and 6.7% (1) were unemployed. Average time of diagnosis for the chronic condition (DM2) was of 11.4 years (±10.3). As for referred complications, 6.7% (1) underwent nephrectomy, 6.7% (1) had had an Acute Myocardial Infarction and 13.3% (2) had already undergone Cardiac Catheterization.

Regarding the intervention protocol, 22 nursing consultations were carried out at the health unit, where eight users participated in one (53, 3%) and seven (46.7%) in two; 35 consultations took place at home, where one user was visited once (6.7%), six (40%) were visited three times, and eight (53.3%) were visited twice. A total of five health education groups were carried out; ten users (66.7%) took part in two of them, and five (33.3%) took part in three. Thus, the minimum activities performed by the intervention protocol were achieved.

From content analysis of the theme, two empirical categories were distinguished: User perception regarding nursing consultation and User empowerment by means of nursing consultation: a dialectic between construction and “regression”.

Category 1: User perception regarding nursing consultation

Nursing consultation for DM was not common at the FHS, so the research participants came to see the nurse practitioner as one of the provided health care actors, pointing out that recognizing the nursing consultation is part of the process.

I think that this contact with (the Nurse) made us feel safe about the treatment, under control, so we won’t mess up [...] so we take the medicines the right way, attend the meetings, right? [...]. (G1)

At the (Nurse) consultation, she really talks to you, gives you the opportunity to open up and talk, right. So she explains the effects, because it is no use for the doctor to say it like this: You stop taking it, this one, because you are diabetic. (G2)

In this context, the user, when recognizing the services available by the team and those that are provided, reflects on the need to value what their FHS makes available, and hopes that such care is kept.

Just last week, I was talking to a guy, and he said that I was lucky, because he says that he visits the FHS at (name of the strategy) [...] does not monitor anything about diabetes. I spoke to him: but there is a nurse at our clinic [...]. (G1)

Category 2: User empowerment from nursing consultation: dialectic between construction and “regression”

Users, when facing their chronic condition, are often unaware of the implications of such a diagnosis for their everyday lives, especially when it comes to cultural issues that may interfere with their worldview and choices.

And when we don’t know the disease, we’re always scared, right? [...] what I heard people say about diabetes, I heard of amputations because of diabetes, and that made me feel scared. Now that we all here got an explanation, we know what the disease is, we deal with it better, right? (G1)

The participants understood that both individual and collective nursing consultations allowed for reviewing old concepts and being open to new conceptions, thus building a foundation for more conscious choices.

[...] it was very important because I was so afraid, with diabetes I was really afraid. (G1)

Users begin to question, to accept themselves, to realize how they stand towards their self-care, and what are the long term implications.

Just as I said: taking medicine is easy; you can’t eat this and this and that. Why? Because you have diabetes [...] But then, that alone is not enough. (G2)

Thus, individuals can empower themselves in face of their condition, and choose based on knowledge acquired during nursing consultations and educational actions.

We couldn’t eat anything; then I learned that we can actually eat everything, but with moderation. So it’s something I’ve been learning. (G2)

It was found that users start to recognize the results achieved from implementing actions that change their lifestyle.

I changed a lot, because it (Glycemia) was always 400 to 600 [...] now it is one hundred, one hundred and something. (G1)

However, some pre-established concepts remain even after monitoring that should be valued and demystified in future approaches.

I think you catch this thing [...] I do not know why this disease has appeared, because my grandfather died of old age. (G1)

DISCUSSION

Study results show that low education and time to diagnosis are similar to other findings and should be critically reflected by the nurse practitioner, since these variables influence the user’s knowledge regarding their chronic condition, and they are relevant when planning care. ^11.17-18

Health care actions planned in different ways, aiming at individual particularities, and encouraging health promotion and self-care are increasingly valued in the DM management, due to the positive impact on the user's life.^15,19 A randomized clinical study followed local users by using this paradigm, and had positive results both in metabolic control and behavioral changes in self-care.

However, there are several daily obstacles for both nurses and the health teams that hinder recommended care practices, such as: high demand, fragility in reference and against reference, inefficient management support, health care maintenance based on biomedical model^3-4 Such factors can influence the user / team relationship and weaken longitudinal care.^18,20-21

This study shows that nursing consultation was not an instituted reality at the FHS as recommended, even though DM is a health care priority target. Similar situations have been observed in other places, where, in addition to its being superficially accomplished, biomedical model maintenance is also present.^18,20-21

Due to the barriers presented by the health system, and the possible individual limitations of professionals, users may not perceive nurses as actors who are involved in their care process, either due to incipient actions performed or failure to routinely perform nursing consultations in the assistance provided. This complex web of relationships and factors can interfere with DM self-care.^18,20

An interactionist perspective sees human nature as the product of communication, and subjects are constantly being constructed via experience.¹³ Thus, social, cultural, and individual issues must be respected and valued, since they influence choices and attitudes regarding health and can become facilitators or barriers in obtaining good results from operations performed.²²

As evidenced in this study, users attended to in a dialogic and systematized process, whether individually or in groups, interact with nurses, receive the care provided, get stronger and build knowledge about their condition, and there is also an exchange of experiences with their peers.^14-15 From the point of view of symbolic interactionism, these points are related and cause reframing of old concepts and openness to new knowledge, transforming subjects over time.¹³

Using Behavior Change Protocol as a guide for implementing care addresses individual needs and works on potentials and limitations, in order to stimulate a feasible care plan, which is defined by the user. ^7,13-15

It is advisable that educational actions about DM in groups or individuals are carried out by nurses and staff, to address topics that encourage self-care.^7,18 The importance of improving the level of user knowledge about their chronic condition and thus instigating their empowerment and sensitizing them about co-responsibility in health care is highlighted, because, and according to symbolic interactionism, individuals act based on what is significant to them.^13,15

A study points out that assessing an educational program, organized and carried out systematically, which was carried out five years after its end, identified the lasting effect of its actions.¹⁸ Using symbolic interactionism and results, this finding allows one to infer that the knowledge users acquire during nurse consults has been significantly internalized.¹³

Results from systematic review showed that nurses have an important role in DM treatment, so that it is necessary to eliminate barriers that stop them from adequately provide care. Besides, this study also described nurses as facilitators of knowledge and advisors of self-care.²³

Such contact, from communication, makes interaction possible between nurses and patients; a significant symbolism arises when this relationship is analyzed from a symbolic-interactionist point of view, since users receive care that becomes significant for them and not just for the nurses.

The positive results of following DM patients show that it is imperative that nursing actions be permanent, for behavioral change does not happen based on a single interaction. Educating adults is complex and needs repetition, always focusing on individual subjectivity.^5,15,17-18

Study limits have to be highlighted, such as using focus groups instead of individual interviews, some users’ natural inhibition, and the short interval of six months of attendance. As a way of making it easier for all parts, in focus groups facilitators tried to stimulate all users into sharing their opinions, while granting secrecy.

FINAL REMARKS

Nursing consultation, individually or in a group, and when planned and focused on care, helps users acknowledge their chronic condition, to demystify fear, while stimulating empowerment and self-care. It is important that nurses empower themselves regarding their duties, and that nursing consultations are instituted within health services systematically and based on updated evidence.

It is expected that the present results stimulate PHC nurses to carry out nursing consultations routinely and with guiding instruments, considering the positive reports of this monitoring.  Besides, other studies are also needed that encompass nurses’ perception on both provided care and management, notwithstanding these actions, as a means of monitoring perceptions with the goal of enhancing and consolidated nurse consultations.

REFERENCES

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18 Lima AF, Moreira ACA, Silva MJ, Monteiro PAA, Teixeira PG. A percepção do idoso com diabetes acerca de sua doença e o cuidado de enfermagem. Ciênc. cuid. saúde. [Internet]. 2016[acesso em 2020 jun 15];8(3):4841-9. Disponível em: http://dx.doi.org/10.4025/cienccuidsaude.v15i3.30884

19 Maia MA, Reis IA, Torres HC. Relationship between the users’ contact time in educational programs on diabetes mellitus and self-care skills and knowledge. Rev. Esc. Enferm. USP. [Internet].  2016[cited 2020 June 15];50(1):59-65. Available from: http://dx.doi.org/10.1590/S0080-623420160000100008

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21. Radigonda B, Souza RKT; Cordoni JrL; Silva AMR. Avaliação do acompanhamento de pacientes adultos com hipertensão arterial e ou diabetes mellitus pela Estratégia Saúde da Família e identificação de fatores associados, Cambé-PR, 2012. Epidemiol. Serv. Saúde (Online). [Internet]. 2016[acesso em 2020 set 16];5(1):115-26. Disponível em: https://doi.org/10.5123/S1679-49742016000100012

22 Paducha A, Kuske S, Schierecka T, Drostea S, Loerbroksc A, Sorensend M, et al. Psychosocial barriers to healthcare use among individuals with diabetes mellitus: a systematic review. Prim. care diabetes. [Internet]. 2017[cited 2020 June 15];11(6):495-514. Available from: https://doi.org/10.1016/j.pcd.2017.07.009

23 Nikitara M, Constantinou CS, Andreou E, Diomidous M. The role of nurses and the facilitators and barriers in diabetes care: a mixed methods systematic literature review. Behavioral Sciences [Internet]. 2019[cited 2020 June 15];9(6):61. Available from: https://doi.org/10.3390/bs9060061

Submission date: 18/05/2020

Acceptance date: 11/12/2020

Publication date: 06/01/2021