gadalean ioana cristina(1).pdf

8/9/2019 Gadalean Ioana Cristina(1).pdf

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REZUMATUL TEZEI DE DOCTORAT

Criterii i mijloace de evaluare a

performanei n nur!in"

Doctorand Ioana Cristina Gdlean

Conduc#tor de doctorat $rof% Dr% Andrei Ac&ima Cadariu


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CUPRINS

INTRODUCERE '(

STADIUL ACTUAL AL CUNOATERII

1. Calitatea serviciilor edicale ')

'%'% Componentele calit#ii !erviciilor medicale '*

'%+% Calitatea !erviciilor medicale din per!pective diferite ',

!. Indicatori de calitate +'

+%'% Definirea indicatorilor de calitate ++

+%+% -m.un#t#irea calit#ii +*

+%/% Evaluarea performanelor +0

+%1% 2radul de !ati!facie al pacientului +,

". Indicatori de calitate #n n$rsin% //

/%'% Definirea nur!in"3ului // /%+% Modelul A!ociaiei Americane de 4ur!in" /1

/%/% Modelul 5erviciului 4aional de 5#n#tate 5coian /0

CONTRI&U'IA PERSONAL(

1. I)ote*a de l$cr$+o,iective 1)

!. St$di$l 1 - Eval$area satisac/iei )acient$l$i 10+%'% Introducere 10

+%+% Ipote6a de lucru7o.iective 1,

+%/% Material i metod# 1,

+%1% Re6ultate 18

+%)% Di!cuii )*+%*% Conclu6ii ),

". St$di$l ! - Eval$area )eroran/elor asistentelor edicale de ctre

ec0i)a edical)8

/%'% Introducere )8

/%+% Ipote6a de lucru7o.iective )8

/%/% Material i metod# *(

/%1% Re6ultate *'

/%)% Di!cuii 0+

/%*% Conclu6ii 0)

. St$di$l " Inciden/a 2i actorii de risc a delir$l$i )osto)erator la)acien/ii s$)$2i c0ir$r%iei oncolo%ice colorectale

00

1%'% Introducere 00

1%+% Ipote6a de lucru7o.iective 0,

1%/% Material i metod# 0,

1%1% Re6ultate 08

1%)% Di!cuii ,1


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1%*% Conclu6ii ,*

3. Concl$*ii %enerale 4sinte*5 ,,

6. Ori%inalitatea 2i contri,$/iile inovative ale te*ei 8'

RE7ERIN'E 8+

ANE8E 99

Cuvinte c&eie : nur!in" ; indicatori de calitate; performan#; !ati!facia pacientului


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INTRODUCERE

Implementarea unui !i!tem de monitori6are e!te e!enial# pentru reali6area unui pro"ram de

m.un#t#ire a calit#ii% C&iar i n ca6ul re!ur!elor limitate !e pot folo!i metodele !i!tematice pentru

a monitori6a n mod re"ulat calitatea n"rijirilor% Un .un !i!tem de monitori6are tre.uie !# !e

adapte6e !ituaiei e9i!tente n or"ani6aia n care !e implementea6# pro"ramul< el tre.uie !#

pornea!c# de la definirea celor mai importani indicatori pentru a ajun"e treptat la !ta.ilirea unui !et

c=t mai complet% Cuantificarea efectului pe care a!i!tenta i activitatea de nur!in" efectuat# de

acea!ta o au n calitatea proce!ului de n"rijire; n evoluia pacientului a devenit e9trem de

importanta pentru a de6volta planuri de per!onal .a6ate pe evidene; pentru a nele"e impactul

nur!in"ului i pentru a optimi6a evoluia pacientului %

Monitori6area calit#ii n"rijirilor e!te proce!ul colect#rii re"ulate i anali6ei unui !et de

indicatori de calitate; i !e a9ea6# mai de"ra.# pe m#!urarea i anali6a proce!elor% Ace!t proce!

permite furni6orilor de !#n#tate !# evalue6e m#!ura n care !unt atin!e o.iectivele unui pro"ram !auperformana "lo.al# %

STADIUL ACTUAL AL CUNOATERII

Or"ani6aia Mondial# a 5#n#t#ii definete calitatea !i!temului de !#n#tate ca nivelul

atin"erii !copurilor intrin!eci ale !i!temului de !#n#tate pentru m.un#t#irea !#n#t#ii i capacit#ii

de r#!pun! la atept#rile "enerale ale populaiei%

$e de alt# parte; p#rintele conceptului modern de calitate; Dona.edian; de!crie calitatea n"rijirilor

de !#n#tate drept acele n"rijiri care !e ateapt# !# ma9imi6e6e dimen!iunea .un#!t#rii pacienilor;

lu=nd n con!iderare ec&ili.rul c=ti"urilor i pierderilor ateptate; care apar n toate etapele

proce!ului n"rijirilor de !#n#tate%

Activitatea de evaluare n nur!in" a nceput c=nd >lorence 4i"&tin"ale a identificat rolul

a!i!tentelor n n"rijire; n calitatea n"rijirii i a nceput !# m#!oare evoluia pacienilor% Ea a utili6at

metode !tati!tice pentru a crea rapoarte care calculea6# evoluia pacienilor n funcie de condiiile

de mediu% $e parcur!ul timpului evaluarea calit#ii n !#n#tate a evoluat% Munca f#cut# n '80( de

A4A; r#!pndirea lar"# a a!i"ur#rilor de calitate i introducerea modelului lui Dona.edian

?!tructur#3proce!3evoluie@ a dovedit o metod# compre&en!iv# pentru evaluarea calit#ii n"rijirii%

Re!tructurarea forei de munc#; nceputul anilor 8(; a demon!trat nece!itatea pentru A4A !#

evalue6e ec&ipa de nur!in" i !# identifice le"#tura ntre acea!ta i evoluia pacientului%2&idul american in!tituit de >orumul 4aional de Calitate a !ta.ilit un !et de m#!uri pentru a

o.ine un ta.lou clar al performanei i calit#ii n"rijirii pacientului de c#tre a!i!tente% 5etul de

m#!uri are ca element central o .oal# !au un !indrom% M#!urile urm#re!c !tructura; proce!ul i

re6ultatul n"rijirii n relaie cu .oala% 5etul de m#!uri iniiale includ m#!uri centrate pe pacient;

m#!uri centrate pe intervenia a!i!tentei i m#!uri centrate pe !i!tem% Datele deriv# din proce!ul de

urm#rire; datele admini!trative ale pacientului i nre"i!tr#rile de la re!ur!e umane%


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Cuantificarea efectului pe care a!i!tenta i activitatea de nur!in" efectuat# de acea!ta o au n

calitatea proce!ului de n"rijire; n evoluia pacientului a devenit e9trem de important# pentru a

de6volta planuri de per!onal .a6ate pe evidene; pentru a nele"e impactul nur!in"ului i pentru a

optimi6a evoluia%

-n decem.rie +((+ ; auditul !coian a pu.licat un raport intitulat : $lanificarea nur!in"ului3pro"ram !au de!i"nB% Raportul nota c# n ciuda num#rului mare de a!i!tente medicale i infirmiere i

a importanei lor n !i!temul de !#n#tate !coian; informaiile oferite !unt limitate la nivel naional%

Acea!ta face dificil# compararea num#rului de a!i!tente; a co!turilor; a calit#ii% 5e tie puin de!pre

planul de lucru i nece!arul de for# de munc#% Ca re6ultat al ace!tor factori; e9i!t# o mare varietate a

per!onalului n 5coia ; a co!turilor a!ociate i a impactului a!upra n"rijirii pacienilor%

I)ote*a de l$cr$+o,iective

5tudiul nur!in"ului e!te e9trem de comple9 aa nc=t definirea calit#ii ace!tuia nu e!te uoar#%

E!te "reu de reali6at o le"#tur# cau6#3 efect ntre activitatea de nur!in" !au lip!a ei i evoluia

pacientului acea!ta fiind influenat# de: !tarea pacientului ; activitatea a!i!tentei medicale ; aciunea

celorlali mem.ri ai ec&ipei medicale ; or"ani6area !pitalului%

De aceea lucrarea de fa# ii propune !# anali6e6e mai multe a!pecte ale performanei

activit#ii de nur!in"%

$rimul a!pect anali6at e!te "radul de !ati!facie al pacientului% 2radul !ati!faciei pacientului

e!te le"at de calitatea actului medical; dar deriv# i din condiiile n care i de!f#oar# munca; iar

e9i!tena !ati!faciei duce la creterea performanei% $rintre a!pectele !ati!faciei pacientului care

tre.uie luate n con!iderare !e afl# i n"rijirile acordate de a!i!tentele medicale% A!tfel primul !tudiu

pre6entat n lucrarea de fa# evaluea6# "radul de !ati!facie al pacienilor internai n !ecia A%T%I% a

In!titutului Oncolo"ic Ion C&iricu# Cluj34apoca%

Al doilea a!pect anali6at e!te evaluarea performanei profe!ionale a a!i!tentelor medicale de

c#tre ec&ipa medical# ? medici i a!i!tente medicale@% Ace!t lucru e!te nece!ar deoarece calitatea

te&nic# a actului medical nu poate fi anali6at# o.iectiv de c#tre pacient%

Ultimul !tudiu cuprinde un indicator te&nic i anume rolul a!i!tentei medicale n prevenirea

delirului po!toperator% Delirul po!toperator e!te o complicaie frecvent#; care poate fi prevenit# %

Introducerea unor !cale de evaluare a ri!cului de delir permite apoi a!i!tentelor medicale !# introduc#

n practic# protocoale non3farmacolo"ice de prevenie a ace!tuia% A!tfel ; o complicaie nepl#cut#

pentru pacient i familie ; cu con!ecine n"rijor#toare poate fi prevenit#; ceea ce duce la cretereacalit#ii actului medical i !c#derea co!turilor aferente%


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!. St$di$ 1. Eval$area satisac/iei )acient$l$i

Calitatea inter)ersonal e!te partea perceput# de pacient7 client% -n mod o.inuit;

pacienii nu po!ed# a.ilitatea !au cunotinele nece!are evalu#rii competenei te&nice a

furni6orului !au a felului n care au fo!t folo!ite m#!urile de control al infeciilor; dar tiucum !e !imt; cum au fo!t tratai i dac# nevoile; atept#rile le3au fo!t ndeplinite% Ei !e

raportea6# ade!eori la po!i.ilitatea de a pune ntre.#ri; i pot aprecia un !erviciu medical

ca fiind convena.il !au nu%

Cercet#rile n domeniu demon!trea6# c# !ati!facia !e relaionea6# cu percepia

aptitudinilor te&nice; inteli"ena i calificarea per!onalului medical% Totui; pacienii aprecia6#

prioritar aptitudinile de comunicare interper!onal# ale per!onalului medical%

A!pecte ale !ati!faciei pacientului care tre.uie luate n con!iderare: n"rijirile medicale i

informaia; facilit#ile de &ran# i ca6are; atmo!fera; n"rijirile a!i!tentelor; cantitatea de &ran#;

or"ani6area vi6itelor%

A fo!t alea!# o !ecie de Terapie Inten!iv# pentru derularea unui !tudiu de evaluare a

!ati!faciei pacientului din dou# motive% $rimul; din punctul de vedere al pacientului i al familiei;

e!te !ecia cu cel mai mare impact a!upra lor% Iar prin pri!ma a!i!tentei medicale e!te !ecia n care

!e efectuea6# un num#r mare de manopere; inva6ive !au nu; iar nc#rc#tura emoional# e!te mare%

!.". 9aterial 2i etod

Lucrarea de fa# de!crie un !tudiu pro!pectiv ; efectuat pe un lot de '(* pacieni; internai n

!ecia de Terapie Inten!iv# a In!titutului Oncolo"ic Ion C&iricu# Cluj F 4apoca n perioada iunie+('' F au"u!t +('' % Re6ultatele o.inute au fo!t anali6ate !tati!tic de!criptiv i analitic folo!ind

aplicaia !tati!tic# 5$55% $entru evidenierea unor relaii7a!ocieri ntre varia.ilele calitative am

folo!it te!tul C&i3p#trat ? a!ociere po6itiv# dac# pG(;() @% $acienilor li !3a aplicat un c&e!tionar

anonim ; la +1 de ore dup# e9ternarea din !ecia de T%I% pentru a nu afecta !inceritatea r#!pun!urilor%

C&e!tionarul cuprinde date demo"rafice : !e9 ; v=r!t# ; nivel de !tudii < dia"no!tic ; num#r de 6ile de

T%I% ; !cor de !ati!facie% De a!emenea e!te format din dou# "rupuri de ntre.#ri : '( referitoare la

!ati!facie i /( care e9prim# in!ati!facie dintre care pacienii au fo!t ru"ai !# alea"# ); re!pectiv '(

din cei mai importani pentru fiecare n parte%

!.. Re*$ltate

-n urma centrali6#rii informaiei; dup# "ruparea pacienilor pe cate"orii mari de dia"no!tic

principal ; ponderea a revenit celor cu dia"no!ticul neo ovarian ? /0;0H @ fiind urmat# de afeciunile

la nivelul colonului ? +0; 1 H @% '1;' H din ca6uri !unt ca6uri de terapie medical# ? limfom ; leucemie@%

Media v=r!tei lotului e!te )1 ani'+ cu o durat# de !pitali6are pe T%I% de );)/ 6ile/ i cu un !cor de


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!ati!facie de 1;1*% 5tudiile medii au predominat ca pre"#tire la pacienii intervievai ?11;/H@; urmate

de !tudiile !uperioare ? /1 H@ ; iar !e9ul predominant a fo!t cel feminin% La pacienii care au ale!

"radul de !ati!facie 1? !ati!f#cut@ media num#rului de 6ile de !pitali6are n T%I% e!te );///;/)* cu IC

8)H: 1;113*;++ iar la cei care au ale! "radul )? foarte !ati!f#cut @ media num#rului de 6ile de

!pitali6are e!te );0*+;/0* cu IC 8)H );(03*;11%

".3. Disc$/ii

Din punctul de vedere al pacientului factorii care influenea6# creterea "radului de

!ati!facie !unt cei ai atitudinii emoionale i faptul c# li !e !ati!fac promt toate !olicit#rile

%Majoritatea pacienilor ?8+H@ au con!iderat c# au fo!t n"rijii core!pun6#tor% Lip!a durerilor a fo!t

!emnalat# de 18%'H din pacieni%

-n urma anali6ei !tati!tice afl#m c# mai muli factori de in!ati!facie pot afecta "radul de

!ati!facie al pacienilor% O parte dintre ei !unt le"ai de re"imul &otelier i de profilul !eciei

re!pectiv: 5aloane mi9te ? pJ(;(((@ ; Avei lumina aprin!# tot timpul ?pJ(;((8@ ; 4u avei

intimitate ? pJ(;((+@ ; -n camera n care v# aflai e!te prea cald !u prea fri" ?pJ(;(+,@% Lip!a

per!onalului din !ecia T%I% conduce la !emnificaia urm#torilor factori de in!ati!facie : $er!onalul

medical nu !e pre6int# ? pJ(;(+0@; Avei !en6aia c# a!i!tentele urm#re!c mai mult aparatele dec=t

pe dv!% ?pJ(%((+@ ; 4u vi !e e9plic# tratamentele i manoperele care vi !e fac ?pJ(;(((@; 5untei

privit ca un o.iect ? pJ(;(('@% Aa cum era de ateptat; durerea? pJ(;(((@ e!te unul dintre factorii

care influenea6# "radul de !ati!facie al pacienilor% La fel i lip!a !omnului ?pJ(;(((@; care de altfel

deriv# din a!ocierea celorlali factori ; are impact ne"ativ a!upra "radului de !ati!facie%

-n +('( ; n alt# !ecie de Terapie Inte!iv# din Cluj34apoca a fo!t ntreprin! un !tudiu !imilar; de c#tre

$op i cola.oratorii% O comparaie ntre cele dou# !tudii arat# c# majoritatea factorilor de !ati!facie

!unt aceeai; cu meniunea c# n !tudiul no!tru !unt mai frecveni menionai factorii de di!confort

care in de ar&itectura !eciei ?!aloane mi9te; nu avei intimitate@ %

". St$di$ !. Eval$area )eroran/elor asistentelor edicale de ctre

ec0i)a edical

2radul !ati!faciei practicianului e!te le"at de calitatea actului medical; dar deriv# i din

condiiile n care i de!f#oar# munca; iar e9i!tena !ati!faciei duce la creterea performanei% -nconclu6ie; ace!ta e!te un factor cau6al al nivelului calit#ii n"rijirilor ; deci poate fi folo!it drept

criteriu de evaluare a calit#ii ace!tora%

Am efectuat acea!t# anali6# n In!titutul Oncolo"ic Ion C&iricu# prin intervievarea medicilor i

a!i!tentelor medicale%


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".". 9aterial 2i etod

Ace!t c&e!tionar ori"inal; a fo!t di!tri.uit a!i!teilor medicali din !eciile clinice i paraclinice

ale In!titutului Oncolo"ic Ion C&iricu# Cluj34apoca n !copul te!t#rii opiniei ace!tora n ceea ce

privete evaluarea !ati!faciei profe!ionale i performana profe!ional# atin!# la momentul

complet#rii c&e!tionarului% -n paralel un alt c&e!tionar ori"inal a fo!t di!tri.uit medicilor din

In!titutul Oncolo"ic Ion C&iricu# Cluj34apoca n !copul te!t#rii opiniei ace!tora n ceea ce privete

evaluarea performanei atin!e de a!i!tentele medicale cu care acetia cola.orea6#%

Ace!ta a fo!t di!tri.uit n perioada mai 3 !eptem.rie +('+%

Din totalul c&e!tionarelor di!tri.uite n In!titutul Oncolo"ic Ion C&iricu# i n urma

e9cluderii celor ) repondeni din !tudiul pilot; precum i a celor care nu !e ncadrau n criteriile de

includere; ')/ de a!i!tente medicale i +) de medici au intrat n calculul !tati!tic al ace!tor

c&e!tionare%

".. Re*$ltate

Di!tri.uia !u.iecilor n funcie de nivelul !tudiilor relev# faptul c# ponderea o repre6int# cei cu

!tudii !uperioare3 *'H? 8/@ fa# de !tudiile po!tliceale /8H ? *(@% Media de v=r!t# a lotului !tudiat a

fo!t /);0');/10; iar media vec&imii n munc# pentru a!i!tentele medicale c&e!tionate a fo!t

'(;)));8/,% La ntre.area cu r#!pun!uri de!c&i!e n care a!i!tentele medicale au fo!t ru"ate !#

numea!c# / caracteri!tici care define!c n opinia lor profe!ia de a!i!tent# medical# r#!pun!urile au

fo!t variate ; cele mai frecvente fiind competena care apare la *,H dintre repondeni; r#.darea

la )0H dintre repondeni i devotament la 10H dintre repondeni%

Competena e!te con!iderat# cel mai important factor implicat n n"rijirea pacientului3 ,/ de

r#!pun!uri? )/H@% Referitor la !inta"mele care caracteri6ea6# profe!ia de a!i!tent medical n

vi6iunea !u.iecilor c&e!tionai; cele mai ale!e au fo!t pa!iunea de c#tre ,(H din repondeni;

competena 3 */H i o modalitate de a3mi cti"a e9i!tena3/'H% *,;*H din a!i!tentele medicale

intervievate !e con!ider# mulumite de performana atin!# la locul de munc#%

Cu privire la !inta"mele care caracteri6ea6# profe!ia de a!i!tent medical !3a evideniat o a!ociere

cu !emnificaie !tati!tic# ntre v=r!t# !i pa!iune ?p=(;(('@; datorie? p=(;(/@%

-n ceea ce privete opinia medicilor de!pre a!i!tentele medicale; majoritatea ace!tora ?8+H@ !unt

mulumii de performana atin!# de cola.oratoarele lor%

Media punctajului acordat de medici ?note de la ' la '(@ unor a!pecte ale cola.or#rii cu

a!i!tentele medicale !unt !ituate ntre 0;8+';08 pentru atitudine adecvat# i 8;1+(;) pentru

punctualitate%


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".3. Disc$/ii

Evaluarea !ati!faciei a!i!tentei medicale cu privire la munca depu!# precum i autoevaluarea

performanei atin!e n me!eria practicat# re!pectiv evaluarea colectivului de a!i!tente medicale e!te

o component# important# care poate avea impact a!upra !i"uranei pacientului; performanei i

calit#ii in"rijirilor % De a!emenea e!te e!enial# opinia medicilor cu privire la performana atin!# de

!taff3ul de a!i!tente medicale deoarece conceptul nvec&it conform c#ruia a!i!tenta a!i!t# medicul

e!te tot mai rar !pre deloc ntlnit# n !i!temul !anitar% Activitatea de!f#urat# n in!tituiile medicale

e!te o activitate n ec&ip# cu o.iective comune i clare : !i"urana pacientului i creterea calit#ii

actului medical%

>actorul care motivea6# cel mai mult performana la locul de munc# a a!i!tentelor medicale e!te

!ati!facia o.inut# din munca pre!tat# ? 8*H@; urmat apoi de dorina de a nv#a lucruri noi?0+;)H@%

E!te de menionat faptul c# nici un participant la !tudiu nu e!te motivat de condiiile de munc#; dar

+0;)H !unt motivai de colectivul n care lucre6# iar /'H de competitivitate% Anali6a !tati!tic# a

evideniat o a!ociere cu !emnificaie !tati!tic# ntre v=r!ta !u.iecilor i urm#toarii factori care

motivea6# performana a!i!tentelor medicale: !ati!facia o.inut# din munca pre!tat# ?p=(;('@;

competitivitatea ?p=(;(('@ dar i continuitatea locului de munc#?p=(;('@ i pre!ti"iul o.inut din

munca pre!tat#?p=(;(('@ %

-n partea a doua a c&e!tionarului unde a fo!t anali6at# evaluarea a!i!tentelor medicale de c#tre

cole"ele lor; media puncajului acordat ?note ntre ' i '(@ a fo!t a!em#n#toare pe toate a!pectele

!upu!e interviului i a fo!t cuprin! ntre ,;'* pentru di!poni.ilitatea acordat# i ,;*8 pentru modul n

care !e re!pect# recomand#rile date de c#tre medici% -n urma corelaiilor efectuate ntre media

punctajului acordat i media de v=r!t# a lotului !tudiat !3a evideniat !emnificaie !tati!tic# ntre

v=r!t# i modul n care !e re!pect# recomand#rile date de c#tre medici?p=(;((,@; ama.ilitatea la

primul contact cu pacientul ?p=(;(+@ i di!poni.ilitatea e9primat# ?p=(;((0@%

E9i!t# diferene de percepie ntre medici i a!i!tente medicale n ceea ce privete factorii care

motivea6# performana profe!ional# a a!i!tentelor medicale% -n timp ce 8*H dintre a!i!tente

con!ider# c# !unt motivate de !ati!facia o.inut# din munca pre!tat#; doar '0H din medicii

intervievai !u!in ace!t factor% Ali itemi anali6ai cu diferene mari ntre opiniile celor dou# cate"orii

profe!ionale !unt : dorina de a nv#a lucruri noi ? ,H medici v! 0+;)H a!i!tente medicale@; !alariul

primit pentru munca pre!tat# ? 0)H medici v! '*H a!i!tente medicale@; continuitatea locului de

munc# ?1+H medici v! 1H a!i!tente medicale@% De a!emenea ; nici unul din medicii intervievai

nu con!ider# c# a!i!tentele medicale !unt motivate de competitivitate%


10/25

O po!i.il# e9plicaie ar fi faptul c# ; n lip!a unor !cale de evaluare o.iectiv# a performanei

a!i!tentelor medicale ; r#!pun!urile !u.iective ale celor dou# cate"orii de repondeni determin#

a!emenea diferene% -n timp ce a!i!tentele medicale !e con!ider# motivate de a!pecte ce in de

!ati!facia moral# o.inut# din munca pre!tat#; medicii con!ider# c# nur!ele !unt motivate de

a!pectele materiale care deriv# din me!eria lor% $ro.a.il de aceea; ,/H dintre medicii care aur#!pun! c&e!tionarului con!ider# c# ar fi util# introducerea unor !cale o.iective; e9acte de evaluare a

performanei n nur!in"%

. St$di$ ". Inciden/a 2i actorii de risc )entr$ delir$l )osto)erator la

)acien/ii s$)$2i c0ir$r%iei oncolo%ice colorectale

Dup# actul ane!te6ico3c&irur"ical; muli pacieni; n !pecial v=r!tnicii ; de6volt# modific#ri

co"nitive; pierderi de memorie i concentrare; !c&im.#ri de per!onalitate i in!ta.ilitate emoional#%

Dei formele de manife!tare ale ace!tora pot fi multiple; dou# cate"orii principale !e

conturea6# ca entit#i oarecum di!tincte : delirul po!toperator i di!funcia co"nitiv# po!toperatorie%

Delirul po!toperator e!te definit ca o tul.urare a funciei co"nitive i a !t#rii de contien#

de6voltat# ntr3o perioad# !curt# de timp ? ore36ile@ i care are un caracter fluctuant%

Delirul po!toperator e!te catalo"at ca o complicaie ce poate fi prevenit# i e!te deci un indicator

de calitate al n"rijirilor medicale%

.". 9aterial 2i etod

''* de pacieni cu v=r!ta pe!te *); !upui c&irur"iei oncolo"ice colorectale i admii n !ecia

de Terapie Inten!iv# a In!titutului Oncolo"ic Ion C&iricu# Cluj F 4apoca n perioada decem.rie

+(''3 fe.ruarie +('/ au fo!t inclui n !tudiu% >uncia co"nitiv# a fo!t te!tat# n preoperator cu

MM5E% Au fo!t e9clui pacienii cu i!toric de AKC; afeciuni p!i&iatrice; meta!ta6e cere.rale; di!functii

p!i&oco"nitive preoperatorii cuno!cute; atero!clero6a cere.ral# i pacienii care au o.inut un !cor

MM5E !u. ',%

$entru dia"no!ticul delirului po!toperator !3a utili6at Confu!ion A!!e!!ment Met&od! ?CAM@

la fiecare '+ & de la admi!ia n TI pe durata primelor 0+%& po!toperator% $acienii au fo!t cla!ificai ca

avnd !au nu delir n acord cu criteriile CAM% In!trumentul de dia"no!tic a fo!t aplicat de c#tre

a!i!tentele medicale in!truite n ace!t !en!%53au con!emnat urm#torii parametri: pre6ena afeciunilor a!ociate ?cardiace;

pulmonare;&epatice@ ; indicele de ma!# corporal# ? MI@ ; i!toricul de a"itaie n antecedentele

pacientului ; a.u6ul de alcool ; fumatul ; nivelul !eric al al.uminei; A5AT; &emo"lo.ina i

&ematocritul% Includerea ace!tor con!tante a pornit de la !tudiul lui $atti i cola.oratorii pu.licat n


11/25

+('' n European ournal of Oncolo"N 4ur!in" deoarece e!te unul din puinele !tudii din literatur#

cu privire la pacienii !upui c&irur"iei oncolo"ice%

$entru perioada intraoperatorie !3au con!emnat : &ipoten!iunea; &iper&idratarea ;

tran!fu6iile de !n"e i derivate % ipoten!iunea intraoperatorie a fo!t definit# ca orice valoare

documentat# a pre!iunii arteriale medie mai mic# !au e"al# cu *( mm"% iper&idratarea a fo!tdefinit# ca infu6ia de mai mult de )((( ml coloi6i i cri!taloi6i %

-n perioada po!toperatorie !3au con!emnat: num#rul de 6ile de !pitali6are n ATI; tran!fu6iile

de !n"e i derivate; incidenta !i tipul complicaiilor po!toperatorii; modalitatea de a!i"urare a

anal"e6iei po!toperatorii %

.. Re*$ltate

Kaloarea medie a v=r!tei ; e9primat# n ani a fo!t 0/;(/1;8':IC?0(;8030+%*,@ % -n cadrul lotului

!tudiat ponderea revine pacienilor care aparin !e9ului ma!culin cu un procent de )';0H la o

frecven# de *( de ca6uri % *1 dintre pacienii inclui n !tudiu; re!pectiv ));)H !unt fum#tori; fapt

ar#tat n ta.elul '% Totodat#; 0+;1H din pacieni declar# c# nu con!um# n mod o.inuit alcool%

-n ceea ce privete pre6ena afeciunilor a!ociate patolo"iei oncolo"ice ,, dintre pacienii

operai au avut a!ociat# o !uferin# cardio3 va!cular#%

Incidena delirului la pacienii din lotul !tudiat a fo!t de +0 H% Media num#rului de ore la care a

ap#rut delirul e!te /,'1:IC?/+31/@% Re6ultatele nre"i!trate privind evoluia po!toperatorie arat# c#

complicaiile ap#rute la pacienii din cadrul lotului !tudiat au fo!t infecii la ');'H din ca6uri i fi!tule

ana!tomotice la ';8H din ca6uri%

Media num#rului de 6ile de !pitali6are n !ecia A%T%I% a fo!t de 00:IC?*38@%

$entru evidenierea unor relaii7a!ocieri ntre varia.ilele calitative am folo!it te!tul C&i3p#trat

?a!ociere po6itiv# dac# pG(;() @% O a!ociere po6itiv# !3a evideniat ntre pre6ena delirului i MI;

nece!arul de tran!fu6ie; anal"e6ia po!toperatorie i i!toricul de a"itaie al pacientului%

.3. Disc$/ii

-n condiiile evoluiei aparaturii medicale i a apariiei continue de medicaie mai eficient# i

mai !i"ur#; precum i a m.un#t##rii te&nicilor ane!te6ice i c&irur"icale; v=r!ta naintat# nu mai

e!te o contraindicaie a actului ane!te6ico3c&irur"ical% Totodat#; prin promovarea pro"ramelor de

prevenie a cancerului i a diver!it#ii metodelor de dia"no!tic; crete con!tant adre!a.ilitatea laIn!titutul Oncolo"ic precum i v=r!ta la care are loc pre6entarea pentru tratament c&irur"ical%

Dei n multe alte !tudii v=r!ta naintat# e!te con!iderat un factor important de ri!c pentru

$D ; la pacienii din !tudiul no!tru nu e9i!t# o diferen# !emnificativ# ntre cele dou#

loturi? pJ(;8)/@%

I!toricul de a"itaie poate fi con!iderat factor de ri!c !emnificativ ? pJ(;(/(@ pentru pacientul

oncolo"ic ; fapt ce concord# cu alte re6ultate o.inute n literatur#: $atti et all%;+(''%


12/25

5tudiul de fa# nu a demon!trat o le"#tur# ntre apariia delirului po!toperator i indicele de

ma!# corporal#; con!umul de alcool ; fumat%

5tudiu no!tru nt#rete ideea creterii num#rului de 6ile de !pitali6are n terapie inten!iv# %

Ace!t lucru atra"e dup# !ine creterea co!turilor pentru unit#ile medicale; i o recuperare "reoaie

pentru pacienti%CAM ? Confu!ion A!!e!!ment Met&od@ a fo!t alea!# ca metod# de dia"no!tic a delirului pentru

!tudiu no!tru deoarece e!te o metod# ce !e poate aplica rapid i care poate fi aplicat# fia.il de

a!i!tentele medicale% >iind prima dat# cnd n !ecia noa!tr# !e aplica o metod# de dia"no!tic al

delirului po!toperator ; a!i!tentele medicale au fo!t in!truite n utili6area CAM%

Identificarea factorilor de ri!c pentru delirul operator la pacienii !upui c&irur"iei oncolo"ice

permite apoi utili6area !calelor de evaluare a delirului po!toperator% $acienii cu ri!c nalt de a

de6volta delir pot intra apoi n protocoalele non3farmacolo"ice de prevenire a ace!tuia%

Implementarea ace!tor protocoale e!te n ntre"ime apanajul a!i!tentei medicale% A!i!tentele

medicale tre.uie de a!emenea in!truite cu privire la in!trumentele de dia"no!tic a deliruluipo!toperator; majoritatea dintre ace!tea fiind con!truite pentru a putea fi utili6ate de c#tre ec&ipa de

nur!in"%

3. Concl$*ii %enerale

1. 5corul de !ati!facie a pacientului o.inut n !tudiul no!tru e!te mare; 1;1*

2. 5corul de !ati!facie e!te influenat de vr!t#; nivel de educaie; num#r de

6ile de !pitali6are n Terapie Inten!iv# i dia"no!tic

/%$entru p#!trarea !corului mare de !ati!facie o.inut n !tudiul no!trum i pentru

creterea ace!tuia tre.uie meninui ca factori de !ati!facie cei care au avut

!emnificaie !tati!tic# ? am fo!t tratat cu c#ldur# i mi !3au !ati!f#cut promt toate

!olicit#rile@%

1%5e impune; de a!emenea reluarea aplic#rii c&e!tionarului periodic pentru evaluarea

re6ultatelor din !ecia noa!tr#

)%Majoritatea medicilor !unt mulumii7foarte mulumii de activitatea ec&ipei de

nur!in"

*%>actorii care !timulea6# cel mai mult performana profe!ional# a a!i!tentelormedicale !unt : !ati!facia o.inut# din munca pre!tat# i dorina de a nv#a lucruri

noi

0%A!tfel; apro9imativ +7/ din a!i!tentele medicale au !tudii !uperioare

8. 5e de!prinde ideea introducerii n practic# a unor !cale o.iective ?te&nice@

de evaluare a performanei profe!ionale a a!i!tentelor medicale


13/25

8%Delirul po!toperator e!te o complicaie frecvent# a c&irur"iei oncolo"ice colorectale

'(% Delirul po!toperator e!te a!ociat cu creterea num#rului de 6ile de

!pitali6are

''% Re6ultatele ace!tui !tudiu !u"erea6# nece!itatea imperativ# a utili6#rii n

!eciile de Terapie Inten!iv# a unei !cale de evaluare a ri!cului de delir po!toperator;adaptate la patolo"ia !pecific# !eciei%

'+% E!te nece!ar a !e implementa la nivelul !eciilor de Terapie Inten!iv#

in!trumente uniforme de dia"no!tic a delirului i protocoale de prevenire i tratament

ale ace!tuia%

'/% Indicatorii de calitate a nur!in"3ului care pot fi introdui n practic# !unt cei

de proce! i re6ultat : prevalena e!carelor; erori n admini!trarea medicamentelor;

rata c#derilor; rata c#derilor cu r#nire; infeciile no!ocomiale; evaluarea durerii%

Ace!tea tre.uie adaptate la !pecificul !eciilor n care !unt aplicate%

'1% Datorit# condiiilor economice actuale con!ider c# indicatorii de !tructur# Fnum#rul de ore de nur!in"7pacient76i ; rata po!turilor vacante 3 nu !unt fia.ili n

ace!t moment%


14/25

A5TRACT

Criteria and tool! for evaluationnur!in" performance

Doctoral !tudent Ioana Cristina Gdlean

Doctoral coordinator $rof% Dr% Andrei Ac&ima Cadariu


15/25

CONTENTS

INTRODUCTION '(

CURRENT STATUS O7 :NO;LEDGE

1. $alit= indicators //

/%'% Definition of nur!in" // /%+% T&e model of t&e American 4ur!e! A!!ociation /1

/%/% T&e model of 4ational ealt& 5ervice for 5cotland /0

PERSONAL CONTRI&UTION

1. ;or?in% 0=)ot0esis+o,@ectives 1)

!. 7irst st$d=- Eval$ation o )atient satisaction 10+%'% Introduction 10

+%+% orSin" &Npot&e!i! 1,

+%/% Material! and met&od! 1,

+%1% Re!ult! 18

+%)% Di!cu!!ion! )*+%*% Conclu!ion! ),

". Second st$d= - Eval$ation o n$rsin% )erorace ,= edical sta )8

/%'% Introduction )8

/%+% orSin" &Npot&e!i! )8

/%/% Material! and met&od! *(

/%1% Re!ult! *'

/%)% Di!cu!!ion! 0+

/%*% Conclu!ion! 0)

. T0ird st$d= Incidence and ris? actors or )osto)erative deliri$

ater colorectal s$r%er=

00

1%'% Introduction 00

1%+% orSin" &Npot&e!i! 0,

1%/% Material! and met&od! 0,

1%1% Re!ult! 08

1%)% Di!cu!!ion! ,1

1%*% Conclu!ion! ,*


16/25

3. General concl$sions ,,

6. T0e ori%inalit= and t0e innovative contri,$tions o t0is t0esis 8'

ATTACB9ENTS 8+

RE7ERENCES 99

eN ord! : nur!in" ; PualitN indicator! ; performance ; patient !ati!faction


17/25

INTRODUCTION

T&e implementation of a monitorin" !N!tem i! e!!ential in t&e creation of a PualitN en&ancement

pro"ram% Even in t&e ca!e of limited re!ource!; !N!tematic met&od! can .e emploNed in t&e re"ular

monitorin" of care PualitN% Care PualitN monitorin" i! t&e proce!! of re"ular collection and analN!i! of

a !et of PualitN indicator!< it i! rat&er focu!ed on mea!urin" and analN6in" proce!!e!%

QuantifNin" t&e effect of nur!e! and t&eir nur!in" activitN on t&e PualitN of care and patient

development .ecame e9tremelN important in t&e development of per!onnel plan! .a!ed on evidence;

in order to under!tand t&e impact of nur!in" and optimi6e development%

T&e monitorin" of care PualitN i! a proce!! involvin" t&e re"ular collection and analN!i! of a

!erie! of PualitN indicator! and focu!in" on mea!urin" and analN6in" proce!!e!% T&i! proce!! allo!

&ealt& provider! to evaluate t&e de"ree to &ic& t&e o.jective! of certain pro"ram! &ave .een met or

"lo.al performance%

CURRENT STATUS O7 :NO;LEDGET&e orld ealt& Or"ani6ation define! PualitN &ealt& !N!tem a! t&e level of ac&ievement of t&e

intrin!ic "oal! of t&e &ealt& !N!tem to improve &ealt& and overall re!pon!ivene!! to t&e e9pectation!

of t&e population%

On t&e ot&er t&e fat&er of t&e modern concept of PualitN; Dona.edian de!cri.e! t&e PualitN of

&ealt& care a! t&at treatment t&at i! e9pected to ma9imi6e t&e !i6e of t&e elfare of patient!; taSin"

into account t&e .alance of e9pected "ain! and lo!!e! t&at occur in all !ta"e! of &ealt& care%

4ur!in" evaluation !tarted &en >lorence 4i"&tin"ale identified t&e role of nur!e! in care and care

PualitN and &en !&e !tarted to mea!ure patient development% 5&e u!ed !tati!tical met&od! in order

to create report! on patient development accordin" to environment condition!% ealt& PualitN

evaluation developed in time% T&e orS performed in '80( .N t&e A4A; t&e ide !pread of PualitN

in!urance and t&e introduction of Dona.edianV! model ?!tructure3proce!!3development@ proved to

.e a compre&en!ive met&od of evaluatin" care PualitN% T&e la.or force re!tructurin" in t&e .e"innin"

of t&e 8(! proved to t&e A4A t&e nece!!itN of evaluatin" nur!in" team! and identifNin" t&e relation

.eteen !uc& team! and patient development%

T&e American "uide created .N t&e 4ational QualitN >orum e!ta.li!&ed a !et of mea!ure! in

order to o.tain a clear picture of performance and patient care PualitN provided .N nur!e!% T&e

mea!ure !et focu!e! on certain di!ea!e! and !Nndrome!% T&e mea!ure! follo t&e !tructure; proce!!and re!ult of care in connection to t&e di!ea!e%

T&e initial !et of mea!ure! include! mea!ure! focu!in" on t&e patient; t&o!e focu!ed on t&e

nur!eV! intervention; and t&o!e centered on t&e !N!tem% Data derive from t&e proce!! of o.!ervin" a

patient; &i!7&er admini!trative data; and &uman re!ource! record!%


18/25

QuantifNin" t&e effect of nur!e! and t&eir nur!in" activitN on t&e PualitN of care and patient

development .ecame e9tremelN important in t&e development of per!onnel plan! .a!ed on evidence;

in order to under!tand t&e impact of nur!in" and optimi6e development%

In Decem.er +((+; t&e 5cotti!& Audit pu.li!&ed a report entitled: W4ur!in" plannin" F

pro"ram and de!i"nB% It a! noted; in t&i! report; t&at de!pite t&e "reat num.er of medical a!!i!tant!and nur!e! and t&eir importance in t&e 5cotti!& &ealt& !N!tem; provided data ere limited on a

national !cale% T&i! made compari!on of nur!e num.er!; co!t!; and PualitN difficult% Little i! Snon on

t&e orSin" plan and rePuired la.or force% A! a re!ult of t&e!e factor!; in 5cotland t&ere i! a ide

varietN of per!onnel; a!!ociated co!t!; and impact on patient care%

PERSONAL CONTRI&UTIONS

;or?in% 0=)ot0esis+o,@ectives

T&e !tudN of nur!in" i! e9tremelN comple9; !o t&at definin" it! PualitN i! not ea!N% It i! difficult

to e!ta.li!& a cau!al relation .eteen nur!in" activitN or it! a.!ence and patient development; !ince

t&e latter i! influenced .N: t&e patientV! !tate ; t&e nur!eV! activitN ; action! of ot&er mem.er! of t&e

medical team ; &o!pital or"ani6ation%

T&erefore t&i! paper aim! to analN6e !everal a!pect! of t&e performance of nur!in" activitie!%

T&e fir!t a!pect analN6ed i! patient !ati!faction% $atient !ati!faction de"ree i! related to PualitN of

care; .ut derive! from t&e condition! in &ic& t&eN are orSin"; and !ati!faction ac&ievement lead!

to increa!ed performance% Amon" t&e a!pect! of patient !ati!faction &ic& mu!t .e con!idered i! t&e

care provided .N nur!e!% T&u! t&e fir!t !tudN pre!ented in t&i! paper evaluate! t&e !ati!faction of

patient! admitted in ICU ard of Oncolo"ical In!titute Ion C&iricu# Cluj34apoca% T&e !econd

a!pect rated i! t&e profe!!ional performance of nur!e! .N medical !taff ?doctor! and nur!e!@% T&i! i!nece!!arN .ecau!e t&e tec&nical PualitN of medical care can not .e con!idered o.jectivelN .N t&e

patient% T&e late!t !tudN include! a tec&nical indicator t&at i! t&e role of t&e nur!e! in preventin"

po!toperative delirium% $o!toperative delirium i! a common complication t&at can .e prevented% T&e

introduction of ri!S a!!e!!ment !cale! for delirium ill allo practice nur!e! to introduce non3

p&armacolo"ical prevention protocol! concernin" t&i! condition % T&u!; an unplea!ant complication

for t&e patient and familN; it& orrNin" con!ePuence! can .e prevented; leadin" to increa!ed

PualitN of care and decrea!ed co!t!%

!. 7irst st$d=. Eval$ation o )atient satisaction

Interper!onal PualitN i! t&e part perceived .N t&e patient 7 client% TNpicallN; patient! &ave no

a.ilitN or Snoled"e needed to a!!e!! t&e tec&nical competence of t&e care "iver or t&e aN in &ic&

t&eN u!ed infection control mea!ure!; .ut t&eN do Sno &o t&eN feel; &o t&eN ere treated and


19/25

&et&er t&e need!; e9pectation! &ave .een met % T&eN often report t&e a.ilitN to a!S Pue!tion!; and

can appreciate a medical !ervice a! convenient or not%

Re!earc& in t&e field demon!trate! t&at !ati!faction i! connected to t&e perception of medical

per!onnel tec&nical aptitude!; intelli"ence; and Pualification% 5till; patient! appreciate more t&e inter3

per!onal communication !Sill! of medical per!onnel%A!pect! of patient !ati!faction t&at !&ould .e con!idered: medical care and information; food and

accommodation facilitie!; environment; nur!in" activitie!;amount of food; vi!itin" !c&edule%[0]

An inten!ive care unit a! elected for conductin" an evaluation !tudN of patient !ati!faction for

to rea!on!% >ir!t; in term! of patient and familN i! t&e lar"e!t divi!ion impact for t&em% And in term!

of &ealt& care i! t&e !ection &ere a lar"e num.er of maneuver! are performed; inva!ive or not; and

emotional .urden i! &i"&%

!.". 9aterials and et0ods

T&i! paper de!cri.e! a pro!pective !tudN conducted on a !ample of '(* patient! &o!pitali6ed in

t&e inten!ive care unit of t&e 4ational Cancer In!titute Ion C&iricu# Cluj34apoca in une +('' 3

Au"u!t +(''% T&e re!ult! ere !tati!ticallN analN6ed u!in" de!criptive and analNtical !tati!tical

!oftare 5$55% To detect relation!&ip! 7 a!!ociation! .eteen Pualitative varia.le! e u!ed c&i3

!Puare te!t ?po!itive a!!ociation if p G (%()@% $atient! received an anonNmou! Pue!tionnaire applied

at +1 &our! after di!c&ar"e from t&e IT department !o t&at t&e re!pon!e! ould .e mo!t !inceritN%

T&e Pue!tionnaire a! &anded to t&e Department of 5ur"erN patient! ; &avin" enou"& time to an!er

; t&en in a !ealed envelope t&e Pue!tionnaire a! delivered to t&e nur!e ard% T&e Pue!tionnaire

include! demo"rap&ic data: !e9; a"e; educational level; dia"no!i!; num.er of daN! !pend in inten!ive

care unit; !core of !ati!faction% It al!o con!i!t! of to "roup! of Pue!tion!: '( related to !ati!faction

and di!!ati!faction and /( &ic& underline di!!ati!faction from &ic& t&e patient! ere a!Sed to

c&oo!e five; and '( of t&e mo!t important%

!.. Res$lts

After analN6in" information; "roupin" patient! on .road cate"orie! of primarN dia"no!i!; ei"&t

returned it& a dia"no!i! of ovarian neo ?/0%0H@ folloed .N di!ea!e! of t&e colon ?+0;1H@% '1%'H

of ca!e! are ca!e! of medical t&erapN ?lNmp&oma; leuSemia@% Avera"e a"e i! )1 Near!'+ it& a

duration of &o!pitali6ation in IT of )%)/ daN!/ and a !ati!faction !core of 1%1*% 5econdarN educationdominated at t&e intervieed patient! ?11%/H@; folloed .N &i"&er education ?/1H@ ?Ta.le +@; and

t&e female !e9 a! predominant%

In patient! &o c&o!e !ati!faction 1 ?!ati!fied@ t&e avera"e num.er of daN! of &o!pitali6ation in

ICU i! )%///%/)* it& 8)H CI: 1%11 to *%++ and t&o!e &o c&oo!e "rade ) ?verN !ati!fied@ t&e

avera"e num.er of daN! of &o!pitali6ation i! )%0*+%/0* it& 8)H CI:)%(0 3 *%11%


20/25

".3. Disc$ssions

>rom t&e patientV! point of vie factor! influencin" t&e "rot& of !ati!faction are of emotional

attitude! t&at are promptlN !ati!fN all rePue!t!% Mo!t patient! ?8+H@ felt t&at t&eN ere properlN

cared for% LacS of pain a! reported .N 18%'H of patient!%

In !tati!tical analN!i! e find t&at manN di!!ati!faction factor! can affect !ati!faction of patient!%

5ome of t&em are tied to; accommodation facilitie! and t&e ard profile t&at: Mi9ed room!

?pJ(%(((@; Xou alaN! &ave li"&t! ?pJ(%((8@; Xou do not &ave privacN ?pJ(%((+@; in t&e room

Nou are i! too &ot 7 too cold ?pJ(%(+,@%

LacS of department !taff in ICUi! !i"nificant for t&e folloin" factor!t&at lead to di!!ati!faction:

T&e medical !taff i! not pre!ent ?pJ(%(+0@; Xou feel t&at nur!e! pur!ue more device! t&an Nou

?pJ(%((+@; Do not e9plain to Nou treatment! and maneuver! t&at Nou do ?pJ(%(((@; Xou are

re"arded a! an o.ject ?pJ(%(('@%

A! e9pected; pain ?pJ(%(((@ i! one of t&e factor! influencin" patient !ati!faction% 5o lacS of!leep ?pJ(%(((@; &ic& al!o derive! from t&e a!!ociation of ot&er factor!; &a! a ne"ative impact on

!ati!faction%

In +('(; anot&er inten!ive care unit in Cluj34apoca a! undertaSen a !imilar !tudN .N $op and

colla.orator!% A compari!on .eteen t&e to !tudie! !&o t&at mo!t factor! of !ati!faction are t&e

!ame; e9cept t&at in our !tudN are mo!t frePuentlN mentioned factor! related to t&e arc&itecture

department di!comfort ?mi9ed ard!; do not &ave privacN@%

". Second st$d=. Eval$ation o n$rsin% )erorace ,= edical sta

T&e de"ree of practitioner !ati!faction i! determined .N t&e PualitN of t&e medical act; .ut

al!o derive! from &i!7&er orSin" condition! and t&e de"ree of !ati!faction tri""er! an increa!e in

performance% In conclu!ion; t&i! i! a cau!al factor of t&e PualitN level of &ealt& care and t&u! can .e

u!ed a! eval$ation criterion o 0ealt0 care >$alit=.

I conducted t&i! analN!i! at t&e Oncolo"N In!titute Ion C&iricu# .N interviein" doctor!

and nur!e!%

".". 9aterials and et0ods

T&e ori"inal Pue!tionnaire a! di!tri.uted to nur!e! in clinical and la.oratorN !ection! of

t&e Oncolo"N In!titute Ion C&iricu# Cluj34apoca to te!t t&eir opinion re"ardin" profe!!ional

performance ac&ieved at t&e time completin" t&e Pue!tionnaire% In parallel; anot&er ori"inal

Pue!tionnaire a! di!tri.uted to doctor! of Oncolo"N In!titute Ion C&iricu# Cluj34apoca to te!t

t&eir opinion re"ardin" performance evaluation of nur!e! t&at t&eN colla.orate it&%


21/25

T&i! a! di!tri.uted in t&e period MaN 3 5eptem.er +('+%

Of t&e total Pue!tionnaire! di!tri.uted at t&e Oncolo"N In!titute Ion C&iricu#; e9cludin"

t&e ) re!pondent! in t&e pilot !tudN and t&o!e &o did not fit t&e inclu!ion criteria; ')/ nur!e! and

+) doctor! &ave entered t&e !tati!tical calculation of t&e!e Pue!tionnaire!%

".. Res$lts

Di!tri.ution of !u.ject! accordin" to t&e !tudN reveal! t&at t&e !&are of t&o!e it& &i"&er

education i! prevailin" *'H ?8/@ compared to po!t3!econdarN education /8H ?*(@% T&e avera"e a"e

of t&e !tudN "roup a! /)%0' )%/10; and t&e avera"e len"t& of e9perience in nur!in" a! '(%))

)%8/,%

At t&e Pue!tion it& open an!er! &ere t&e nur!e! ere a!Sed to name t&ree

c&aracteri!tic! t&at define t&eir vie nur!in" profe!!ion t&e an!er! ere varied; t&e mo!t common

.ein" t&e competence t&at occur! in *,H of t&e re!pondent!; patience to )0 H of re!pondent!

and devotion to 10H of re!pondent!%

Competence i! con!idered t&e mo!t important factor involved in patient care; ,/ re!pon!e! ?)/H@%

Re"ardin" t&e e9pre!!ion! t&at c&aracteri6e t&e profe!!ion of nur!in" a! !een on t&e re!pondent!;

t&e c&o!en ere pa!!ion .N ,(H of re!pondent!; competence 3 */H and mN aN of earnin" a

livin" 3/'H % *,%*H of nur!e! !urveNed are !ati!fied it& t&e performance ac&ieved at t&e

orSplace%

On e9pre!!ion! t&at c&aracteri6e t&e profe!!ion of nur!e !&oed a !tati!ticallN !i"nificant a!!ociation

.eteen a"e and pa!!ion ?$ =(%(('@; de.t ?p =(;(/@%Re"ardin" medical opinion a.out nur!e!;

mo!t of t&em ?8+H@ are !ati!fied it& t&e performance ac&ieved .N t&eir colla.orator!%

Avera"e !core "iven .N doctor! ?"rade! ' to '(@ to a!pect! of t&e nur!e! orS are located .eteen

0%8+ '%08 for appropriate attitude to 8%1+ (%) and for punctualitN%

".3. Disc$ssions

4ur!e !ati!faction !urveN on orS and !elf evaluation performance ac&ieved in t&e

profe!!ion practiced re!pectivelN collective a!!e!!ment of nur!e! i! an important component% T&i!

maN impact patient !afetN; performance and PualitN of care%?1@ Al!o e!!ential i! medical opinion on

t&e performance ac&ieved .N !taff nur!e! a! t&e old concept t&at nur!e a!!i!t! t&e doctor i!

noadaN! rarelN encountered in t&e &ealt& !N!tem% T&e orS undertaSen in &o!pital! i! a teamactivitN it& clear and common o.jective: patient !afetN and PualitN of care%

T&e factor t&at motivate! performance at orS for mo!t nur!e! i! t&e !ati!faction derived

from t&eir orS ?8*H@; folloed .N t&e de!ire to learn ne t&in"! ?0+%)H@% It !&ould .e noted t&at

no participant in t&e !tudN i! motivated .N orS condition!; .ut +0%)H are motivated .N t&e team

t&at are orSin" it& and /'H of competitivene!!% 5tati!tical analN!i! revealed a !tati!ticallN


22/25

!i"nificant a!!ociation .eteen a"e of !u.ject! and t&e folloin" factor! t&at motivate nur!e!Y

performance: t&e !ati!faction o.tained from orS performed ?pJ(; ('@; competitivene!! ?pJ(; ('@ ;

continuitN of emploNment ?p J(; ('@ and pre!ti"e from t&eir orS ?pJ(;(('@%

In t&e !econd part of t&e Pue!tionnaire analN6ed a! t&e evaluation of t&e nur!e! .N t&eir

nur!e! collea"ue!; t&e avera"e note! "iven ?note! ' to '(@ a! !imilar in all matter! !u.ject tointervie and ran"ed from ,%'* for t&e availa.ilitN and ,% *8 for &o t&e recommendation! "iven .N

doctor! are complied % >olloin" correlation! made .eteen t&e avera"e !core "iven; and t&e

avera"e a"e of t&e !tudN "roup a! revealed !tati!tical !i"nificance .eteen a"e and &o t&e

recommendation! "iven .N p&N!ician! are complied ?$ =(%((,@; courte!N of t&e fir!t contact it& t&e

patient ?$ =(%(+ @ and e9pre!!ed illin"ne!! ?$ =(%((0@%

T&ere are difference! in perception .eteen p&N!ician! and nur!e! re"ardin" factor! t&at

motivate nur!e!Y profe!!ional performance% &ile 8*H of nur!e! .elieve t&eN are motivated .N t&e

!ati!faction derived from orS performed; onlN '0H of p&N!ician! !urveNed !upport t&i! factor%

Ot&er item! analN6ed it& remarSa.le difference! .eteen t&e to profe!!ion! are: t&e de!ire to

learn ne t&in"! ?,H v!% 0+%)H doctor! nur!e!@; !alarN received for orS ?0)H v!% '*H doctorV!

nur!e!@; and continuitN at orSplace ?1+H v!% 1H doctor! nur!e!@% Al!o; none of t&e doctor!

intervieed .elieve! t&at nur!e! are motivated .N competitivene!!%

A po!!i.le e9planation could .e t&at; in t&e a.!ence of performance !cale! for nur!e!; !u.jective

re!pon!e! of t&e to cate"orie! of re!pondent! could .e diver"ent !ince t&eN &ave no clear model to

compare or .e compare it&% &ile nur!e! are con!idered motivated .N matter! of moral

!ati!faction derived from orS performed; doctor! con!ider t&at nur!e! are motivated .N material

i!!ue! ari!in" from t&eir jo.% $er&ap! t&atY! &N ,/H of p&N!ician! &o re!ponded t&e Pue!tionnaire

.elieve it ould .e u!eful to introduce !ome o.jective !cale; accurate in nur!in" evaluation

performance%

. T0ird st$d=. Incidence and ris? actors or )osto)erative deliri$ ater colorectal

s$r%er=

After "oin" t&rou"& ane!t&e!ia and !ur"erN; numerou! patient!; e!peciallN t&e elderlN; !&o

co"nitive modification!; memorN and concentration lo!!; per!onalitN c&an"e! and emotional

in!ta.ilitN% De!pite t&e fact t&at t&e!e c&an"e! can manife!t in variou! aN!; one can identifN to

main cate"orie! a! !li"&tlN di!tinct entitie!: po!toperative delirium and po!toperative co"nitivedN!function%

T&e po!toperative delirium i! defined a! a !tate of co"nitive and con!ciou!ne!! di!order

developed over a !&ort period of time ?&our!3daN!@ and i! fluctuant in c&aracter%

$o!toperative delirium i! cla!!ified a! a complication t&at can .e prevented and i! t&erefore

an indicator of t&e PualitN of medical care%


23/25

.". 9aterials and et0ods

T&e !tudN include! ''* patient! a"ed over *) &o underent colorectal oncolo"ical !ur"erN

and ere admitted in t&e Inten!ive T&erapN Unit of t&e Ion C&iricu# Oncolo"ical In!titute .eteen

Decem.er +('' and >e.ruarN +('/% T&eir co"nitive function a! te!ted .efor !ur"erN t&rou"&

MM5E% e &ave e9cluded t&o!e patient! it& AKC &i!torN; p!Nc&iatric affliction!; cere.ral meta!ta!i!;

Snon po!toperative p!Nc&o3co"nitive dN!function!; cere.ral at&ero!clero!i!; and patient! it& a

MM5E !core loer t&an ',%

T&e po!toperative delirium a! dia"no!ed t&rou"& t&e CAM ?Confu!ion A!!e!!ment Met&od@

at eac& '+ &our! from t&e patientV! admi!!ion into t&e T%I% durin" 0+ &our! after !ur"erN%

T&e folloin" parameter! ere taSen into con!ideration: t&e pre!ence of a!!ociated affliction!

?cardiac; pulmonarN; &epatic@; oncolo"ic dia"no!i!; .odN ma!! inde9 ?MI@; antecedent! of a"itation

in t&e patientV! &i!torN; alco&ol a.u!e; !moSin"; t&e level of !erum al.umin; A5AT; &emo"lo.in and

&ematocrit% T&e inclu!ion of t&e!e con!tant element! !tarted from a !tudN pu.li!&ed .N $atti and

colla.orator! in +('' in t&e European ournal of Oncolo"N 4ur!in"; !ince it i! one of t&e fe e9i!tin"

!tudie! on patient! under"oin" oncolo"ical !ur"erN%

Durin" t&e intraoperative period; t&e folloin" element! &ave .een recorded: &Npoten!ion;

&Nper&Ndration ; and tran!fu!ion! of .lood and derivate!% Intraoperative &Npoten!ion a! defined a!

anN documented value of t&e mean arterial pre!!ure le!! or ePual to *( mm"% Nper&Ndration a!

defined a! t&e infu!ion of more t&an )((( ml of colloid! and crN!talloid!%

Durin" t&e po!toperative period; t&e folloin" element! &ave .een recorded: num.er of

&o!pitali6ation daN! in t&e ATI; tran!fu!ion! of .lood and derivate!; t&e incidence and tNpe of

po!toperative complication!; and t&e mean! to en!ure po!toperative anal"e!ia%

.. Res$lts

Re"ardin" t&e pre!ence of condition! a!!ociated to cancer pat&olo"N ,, from operated

patient! &ad a!!ociated cardiova!cular !ufferin"%

T&e incidence of delirium in patient! in t&e !tudN "roup a! +0H% Avera"e num.er of &our! t&at

occurred delirium i! /, '1: IC ?/+31/@% Re!ult! recorded on po!toperative evolution !&o t&at t&e

complication! occurred in patient! from t&e !tudied "roup ere infection in ')%'H of ca!e! and

ana!tomotic fi!tula in '%8H of ca!e! % Avera"e num.er of daN! of &o!pitali6ation in t&e ICU ard a!

0 0: IC ?*38@%

To &i"&li"&t t&e relation!&ip! 7 a!!ociation! .eteen Pualitative varia.le! I u!ed C&i3!Puare te!t ?p G

(%() &en po!itive a!!ociation@% A po!itive a!!ociation &a! .een !&on .eteen t&e pre!ence of

delirium and MI; tran!fu!ion rePuirement!; po!toperative anal"e!ia and t&e patientY! &i!torN of

turmoil%


24/25

.3. Disc$ssions

A! medical ePuipment develop!; increa!in"lN efficient and !afe medication .ecome! availa.le; and

ane!t&etic and !ur"ical tec&niPue! are improved; old a"e i! no lon"er a counter3indication inane!t&etic3!ur"ical practice!% In t&e !ame time; t&rou"& t&e promotion of cancer prevention

pro"ram! and t&e diver!itN of dia"no!i! met&od!; t&e addre!!a.ilitN of t&e Oncolo"ical In!titute

increa!e! continuou!lN and !o doe! t&e a"e in &ic& patient! turn to !ur"ical treatment

T&ou"& t&e aut&or! of !everal ot&er !tudie! .elieve t&at advanced a"e i! a ri!S factor for $D; in

t&e ca!e of patient! included in t&e pre!ent !tudN no !i"nificant difference .eteen t&e to lot! &a!

.een noted ?pJ(%8)/@%

T&e patient!V &i!torN of a"itation can .e re"arded a! a !i"nificant ri!S factor ?pJ(%(/8@ for

oncolo"ical patient!< t&i! !upport! previou!lN pu.li!&ed re!ult!: $atti et all%; +(''%

T&e pre!ent !tudN al!o did not reveal anN connection .eteen t&e on!et of po!toperative

delirium and t&e con!umption of alco&ol or !moSin"%

Our !tudN !tren"t&en! t&e !u""e!tion t&at t&e num.er of &o!pitali6ation daN! in inten!ive care

!&ould .e increa!ed in t&e ca!e of patient! developin" po!toperative delirium% T&i! rai!e! t&e co!t!

involved for medical unit! and lead! to patient! recoverin" more !lolN and it& difficultN%

>or t&e pre!ent !tudN; t&e CAM ?Confu!ion A!!e!!ment Met&od@ a! !elected a! dia"no!i!

met&od .ecau!e it can .e applied fa!t and fea!i.lN .N nur!e!%ein" t&e fir!t time &en in our ard

a met&od for dia"no!i! of po!toperative delirium a! applied; nur!e! ere trained in t&e u!e of CAM%

T&e identification of ri!S factor! for operative delirium in t&e ca!e of patient! under"oin"

oncolo"ical !ur"erN allo! for a !u.!ePuent u!e of evaluation !cale! for po!toperative delirium%

$atient! it& a &i"& ri!S of developin" $D maN t&en enter non3p&armacolo"ical protocol! of $D

prevention% T&e implementation of t&e!e protocol! fall! entirelN under t&e re!pon!i.ilitN of nur!e!

&o mu!t al!o .e trained on t&e dia"no!tic in!trument! of po!toperative delirium% Mo!t !uc&

in!trument! are de!i"ned !o a! to .e u!ed .N t&e nur!in" team%

3. General concl$sions

'% $atient !ati!faction !core o.tained in our !tudN i! &i"&; 1%1*+% 5ati!faction !core i! influenced .N a"e; education level; t&e num.er of daN! of &o!pitali6ation

in inten!ive care and dia"no!i!%

/% To maintain &i"& !ati!faction !core o.tained in our !tudN and it! "rot& !&ould .e maintain

t&e !ati!faction factor! t&at ere !tati!ticallN !i"nificant ?I a! treated it& &eat and I a!

!ati!fied all rePue!t! promptlN@%


25/25

1% It al!o rePuire! t&e re!umption of t&e Pue!tionnaire periodicallN to a!!e!! t&e re!ult! of our

!ection%

)% Almo!t all medical team mem.er! are !ati!fied7 verN !ati!fied it& t&e performance

ac&ieved .N t&e nur!in" !taff%

*% 4ur!e! declare rea!on! for !ati!faction derived from t&eir orS and illin"ne!! to learn ne

t&in"!%

0% Mo!t nur!e! !urveNed &ave &i"&er education

8. It i! &i"&li"&ted t&e idea of introducin" in practice certain o.jective !cale! ?tec&nical@ for

performance evaluation of profe!!ional nur!e!

8% $o!toperational delirium i! a relativelN frePuent complication in patient!; includin" t&o!e

under"oin" oncolo"ical !ur"erN%

'(% It i! a!!ociated it& t&e increa!ed num.er of &o!pitali6ation daN! in t&e Inten!ive Care Unit%

''% A .etter Snoled"e on t&i! complication can .e u!eful to ane!t&etic3!ur"ical team! in order

for t&em to !N!tematicallN identifN t&e main ri!S factor! and to implement t&e protocol! for

t&e prevention and treatment of po!toperational delirium%

'+% T&e re!ult! of t&e pre!ent !tudN !u""e!t t&e imperative u!e of an evaluation !cale of t&e ri!S

of po!toperational delirium in Inten!ive Care unit!% T&i! !cale mu!t .e adapted to t&e !pecific

pat&olo"N of eac& unit%

'/% QualitN indicator! t&at can .e placed in nur!in" practice are t&e proce!! and outcome:

prevalence of pre!!ure !ore!; error! in dru" admini!tration; t&e rate of fall!; rate! of fall!

it& injurN; no!ocomial infection!; pain a!!e!!ment% T&eN mu!t .e adapted to t&e !pecific

ard! t&at are applied to%

'1% Due to current economic condition! I con!ider !tructural indicator!3t&e num.er of &our! of

nur!in" 7 patient 7 daN vacancN rate 3 not relia.le at t&i! time%

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