Study design, materials and methods
It is applied research with a quantitative and qualitative approach.
A synchronous online workshop was developed and disseminated nationally, through digital media, for nurses working in primary health care to compose the sample,
Registered nurses were organized into five instant messaging groups according to the region of the country where they worked.
On the first day of class, everyone was informed about the research and invited to participate by filling out an online form.
The collected data were transferred to a Microsoft Excel® spreadsheet. Data were tabulated and statistically analyzed using the Stata/SE v.14.1 computer program. StataCorpLP, USA.
For the qualitative stage, the nurses gathered for Focus Group sessions. The sample for this phase was drawn from the participants in the previous phase. In each group (North, Northeast, Midwest, Southeast, South), four nurses were randomly selected to participate in the online and synchronous focus group.
The guiding questions of the discussion were: “What do you consider essential in a training course on Conservative Treatment of Lower Urinary Tract Dysfunctions to feel safe to offer this service in Primary Health Care?”
The sessions were transcribed and analyzed using the Braun and Clark Thematic Analysis method (1).
Results
One hundred forty-five nurses participated in the quantitative stage. The mean age among them was 37.5 years (SD 7.4). As for gender, 89.7% were women. Nurses from 20 Brazilian states participated.
The average training time of the nurses in the sample was 11.8 years (SD 7.1). Nineteen nurses (13.1%) had other higher education training, and 129 (89%) had a postgraduate degree. The predominant area was public health, with 55.8% of the sample, followed by obstetrics (17.1 %) and stoma therapy (17.1%). A percentage of 17.1% had a Master's degree, and 51.9% had more than one graduate course. Thirty-one nurses (21.4%) had at least one more job.
Most of the sample (93.1%) had already assisted people with incontinence or urinary retention, with just over half (54.4%) receiving some guidance, with a predominance of Pelvic Floor Muscle Training (75.8%), followed by guidelines for Clean Intermittent Catheterization (19.7%).
Questioned about what would prevent them from acting in the treatment and prevention of LUTD if they had access to knowledge, the majority (36.1%) answered that nothing would stop them, 20.2% still felt that they could find insufficient knowledge or feel insecure in the service and the same percentage indicated that the question of time, demand and agenda could be an impediment.
As a result of the qualitative stage, generated from the focus group and thematic analysis, suggested actions emerged that the participants considered effective in guaranteeing safe and effective practice. The availability of recorded classes was a frequent suggestion, especially with the insertion of videos demonstrating assessment techniques. The participants expressed the need for the recorded content to be made available in writing in a protocol format that directs the evaluation and treatment actions. Practical training was cited as necessary to awaken confidence in performance. In addition to the items mentioned, the participants suggest a form of support after the training, in groups and individually, so they can resort to it when doubts arise in their practice.
Finally, the training program built is made up of three principal axes: recorded classes made available on a digital platform, a week of face-to-face activities with different teaching methodologies, and individual and collective support for conducting the cases.
The initial classes are recorded and made available on a digital platform. There are six forty-minute classes with the themes: voiding physiology and classification of Lower Urinary Tract Dysfunctions; anatomy of the pelvic floor musculature and functional evaluation; Stress Urinary Incontinence and Pelvic Floor Musculature training programs; bladder diary and other assessment tools; Urge Urinary Incontinence and behavioral modifications; urinary retention and clean intermittent catheterization.
The face-to-face actions last one working week (Monday to Friday). The first day of the face-to-face action is intended to discuss doubts and review the content and practices on mannequins and realistic simulation of consultations by applying patient assessment instruments.
On the second day, a social action takes place in a place with a large circulation of people in the municipality to guide passers-by regarding the prevention and treatment of LUTD. The action aims to bring nurses closer to the subject, provide them with a moment to practice the assessment through a focused interview, and provide guidance relevant to the case presented.
The schedule for the third and fourth days includes a joint effort to assist people waiting for a medical appointment due to a LUTD complaint. These people are scheduled hourly by one of the four professors and are assisted by one of the three nurses who accompany the consultation under the supervision of the professor. The nurse who assists the patient assumes the case management until resolution or referral.
On the last day, printed and online protocols are distributed among course participants, and strategies to act as multipliers after three months of supervised care are discussed.
After the face-to-face phase, professors provide individual remote support for conducting cases or through the instant messaging group created for this purpose. In addition, to support this, there are live online meetings for group case discussions to resolve doubts and improve clinical reasoning.
Finally, a professional is hired in the municipality to collect data regarding the services the trained professional provides for twelve months.
Interpretation of results
It is noted that nurses working in Primary Health Care in Brazil have yet to receive training regarding their possibilities of acting in preventing and treating people with Lower Urinary Tract Dysfunctions. However, despite the lack of preliminary knowledge, the contact with the subject was an excellent motivator for the group in the sense of believing that nurses can have part of their agenda directed to the care of these patients.
The scenario of lack of knowledge and positive attitude is repeated in publications from other countries. For example, in a cross-sectional study conducted in two public hospitals and four private hospitals in Turkey, 254 nurses' knowledge and attitude towards UI were assessed using the same validated instruments applied by the previously mentioned study. The results were also similar. The average score for knowledge was 15 (0-24), and for attitude was 46 (15-60) (2).
On the one hand, the lack of knowledge is perceived, and on the other hand, the effectiveness of the performance of trained nurses. A Chinese study published in 2015 demonstrated generalist nurses' effectiveness in PHC in treating LUTS. This case-control study that selected 360 patients for the experimental group and 360 patients for the control group showed statistically significant results in the reduction of LUTS, improvement in QoL, reduction in medical appointments, and reduction in medication use (3).
Concluding message
The educational program built together with the target population (primary care nurses) includes recorded classes, assessment of content fixation, face-to-face review, case simulation, population orientation activity, face-to-face practice through carrying out a joint effort of care, individual and group remote support, and monitoring of results. The training can be acquired by municipal and state health departments when there is interest in offering the first line of treatment to adults with Lower Urinary Tract dysfunction.