Study design, materials and methods
This is a methodological study the reference followed for the construction of the didactic instructional material was the social communication process with a focus on health. The first stage counted on the participation of nurses to indicate the strategies to face the barriers to adherence to CIC according to their experience. The population was composed of Brazilian nurses who work or have experience guiding patients who need CIC. The inclusion criteria were: being a nurse, having active registration with the nursing council, and having experience with CIC training; the exclusion criteria were having been a nurse for less than three years.
To compose the sample, two national events were held by a stomal therapist nurse and national reference in the area of voiding dysfunctions, a company that develops products and services in the areas of stomas, urology, continence, and wound care. The events took place on 05/26/21 and 07/29/21, from 7:30 pm to 9:00 pm on both days, through the Microsoft Teams® platform, with no limit of participants. The second questionnaire was composed of the description of eight barriers, which were defined after reading and interpreting studies on the subject, especially a market study with 2942 patients, conducted in eight countries, with 189 nurses, 12 physicians, whose listed barriers were: "I feel overwhelmed", "I don't know my anatomy", "I feel afraid of hurting myself", "I feel alone", "I will never learn/remember clean intermittent catheterization", "I can't leave the house anymore", "clean intermittent catheterization will limit my sex life", "I am afraid of getting a urinary tract infection" (3). After each barrier had a discursive response space for the nurse to share their coping strategy or strategies.
Results
Thirty-eight nurses participated in the study. There were three exclusions, two for duplicate board registration and one for non-completion. Women were 94.7% and 5.3% men, with an age of 39.2 years and a standard deviation of (SD 6.86). Nurses from all Brazilian regions participated. The thematic analysis of the six categories listed 107 main generating statements, five subthemes (active listening, follow-up, support materials, lubrification and urethral injury prevention, and control of urinary infection), and 39 indications of practical actions. The researcher conducted the six stages of the Thematic Analysis(2): Step one becoming familiar with the theme, step two generating initial codes, step three searching by themes, step four revisiting the themes, this step generated the six final themes: "Reception and care plan", "translation of technical knowledge to the user", "use of support materials for technique training and prevention of complications", "adaptation of CIC in the routine, sexuality with a focus on the quality of life", "support networks - the importance of professionals, family and friends", and "accessibility". In step six (producing the report), a table with three columns was built, one for the presentation of the six major themes, another for the representative speeches, and the selection of the lessons was done carefully so that all the subthemes of the previous step and participants from all regions would compose it, reinforcing the representativeness of the speeches.
Interpretation of results
The study presents instructional teaching material based on six major themes, wich will be described with the speeches that best represent them. First theme "Reception and care plan":
"...Dialogue to minimize anxieties and fears." E16
"...To discover his beliefs to speak a language closer to his reality." E18
"...Listening about how they feel about their health status, and what the expectation for care is...". E22
Theme two "Translation of technical knowledge to the user":
"...Priority the clarification of anatomy and the importance of explaining that anatomically men and women have their distinct anatomy...". E22
"...Perform detailed orientation to the patient on the anatomy of the urinary tract, if possible, using technologies (video, illustrated booklet, websites) ...". E14
"...clarification of the benefits of clean intermittent catheterization." E31
Theme three "Use of support materials for technique training and prevention of complications":
"Use real and playful illustrative figures...". E10
"First, I demonstrate on a prototype for him to become familiar with the whole anatomical system, and then he has to demonstrate on the patient himself...". E17
"Explain the reasons for infection and answer his questions about the subject. E2
Them four "Adaptation of the CIC in routine and sexuality with a focus on quality of life":
"...engage him to do a mictional diary to instigate him to know his need for catheterization." E5
"...structuring with the patient organizational measures that may favor the practice of CIL by including this practice in their daily life...". E38
"...I always talk about sexuality, many times they are ashamed and if you don't talk about it, they keep that anguish...". E33
Theme five "Support networks and the importance of professionals, family and friends":
"...another possibility is to identify with him a family member who might be helping at this time..." E2
"...we professionals and family members are your support network...". E10
"...stimulate/motivate the patient's participation in groups of people experiencing the same condition, enabling the exchange of experiences; guide to seek support from friends and/or family..." E14
Theme six "Acessibility"
"...Introducing the technologies in the market that can help...". E15
"...explain access via public system, privaty or purchase (according to condition) ...". E5
"...Demand from sites accessibility according to the law; explain about the laws." E5