INTRODUCTION

Palliative care (PC) is conceptualized by the World Health Organization (WHO) as a means of bringing comfort and enabling improvements to the quality of life of people who go through the terminality process through suffering prevention and relief, dignity, comprehensive and systematic care promotion, in addition to ensuring efficient symptom management and understanding of the biopsychosocial and spiritual suffering of patients and their families⁽¹⁾.

The WHO estimates that 40 million people worldwide need PC each year, and only 14% of patients who need this care actually receive it, and yet 78% of adults live in low- and middle-income countries. In Brazil, the expected population increase for 2000-2040 is 31.5% and the minimum estimate of patients with PC needs was 662,065 in 2000 and 1,166,279 for 2040^(2,3).

It should be noted that with the increase in life expectancy, the presence of cardiovascular, respiratory and metabolic disorders, as well as cancer, is observed, which cause loss of quality of life, corroborating for negative impacts on the economy and on family and social relationships, in addition to being associated with the need for prolonged assistance. Therefore, along with senility, the decline of organ systems also facilitates the development of life-threatening diseases and, consequently, there is a need for PC⁽⁴⁾.

From this perspective, demands for specific care for this clientele arise, bearing in mind, for example, that in most cases, mobility is compromised, thus maximizing the occurrence of wounds, especially pressure injuries (PI). Wounds are important complications in terminally ill patients, affecting almost a third of those under PC, a fact aggravated by the difficulties in its management due to patients’ discomfort and the generally complex nature of these injuries. It is estimated that 50% of them are pressure injuries, 20% ischemic and that the remaining 30% include various types of injuries, such as: surgical, venous, neoplastic and “skin tears”. Complex wounds are capable of gradually disfiguring the body and being accompanied by symptoms that objectively demonstrate what can be interpreted as failure in care, if knowledge and guidance regarding its scope and limitations are not obtained⁽⁵⁾.

Nurses play an important role under PC care and wound care, given that these professionals are responsible for coordinating the team to provide adequate care, directly and continuously, as they remain with patients full time. Thus, it is essential that they have an attentive look and are directed at the specific demands of patients who deal with the end of life, as this process needs to be lived with full dignity, satisfaction and comfort⁽⁶⁾.

Given this scenario, there is a lack of studies related to the topic at hand and, in the meantime, it presents the guiding question: what is the perception that nurses have about care for patients with wounds who are under PC? Therefore, in order to answer this question, the present research was carried out with the objective of understanding nurses’ perceptions about care for patients with wounds who are under PC.

METHOD

This is a descriptive, exploratory study with a qualitative approach. The COnsolidated criteria for REporting Qualitative research (COREQ) criteria were considered⁽⁷⁾.

The research was carried out in a hospital located in the metropolitan region of João Pessoa-PB. The hospital has 106 beds, 46 of which are for clinical admissions, and eight for intensive care beds. Despite not being a reference under PC, an increasingly significant number of patients experiencing terminality has been observed. In addition to these, the institution was chosen because it is a field of practices for nursing and medical students, as well as residency programs, and, in this context, the issues inherent to the permanent training process were considered.

The population was composed of the hospital’s clinical nurses, and non-probabilistic and convenience sample consisted of 15 nurses who agreed to participate in the research, taking into account the inclusion criteria as well as the saturation criteria. Nurses who worked as assistants, with more than six months in service and who were not performing management activities were included. Nurses who were absent on vacation or leave during collection, and those who acted as volunteers, were excluded.

Data collection took place in October 2022, and nurses were approached in the three shifts in the medical clinic and Intensive Care Unit (ICU) sectors. The study objectives as well as the consent form for signature were presented. When it was impossible to carry out the interview at the time of approach, an appointment was made. When the shift and the environment were favorable, this took place at the nursing station or in the prescription room, when it was not possible, nursing rest was used for without a reserved and quiet environment.

A semi-structured interview was used as a technique, and a script with questions consisting of two parts, as an instrument: the first covering sociodemographic and professional data, and the second with the following questions: how do you perceive the care of nurses to patients with wounds and are under PC? What are the main purposes of caring for wounds in patients undergoing PC? What factors are considered as limiting factors for carrying out this type of care? What strategies could be identified as possibilities for improvements in the conduct of this care?

The interviews lasted about 20 minutes, and after being recorded and transcribed, the categorical content analysis proposed by Bardin was carried out, which was organized around pre-analysis with material exploration, coding and inference, and finally interpretation of results. This analysis addresses a set of methodological instruments in constant improvement, which are applied to specific discourses (contents and continents) and which present extremely diversified⁽⁸⁾.

The conference of the collected and transcribed data occurred by two pairs independently formed by an undergraduate student and a professor. To ensure anonymity, participants were sequentially coded with the letter N referring to the word nurse and a cardinal number related to the chronological order of performance.

The study was approved by the Research Ethics Committee of the Centro Universitátio de João Pessoa (UNIPÊ), under Protocol 5,659,061.

RESULTS

Of those who participated in the study, most had only one job, while four worked in two, of which 12 were female, with a mean age between 21 and 45 years. All declared to be married and to have an income higher than two minimum wages. Regarding workload, 13 reported that they worked 44 hours a week, one around 88 hours and the other 24 hours a week. Of these nurses, 13 had lato sensu graduate degrees. Years of experience in nursing ranged from one to 20 years, with an average of eight years.

Still three reported not having experience in the treatment of people with wounds, while the others had a minimum experience of six months. As for training, eight said they had taken some course in the area of skin injury prevention and treatment, but with regard to PC, only five.

Empirical material analysis enabled creating the following categories: Recognition of the importance of nursing care for patients with wounds and undergoing palliation; Weaknesses in the care of patients who have wounds and are under palliative care; and Strategies for improvements in nursing care directed to patients who have wounds and are under palliative care.

Recognition of the importance of nursing care for patients with wounds and undergoing palliation

Nurses recognize the importance of PC and have a certain understanding regarding the principles as well as express the need to properly care for wounds. Many report that this care must be carried out with quality and in full, according to the following reports:

I think that people in palliative care, no matter how palliative it is, we should provide the best possible quality of that care. Treating these wounds, from my point of view, will provide this comprehensive care, which we must have, regardless of whether the person is palliative or not. (N9)

Palliative care brings a lot of pain relief. So, it is important for health professionals to know that that wound, regardless of the stage, is bothering patients and causing pain. (N8)

I think it will affect the quality of life of this patient, there is the issue of odor, right? Above all, provide quality of life. (N11)

Just because you’re in palliation that you’re going to be without any kind of procedure? The dressing has to be done daily. (N10).

[...] it just can’t stop being done, right? Because the patient did not die, he is palliative. (N3)

Nurses are of great importance in this process of treating wounds. (N4)

Weaknesses in the care of patients who have wounds and are under palliative care

In this category, despite nurses pointing out the importance of care for patients with wounds and PC, especially with regard to suffering relief through comfort measures, report the lack of assistance and weaknesses regarding nurses’ knowledge about caring for wounds in patients who are under PC. Despite most claiming to have training in the treatment of people with wounds, a limitation is perceived when associated with the context of PC, as follows:

On the part of nursing, we do our best to bring comfort and good care to this wound and to these patients in palliative care. (N12)

A little scary for some. It’s like something new, despite being so old and so debated. (N8)

It is not offered properly, because it is palliative care, it leaves much to be desired. (N13)

I still see a lot of flaws here because when talking about palliative care, there are many professionals who don’t have the vision, like, to continue treatment. In fact, they see palliative care as the end of life and do not provide that certain assistance, that greater care, that they should. I actually see it in practice. (N15)

Despite advances on the subject, the weaknesses present in the hospital routine are perceptible. Nurses point out numerous issues that present themselves as weaknesses in which it is inferred that it is not just an isolated reality. Furthermore, they recognize the lack of assistance, the incipient knowledge that even in a context where the majority declares to have training in the treatment of people with wounds.

Material availability to carry out procedures for both prevention and treatment is identified as a challenge for the provision of nursing care, as evidenced in the speeches:

In a hospital environment, usually the material issue, right? There are materials that cost very high and the SUS will not invest in a treatment like that, too high, especially for patients in palliative care. (N6)

Treatments for injured patients are very precarious. If there is a skin commission, but it is not enough for all patients, we do not have all the coverage that they have to have, right? But what we use most is silver sulfadiazine. Sunflower oil and barrier cream never seen here. (N10)

We know that there are limitations and that the appropriate materials are not available and this makes nursing work difficult. (N7)

What limits many people within the power of public health is the need for material that sometimes we do not have. But, with the little we have, we also serve. (N14)

Another limiting reason is the lack of Permanent Health Education (PHE) of professionals, or the belief that caring for patients with wounds is exclusive to specialist nurses or skin committees. See the statements below:

I think the training of professionals, especially nurses. Often what is lacking is the professionals’ interest in wanting to be a specialist, in seeking this autonomy, this empowerment. (N11)

It would be a matter of preparing the team, bringing more knowledge about the issue of wounds and also palliative care. (N4)

As for the wounds? I think the care provided by nurses, in fact, specialist nurses, right? Makes all the difference in wound care. (N6)

I realize that even myself in wound care, several times, I’ve had my difficulties. Precisely because of lack of training, so if you don’t train, you don’t recognize the environment in which you work. And then deal with that quality of patient that you have. It is precisely a factor that interferes in this care. (N9)

Work overload is referred to as another limiting factor to be overcome in the following statements:

The professional overload, in addition to the lack of inputs and not only professional unpreparedness as well. (N9)

My experience in palliative care is still the “teame”. (N11)

When it’s more like nursing care, I see that it’s a lot of negligence for professionals to feel considerably tired due to the demand of patients. So, it turns out that they do, like, any basic dressing on top or sometimes they pass the shift and they don’t, they record what they did and didn’t. I already got this in my everyday life. [...] (N9)

Strategies for improvements in nursing care directed to patients who have wounds and are under palliative care

In this category, the deponents refer to the possible strategies that can overcome the weaknesses in which one of the means would be the PHE provided by the institution in which they work. As can be seen in the following statements:

I think offering training, doing it for free or at a more affordable price. Or some program that draws more attention from nurses related to this. (N13)

I think that something like this is continuing education [...]. I see that even in terms of identifying the injury, there is already a difficulty. A way of continuing education that was also practical, you know? Because sometimes it’s no use getting there just talking. Just talking and not having practice, right? (N1)

I think it is continuing education, continuing education for professionals, especially nurses with their technicians and nursing assistants. If nurses are trained, they care about the work they are doing, it goes in a cascade, from the nurse to the technician, from the technician to the assistant. (N11)

Training! I see people who don’t have that vision, don’t have that qualification, don’t have that look, I believe that with training, investing in this area, they will change their view of caring. (N15)

I need to train myself! To be able to provide the best care for that patient. In addition to wound care, we also recognize this palliative care. (N9)

Another point raised concerns mitigating the lack of investment in materials. Many nurses claim that there should be more government funding for both materials and technologies in dressings for the care of patients undergoing palliation. The lack of basic materials is a constant complaint and nurses are faced with an abysmal distance from the products and technologies available on the market, as evidenced in the excerpts:

I think that the general vision of the hospital, municipal, state manager should be better for this care with palliative patients, as in the case of the dressing. People don’t care much. I don’t have a broad view on this. (N7)

Monetary investment in relation, because if we have an extra investment, we can improve quality of care. (N6)

Work overload is directly related to the issue of investments in the adequate sizing of professionals in services. Nurses also indicate the need for interprofessional care. This glimpse to solve this problem is evident in the following speeches:

A more suitable skin commission. It’s a small number of professionals, it has to be more people. In each sector, there must be a committee to care for dressings. (N10).

In the hospital environment, I think that the issue of culture of care for palliative patients in the multidisciplinary environment should first be addressed. That had to be the priority. (N2)

DISCUSSION

The increasing aging of the population, associated with the prevalence of chronic non-transmissible and degenerative diseases, in a scenario of poverty, little political organization and difficulty in accessing health services means that approximately 40% of patients who need PC in the world, belong to the group of people aged 70 or over. This finding highlights the demand for structures and organizations that accompany individuals with progressive and incurable diseases in the search for dignified care for their health issues, based on different assistance modalities⁽¹⁾.

Nursing, as a profession that is in direct contact with the patient, is responsible for a holistic view that contemplates the care process in the biological, psychological, social and spiritual dimensions of the human being. In the implementation of this care, there is a need for the intervention of a team of professionals adequately trained and experienced in management of symptoms of a non-biological nature, but also with excellent communication potential so that patients and their families understand the evolutionary process they are going through and have knowledge of the natural history of the ongoing disease so that they can act in a way that provides not only relief, but the prevention of a symptom or crisis situation⁽⁹⁾.

When relating nursing care to people with wounds and who are also under PC, it is emphasized that when characterized in terms of time of evolution, they are characterized as acute or chronic. Acute wounds are traumatic injuries that are quickly treated and respond easily to therapeutic interventions, such as surgical wounds, lacerations, abrasions and puncture wounds. Chronic ulcers, in turn, remain open for a long time, generally longer than six months, and are commonly associated with complications arising from degenerative diseases, such as diabetic foot, venous ulcers, arterial ulcers and those resulting from neoplastic processes. In Brazil, approximately 3% of the country’s population has some type of injury, regardless of sex, age or ethnicity, with chronic wounds being the most prevalent⁽¹⁰⁾.

In order to guarantee a practice based on the best scientific evidence, it is essential that nurses maintain a study routine and, consequently, search for new knowledge. When caring for wounds, they assume a relevant role that comes with considerable responsibility. Some wounds become chronic, the incidence of which is gradually increasing all over the world, and have had a negative impact on the quality of life of patients, as they cause pain at different levels and are repetitive⁽¹¹⁾.

In a study carried out with 17 nurses in the city of Fortaleza on care related to IP in people who were under PC, it was possible to conclude the relevance of nursing role in care, by envisioning measures of comfort and pain management, in addition to the criteria eligibility for the use of products, in which service availability and each patient’s individual needs are considered attentive. In this study, interprofessionality was also evidenced, when considering the dialogue with the medical team to perform analgesia on average 30 minutes before the procedures⁽¹²⁾.

A systematic review published in 2020, with the objective of mapping the best evidence about wound care for patients with PC, after analyzing 41 studies, pointed out the importance of careful assessment and definition of criteria for the treatment of different types of wounds. Aspects about care management as well as attention to psychosocial and spiritual aspects were highlighted⁽¹³⁾.

In this study, there was no mention of psychosocial or spiritual issues, which infers a gap in the provision of comprehensive and humanized care. Access to PC has been recognized as a basic human right for all human beings, which must be ensured regardless of the type of disease, income and age.

However, gaps in the training process have greatly compromised the quality of care provided. In a study carried out in 2019, aiming to assess nurses’ knowledge about palliative care and attitudes towards end-of-life care in public hospitals in the Wollega areas of Ethiopia, the Palliative Care Quiz for Nursing (PCQN) and Frommelt Attitudes Towards Care of the Dying (FATCOD) were used. Both questionnaires were applied to 422 nurses and revealed that nurses’ knowledge about PC is inadequate and professionals behave with a less favorable attitude towards end-of-life care⁽¹⁴⁾.

In Brazil, a study that sought to assess nurses’ perception about their academic training and professional qualification for providing PC revealed a low theme and subject exploration throughout nurses’ training process, since the significant majority of respondents, in addition to not having subjects, reported never having participated in PHE programs⁽¹⁵⁾.

When considering the aspect of training for wound care in the face of terminality, exploration becomes null. Such care is considered indispensable for physical stability during end-of-life care. In a study carried out with nurses who completed the Fellowship of the Korean Wound Academy program and participated in training for wound care under PC, when using the Q methodology to analyze their subjective points of view, 4 Q-factors were revealed: “Focusing on care within the boundary of current patient demands,” “Comparing continuously the priorities on wound healing and disease care,” “Preparing and preventing from worsening via tracking care in advance,” and “Moving forward with a clear direction by confronting the declining condition”⁽¹⁶⁾. Thus, the need to rethink the study on the subject both at graduation and transcend and remain during the implementation of qualification strategies emerged.

When referring to the weaknesses inherent in the work overload and incipient number of nursing professionals in the team, a study conducted based on the Donabedian framework with 35 ICU nurses on eligible PC patients signaled considerable concerns about this aspect, since undersizing predisposes the occurrence of adverse events due to work overload and precariousness⁽¹⁷⁾.

The fact that there are no specific criteria in the literature to properly size teams working under PC recommends that the Brazilian National Health Regulatory Agency (ANVISA - Agência Nacional de Vigilância Sanitária) requirements and the Professional Class Councils norms be observed and, with this, reduce risks and unnecessary damage to patients’ health⁽¹⁸⁾.

Allied to insufficient sizing, the lack of materials compromises nursing care. In a study conducted in the state of Pernambuco, 80% of nursing professionals stated that they were unable to develop their routine practices and offer a service in a qualified manner, and 95% of nurses reported that they are harmed due to the lack of inputs in different situations⁽¹⁹⁾.

Rethinking and optimizing fundraising measures is one of the emerging strategies for PC improvements in Brazil. The Brazilian National Academy of Palliative Care (ANPC - Academia Nacional de Cuidados Paliativos) released in 2019 the Palliative Care Atlas in Brazil. In this document, 191 services were catalogued, distributed as follows: seven in the North Region; 20 in the Midwest Region; 26 in the Northeast Region; 33 in the South Region; and 106 in the Southeast Region. This also reiterates that, sometimes, they are not services that provide care in its entirety, but only with some wards or beds reserved for this purpose. Thus, the number of PC beds in the country corresponds to only 789 beds⁽²⁰⁾.

When reflecting on the interrelationship in caring for the wounds of people with PC, the problem arising from the lack of resources that imposes limitations on adequate care in both situations is enhanced, as reported in a study carried out at a public hospital in Paraíba, reiterating that professionals have limited care activities due to insufficient materials to provide care and that this reality is one of the great challenges for health teams and public managers⁽²¹⁾.

With the lack of inputs combined with the lack of a routine offering courses and training, the institutions that manage to set up a skin commission compromise their performance, considering that their involvement and participation in monitoring patients in the prevention and treatment of injuries already existing is essential. In a study carried out in Curitiba with 27 nurses, the relevance of committees in conducting care for complex wounds was highlighted as well as regarding demands such as debridement, dressings, coverings, among other related issues⁽²²⁾.

The limitations that can be considered in this study are centered on the type of research that presents limited generalization potential range, which does not invalidate the research. Another important point is the fact that this is a specific reality of a single institution. It is hoped that new studies can be carried out with a view to tracing a broader reality as well as the use of other methodological approaches.

FINAL CONSIDERATIONS

When investigating the main findings in this study, it was observed through the nurses interviewed that nurses understand the importance of carrying out care in patients under PC who have wounds. They highlight the relevance of promoting measures of comfort and pain management as well as promoting quality of life amidst the terminality process.

They reveal how much the lack of permanent education and materials compromise care and that the lack of adequate sizing does not allow for comprehensive care. It was observed that there was no mention of spiritual care, and the look at the family was incipient, inferring a certain distance from the philosophy of PC, a situation that can be minimized by strengthening strategies aimed at training from graduation.

The demographic transition process is ongoing with the presentation of an ever-increasing number of older adults and, therefore, chronic non-communicable diseases. Thus, it is imperative to rethink fundraising, increase the supply of beds and urgently promote PHE measures. During the search for studies, in order to substantiate the results found, it was noticed the lack of research that addressed the theme in the Brazilian reality. For this reason, it is hoped that this can contribute to new insights for further studies.

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Fomentation: There is no development institution

Scientific Editor: Francisco Mayron Morais Soares. Orcid: https://orcid.org/0000-0001-7316-2519

Rev Enferm Atual In Derme 2023;97(1):e023009