Satisfaction of Elderly Patient ’ s Caregiver with the Assistance Instructions Given at an University Hospital

Results: It was verified that 79 caregivers (77.5%) affirmed having received discharge instructions before leaving the hospital. Out of these, 81% found it as excelent or good, and 53.9% considered instructions adequate to the elder’s socioeconomic condition. It was observed that 55.2% of those who rated discharge teaching as excelent had been given by doctors. From the caregivers that felt poorly confident after discharge, 75% did not receive any the discharge instructions.


Introduction
The elders use the hospital services in a more intense way than the others age groups, involving more costs, longer treatments and slower recovery [1]. The hospital discharge represents the transference of the care of the elderly patient from the hospital to the other health contexts or to their own homes [2], expecting from their families, or caregivers, the duty of the continuity of the care [3]. The hospital's assistance team must also be concerned in preparing the caregiver so that the process of returning home occurs in a physical, psychological and social independence conditions for the elderly [4]. The offered assistence to the elder in the hospital environment can generate dependences that difficult the home returning. So the hospital discharge can bring to the patients, above all, the elders, as to their families, ambiguous feelings, as the satisfaction as the fear, satisfaction for the recory and returning home and fear, for feeling insecure without the medical presence and nursing [5]. In this context the caregiver, the responsible person for the home assistance to the debilitated patients, is in general part of the household, assumes this work without being prepared for [6].
When the main responsible for the attention to the elderly patient is part of his family is named informal caregiver [7]. This is one of the main agents in the treatment of dependent elder, but has received little attention from health professionals working in the hospital sector, in order to better enable to continue the assistance. [4]. The caregivers more involved in the planing of the hospital discharge have more satisfaction and acceptance in their work [8]. So it's important to know how the caregivers evaluate the attendence that the elders receive during the time in the hospital, therefore to estimate the quality of the received information from the health team to the aftercare discharge time. The Ministerio da Saúde (Health Ministry) encourages the conduction of researches about the opinion of caregivers in internment times [9]. This study objective is to evaluate the satisfaction of the caregiver with the elderly attendance during the internment and guidance provided by the health team for home care after discharge in a university hospital, therefore the association of these variables with sociodemographic datas.

Methods
It was performed a cross-sectional study involving 102 elderly caregivers interned in the Medical Clinic of University Hospital Lauro Wanderley (HULW) between September and March 2015. The hospital HULW is a teaching hospital where doctors, professor and other health professionals work along with medical students as residents. As part of the Sistema Único de Saúde, SUS, the National Health Care Program, the mission of the Medical Clinic is to fulfil the secondary and tertiary care and attention of patients above 18 years old without delimitation of cover area.
The data collection consisted in performing direct interviews with the elderly carergivers during the internment of them and after their hospital discharge. In the interviews were used semi prepared forms elaborated by the authors and tested earlier in a pilot study. The items of the form were applied orally and at the time as the caregiver answered, the interviewers (medical students) filled them in writing. The questions concerned to the post discharge period of the patient were carried out by phone calls to caregiver previously interviwed after 15 days of the patient discharge. In case when any of the elders had more than one caregiver during the hospitalization, the interviews were conducted with those that stayed more time in contact with the elder. Were excluded from the study the caregivers that didn't answered all the items the data collect of the form and those ones that was not possible to get contact by the phone with the researchers in a period of time of 15 days after the elderly discharge.
The collect data instruments were, (1) clinical demographic forms with directed questions to the participants identification and the demographic data registration of the caregiver (provenience, gender, age, relationship, marital status, schooling and occupation situation), (2) forms with questions related to the caregiver satisfaction with the initial attendence of the elder, e (3) forms with questions related to the caregiver satisfaction with guidance provided by the health team for the discharge period of time.
It was prepared an electronic plan to store the data by the Excel program and posteriorly imported from a statistician program "STATISCAL PACKAGE FOR SOCIAL SCIENCES" (SPSS) version 20.0. In the descritive statistician, were determined the relative and absolute frequencies of the qualitative variable and average and diversion patterns of the quantitative variable. In inferential statistician were used the tests Qui.square, exact test of Fisher and Correlation Linear of Spearman. The significance level to all the inferential procedures was 5%.

Results
The age of 102 caregivers participants of the research ranged between 18 to 68 years old, with average of 38.5 (±12.2) years, 84.3% were female. The majority of the individuals of the sample (61-59.8%) were married. Eighty six (84.3%) presented some relationship with the elder, 43 (42.2%) had the complete gramar school and 81 (79.4%) had any kind of income (Table 1).
According to the satisfaction on the initial attending 83 (81.4%) of the interviwers easily found the sector of the first attending inside the HULW and 19 (18.6%) referred the reverse. Saying about the reception 97.1% considered welcome and the ap-  proach was satisfactory. The waiting time to get the first attending in HULW was till one day to 24 (23.5%) of the caregivers, till a week to 42 (41.2%), more than a week to 29 (28.4%) and more than a month to 7 (6.9%). Saying about the time interval between the initial attending and the internment, it was observed that 5.9% were interned in less than 30 minutes, 48% in an hour, 35.3% in more than one hour and 10.8% after 3 hours.
It was checked that 79 (77.5%) affirmed to receive from the health team orientations for the treatment continuity in post discharge period of time. Among the caregivers that received orientations from the team, 29 (36.7%) consider them excelente ones, 34 (44.3%) as good, 12 (15.2%) as regular and 3 (3.8%) as bad one.
Among the 79 answeres that received information for the care continuity, related the conditions of accomplishment of this care to the elder after the discharge, 55 declared that the orientations were adequated to the socioeconomic conditions of the family and 24 disagred.
The orientation received report after discharge was diferente according to the gender (χ 2 = 1.09, p=0.29).
According to the responsible professional for giving the discharge orientations, it was observed more participation by the doctor (Table 2).
When answered about the satisfaction of the received orientations for the continuity of the treatment after discharge, it was observed 55.2% of those that classified the received orientations as "excelent" had been oriented by the team doctors. From those that classified as "regular", 33.3% had received informations by the nursing team.
According to the confidence in fulfilment the basic cares with the elder in the post discharge period time, it was observed that 57.1% from those who answered "highly confident" were instructed only by doctors. From those who answered "poorly confident", 75% had not received orientation for caring post discharge ( Table 3).
The caregiver confidence to execute the cares with the elder after the discharge did not show difference between the genders (χ 2 =2.55, p=0.28), but was significantly distinct according to the patient origin (χ 2 =20.25, p<0.001). Caregivers coming from João Pessoa(PB) feel more assured than the others in Paraíba state.
Concerning to the time to the discharge time, 5 (4.9%) returned home in till one day, 25 (24.5%) in 3 days, 37 (36.3%) in a week and 35 (34.3%) after this time.
It was observed that among the 79 caregivers that received informations related to the elderly home care at the discharge time, 28 (35.4%) stil have doubts about this theme.

Discussion
The women predominancy in this role confirms the literature data about caregivers [10,11]. In a study performed in Colombia involving dependents elderly caregivers, it was showed that the majority was female (91%), with mediun age 49.4 years old. The predominant relationship the cared elder was the daughter (57%) [12], similar characteristics found in this study. In another study accomplished [13] involving 115 elderly caregivers, it was observed that the majority was the women (87.5%), similiar results found in another group [14], conducted with 101 elderly caregivers. Revising the literature about the elderly caregivers characteristics it was identified that they were represented predominantly by women with about 50 years old [15]. Besides that, the biggest longevity of the women makes that the men been cared by their wives, while the women had been cared by their daughters. This predominancy of caregivers of the female gender shows that the society through its culture imputes to the women the caregiver role, been her the spouse, the daughter or the elderly grandchildren.
The marital status of the caregivers differed from those ones found in another work [11], where the biggest part was single. In this sense, in the present studied sample, it's possible to supose that a familiar hospitalization tends to provoke instability in the Family organization, because the involved members, generally are married, keep dedicating time that could be given to the spouse and children companionship to follow the internment familiar process, what can generates intrafamiliar tension [16]. In this adaptation process to this new situation, the caregiver has to administrate her time between the personal cares, activities with the nuclear, with the house organization, dedication with children and husband, and those ones to the hospitalized familiar. It demands that the follow familiar develop the time organization hability to conciliate all these activities [17].
The schooling of the caregivers of the present study was similar to the other found in another ones performed in Brazil [4,13]. Emphasizes the shooling importance, interfering direct or indirectly on the cares to the elders. There is a fall in the quality service, when the caregiver has a low level schooling, because this one needs to follow diets, medical prescriptions and manipulate medicaments (read medical prescriptions, understand the dose and administration and the others), actions that can be difficulted for the low level of schooling [18]. The fact of the most than half of the sample has income, nevertheless, opposes the conjecture that the integral care to the sick elder difficults or prevents him-her to get a paid job [19]. These caregivers in general women, have to deal with several responsibilities and stress sources, and generally did not get familiar or governamental help [20]. The age average of the participants, a little smaller than others found in another Jobs [14], indicating that was in a social productive age.
In general the participants showed satisfaction with the received informations, demonstrating that the receiving informations were according with the expected to the answers. Nevertheless, opposing more than one third of them affirmed that still have doubts about to be given to elders. These results were similar to a brazilian study to evaluate the satisfaction of elders and caregivers groups with the discharge plan, the participants affirmed to be in conditions in continuing the cares [21]. In the referred study, was not also observed the correlaction between the observed satisfaction with sex, schooling and home place.
In a conducted study with 43 caregivers, 83.72% related had received orientations to the hospital discharge, similar result found in our research [22]. Tried to understand the perception of the sick people and the caregivers relatively with the received information and their utilization after internment, observing that 70% of the caregivers were informed about health problems of the sick people after be released [23].
According to the necessary time to get attendance in HULW, 64.7% got in a week and only 6.9% in more than a month. In a study fulfilled in a Hospital de Base no Distrito Federal (Base Hospital in Federal District), verified that the waiting time to the patient attendance in HBDF was over than two months in 91.8% of the users still had not been attended even after 12 months [24].
The results showed that the biggest part of the sample referred that the received orientations were adequated, what diverges what was observed in other study [25], in which the caregivers classified the plan quality of high as low, attesting that in the majority of times of the Family necessities are not known at the moment of the patient discharge. Possibly the hospital discharge of many elders is done before the Family feels ready for the continuity of the necessary treatment for his or her better conditions of improvement.
The results of the study shows a great vinculation in the doctor figure for more orientations in the home care, as a attest in a study that tried to know the discharge process in a central hospital in São Paulo interior, where the biggest part of the caregivers (81.4%) answered that the orientation to the hospital discharge were carried out by doctors, being in a group with others professionals or not [22].
Noticed also that there was insuficient inclusion and develop from nursing team in caregiver preparing process in helping his-her patient. In spite of being developed some efforts in matters of improving the preparation of nursing discharge, much more can be accomplished to improve the knowledge and habilities of the sick people in relation to their health and sickness seeing the return home [26]. Many of the times the discharge began late, centered in medical prescriptions delivery, desconsidering another essencial aspects to the management and health condition maintance, such as: nutrition, physical cares, lifestyle and others. Is need to detach, even more, the medular importance of the health team, especially the nursing, has a wide optic, realizing its action to beyond the patient, including the caregiver and the family in his-her plan and care system, having more effective participation and trying to be objective and clear, because his or her improving potential and the contributions resulting from this can be elevated.
In matters of orientation about nutrition of the elder in post discharge 42.2% did not receive this kind of information, worrying data seeing that the patients in recuperation must have a balanced diet and rich one in nutrientes to have a perfect recuperation.
Concerning to the time to carry out the discharge, about 70% did not show hability in the discharge process, taking more than three days to be done. Similar datas found in another research [27], on which were analysed 395 consecutive patients handbooks in irfirmaries of Medical Clinic of two teaching public hospitals: Hospital das Clínicas da Universidade de Minas Gerais e Hospital Odilon Behrens. The delay in the hospital discharge ocurred in 60% of the 207 internments of the Clinic Hospital and in 58.0% of 188 internments of the Odilon Behrens Hospital, similar results found in this work.
It was verified that 35.3% kept in doubts in cares to be done in post discharge. Others authors observed that during the orientation of the elder hospital discharge, from the 38 participants caregivers, 11 (28.9%) presented doubts in matter of the prescripted medicaments for using home, mainly when talks about the medicaments names and doses [28]. According to the authors, the participants did not ask enough about the instituted medicament therapy and, when they do, received a reduced number of informations, sometimes incorrect. For them the caregivers must receive the necessary orientations before the previous time for formal hospital leaving, avoiding the accumulation of informations and possibiliting the evaluation of the compreenhesion in matter of the given informations and the clarification of the doubts.
Considering the findings of this study it can confirms the complex nature of the care. Became evident the caregiver reception importance by multidisciplinary team, as that a bigger participation in the post discharge, reverberates in a bigger satisfaction, acceptance of the role and particularly a feeling preparation to take care of the elder.
After all, some analysis must be done, such as: will a care strategy reflect effectively in this citizen care in the hospital and in his or her familiar context? This reflection will be primordial during all this segment, with the objective of pondering that the care does not happen only in infirmaries, not even only carried out by health professionals.

Conclusion
This study revealed that the interviewed caregivers became very satisfied with all the related context to the elderly initial treatment, especially the received assistance on this stage. On the other hand, the satisfaction of the evaluation with the received orientations to the discharge period of time showed that there is so much more can be done to improve in this primordial stage for the continuity of the care started in hospital atmosphere, finding support with the compared studies.
Thus, an action plan aiming the elder assistance, beyond identifying their necessities, must also evaluate the orientation and skills development as a caregiver. This research contributes to emphazise the importance of the rended informations to the one that will give the sequence to the care of the elderly patient, whereas, the better the instructions are given, the more safe and confident the caregivers will be, and better performed will be the care post hospitalization.