PIELĘGNIARSTWO POLSKIE POLISH NURSING. KWARTALNIK / QUARTERLY Nr 4 (70) 12/2018

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1 Uniwersytet Medyczny im. Karola Marcinkowskiego w Poznaniu Poznan University of Medical Sciences Wydział Nauk o Zdrowiu Faculty of Health Sciences PIELĘGNIARSTWO POLSKIE POLISH NURSING KWARTALNIK / QUARTERLY Nr 4 (70) 12/2018 Indeksowane w / Indexed in: Ministerstwo Nauki i Szkolnictwa Wyższego/ Ministry of Science and Higher Education 6,0 Index Copernicus Value (ICV) 88,81

2 PIELĘGNIARSTWO POLSKIE POLISH NURSING Skrót tytułu czasopisma/abbreviated title: Piel Pol. Copyright Uniwersytet Medyczny im. Karola Marcinkowskiego w Poznaniu ISSN eissn Korekta/Proofreading: Barbara Grabowska-Fudala Barbara Błażejczak Korekta tekstów w j. ang./language editor: Agata Dolacińska-Śróda Skład komputerowy/desktop publishing: Beata Łakomiak Projekt okładki/cover project: Bartłomiej Wąsiel Sprzedaż/Distribution and subscription: Punkt Sprzedaży Wydawnictw Naukowych UMP Poznań, ul. Przybyszewskiego 37a tel. (phone)/fax: sprzedazwydawnictw@ump.edu.pl Redakcja deklaruje, że wersja papierowa Pielęgniarstwa Polskiego jest wersją pierwotną (referencyjną) Editorial Staff declares that printed version of Polish Nursing is the original version (reference) Zasady etyczne Pielęgniarstwo Polskie stosuje zasady etyczne i procedury zalecane przez COPE (Committee on Publication Ethics), zawarte w Code of Conduct and Best Practice Guidelines for Journal Editors, Peer Reviewers, Authors dostępne na stronie internetowej COPE: Ethical guidelines Polish Nursing applies the ethical principles and procedures recommended by COPE (Committee on Conduct Ethics), contained in the Code of Conduct and Best Practice Guidelines for Journal Editors, Peer Reviewers and Authors available on the COPE website: WYDAWNICTWO NAUKOWE UNIWERSYTETU MEDYCZNEGO IM. KAROLA MARCINKOWSKIEGO W POZNANIU Poznań, ul. Bukowska 70 Ark. wyd. 5,8. Ark. druk. 8,3. Format A4. Zam. nr 243/18. Druk ukończono w grudniu 2018.

3 PIELĘGNIARSTWO POLSKIE POLISH NURSING KOLEGIUM REDAKCYJNE Redaktor Naczelny dr hab. Krystyna Jaracz, prof. UM Zastępcy Redaktora Naczelnego dr hab. Krystyna Górna, prof. UM dr hab. Danuta Dyk prof. dr hab. Małgorzata Kotwicka RADA NAUKOWA prof. Vincenzo Antonelli dr hab. Grażyna Bączyk prof. Merita Berisha mgr Regina Bisikiewicz prof. Antonio Cicchella prof. Susumu Eguchi dr hab. Aleksandra Gaworska-Krzemińska dr Barbara Grabowska-Fudala dr hab. Elżbieta Grochans dr Aleksandra Gutysz-Wojnicka prof. Lotte Kaba-Schönstein doc. Helena Kadučáková mag. Karin Klas prof. Christina Koehlen dr hab. Maria Kózka dr Halyna Krytska dr hab. Anna Ksykiewicz-Dorota dr hab. Joanna Lewko prof. Mária Machalová dr hab. Ludmiła Marcinowicz prof. dr hab. Ewa Mojs dr Jana Nemcová prof. dr hab. Grażyna Nowak-Starz dr hab. Beata Pięta prof. UM prof. Hildebrand Ptak prof. dr hab. Joanna Rosińczuk Silvia Scelsi prof. dr hab. Maria T. Szewczyk prof. dr hab. Arkadii Shulhai dr hab. Robert Ślusarz dr Dorota Talarska dr hab. Monika Urbaniak prof. UM dr Frans Vergeer dr hab. Ewa Wilczek-Rużyczka dr Katarína Žiaková Sekretarz Naukowy dr n. med. Barbara Grabowska-Fudala Sekretarz Redakcji dr n. med. Barbara Grabowska-Fudala LUISS Guido Carli di Roma (Włochy) Uniwersytet Medyczny im. Karola Marcinkowskiego w Poznaniu (Polska) University of Prishtina (Kosowo) European Association of Service Providers for Persons with Disabilities (EASPD) University of Bologna (Włochy) Graduate School of Biomedical Sciences, Nagasaki University (Japonia) Gdański Uniwersytet Medyczny (Polska) Uniwersytet Medyczny im. Karola Marcinkowskiego w Poznaniu (Polska) Pomorski Uniwersytet Medyczny (Polska) Uniwersytet Warmińsko-Mazurski w Olsztynie (Polska) Hochschule Esslingen (Niemcy) Katolícka Univerzita v Ružomberku (Słowacja) Studiengangsleitung Gesundheits- und Krankenpflege, IMC FH Krems (Austria) Evangelische Hochschule Berlin (Niemcy) Uniwersytet Jagielloński Collegium Medicum (Polska) Państwowy Uniwersytet Medyczny im. I. Ya. Horbaczewskiego w Tarnopolu (Ukraina) Uniwersytet Medyczny w Lublinie (Polska) Uniwersytet Medyczny w Białymstoku (Polska) Prešovská Univerzita (Słowacja) Uniwersytet Medyczny w Białymstoku (Polska) Uniwersytet Medyczny im. Karola Marcinkowskiego w Poznaniu (Polska) Comenius University in Bratislava (Słowacja) Uniwersytet Jana Kochanowskiego w Kielcach (Polska) Uniwersytet Medyczny im. Karola Marcinkowskiego w Poznaniu (Polska) Evangelische Hochschule Berlin (Niemcy) Uniwersytet Medyczny im. Piastów Śląskich we Wrocławiu (Polska) Vice president of Aniarti, Director of nursing and health professions department, Children's Hospital G. Gaslini Genoa (Włochy) Collegium Medicum w Bydgoszczy UMK w Toruniu (Polska) Państwowy Uniwersytet Medyczny im. I. Ya. Horbaczewskiego w Tarnopolu (Ukraina) Collegium Medicum w Bydgoszczy UMK w Toruniu (Polska) Uniwersytet Medyczny im. Karola Marcinkowskiego w Poznaniu (Polska) Uniwersytet Medyczny im. Karola Marcinkowskiego w Poznaniu (Polska) Fontys Hogescholen (Holandia) Krakowska Akademia im. Andrzeja Frycza-Modrzewskiego (Polska) Comenius University in Bratislava (Słowacja) ADRES REDAKCJI Pielęgniarstwo Polskie Wydział Nauk o Zdrowiu Uniwersytetu Medycznego im. Karola Marcinkowskiego w Poznaniu ul. Smoluchowskiego 11, Poznań tel.: , fax: pielegniarstwopolskie@ump.edu.pl

4 PIELĘGNIARSTWO POLSKIE POLISH NURSING REDAKTORZY TEMATYCZNI mgr Katarzyna Gołębiewska dr Katarzyna Plagens-Rotman dr Joanna Stanisławska mgr Renata Szpalik Uniwersytet Medyczny im. K. Marcinkowskiego w Poznaniu (Polska) Uniwersytet Medyczny im. K. Marcinkowskiego w Poznaniu (Polska) Uniwersytet Medyczny im. K. Marcinkowskiego w Poznaniu (Polska) Uniwersytet Medyczny im. K. Marcinkowskiego w Poznaniu (Polska) REDAKTOR STATYSTYCZNY dr inż. Renata Rasińska LISTA RECENZENTÓW dr Agnieszka Bańkowska dr hab. Grażyna Bączyk dr Benedykt Bober prof. Antonio Cicchella dr Justyna Cwajda-Białasik dr Józefa Czarnecka dr Grażyna Czerwiak dr hab. Joanna Gotlib dr Grażyna Iwanowicz-Palus doc. Helena Kadučáková Douglas Kemerer dr Ewa Kobos dr Halina Król dr Urszula Kwapisz dr Włodzimierz Łojewski prof. Mária Machalová prof. Anders Møller Jensen prof. dr hab. Henryk Mruk dr Jana Nemcová dr inż. Iwona Nowakowska dr Jan Nowomiejski dr Piotr Pagórski prof. dr hab. Mariola Pawlaczyk dr hab. Beata Pięta prof. UM dr Wojciech Grzegorz Polak Ottilie Rung dr Zofia Sienkiewicz dr Beata Skokowska dr Ewa Szynkiewicz dr Dorota Talarska dr hab. Monika Urbaniak prof. UM dr Aleksandra Zielińska dr Katarína Žiaková prof. Klaudia J. Ćwiękała-Lewis Collegium Medicum w Bydgoszczy UMK w Toruniu (Polska) Uniwersytet Medyczny im. K. Marcinkowskiego w Poznaniu (Polska) NZOZ Nadmorskie Centrum Rehabilitacji (Polska) University of Bologna (Włochy) Collegium Medicum w Bydgoszczy UMK w Toruniu (Polska) Warszawski Uniwersytet Medyczny (Polska) Uniwersytet Jana Kochanowskiego w Kielcach (Polska) Warszawski Uniwersytet Medyczny (Polska) Uniwersytet Medyczny w Lublinie (Polska) Katolícka Univerzita v Ružomberku (Słowacja) Nursing Clinical Instructor at York County School of Technology (USA) Warszawski Uniwersytet Medyczny (Polska) Uniwersytet Jana Kochanowskiego w Kielcach (Polska) Uniwersytet Medyczny im. K. Marcinkowskiego w Poznaniu (Polska) Uniwersytet Medyczny im. K. Marcinkowskiego w Poznaniu (Polska) Prešovská Univerzita (Słowacja) VIA University College Denmark (Dania) Uniwersytet Ekonomiczny w Poznaniu (Polska) Comenius University in Bratislava (Słowacja) Uniwersytet Medyczny im. K. Marcinkowskiego w Poznaniu (Polska) Uniwersytet Medyczny im. K. Marcinkowskiego w Poznaniu (Polska) Uniwersytet Medyczny im. K. Marcinkowskiego w Poznaniu (Polska) Uniwersytet Medyczny im. K. Marcinkowskiego w Poznaniu (Polska) Uniwersytet Medyczny im. K. Marcinkowskiego w Poznaniu (Polska) University Medical Center Rotterdam (Holandia) The University of Arizona College of Nursing (USA) Warszawski Uniwersytet Medyczny (Polska) Uniwersytet Medyczny im. K. Marcinkowskiego w Poznaniu (Polska) Collegium Medicum w Bydgoszczy UMK w Toruniu (Polska) Uniwersytet Medyczny im. K. Marcinkowskiego w Poznaniu (Polska) Uniwersytet Medyczny im. K. Marcinkowskiego w Poznaniu (Polska) Uniwersytet Medyczny im. K. Marcinkowskiego w Poznaniu (Polska) Comenius University in Bratislava (Słowacja) Faculty at Health Sciences and Nursing, Phoenix University (USA)

5 PIELĘGNIARSTWO POLSKIE POLISH NURSING EDITORIAL BOARD Editor-in-Chief Krystyna Jaracz Vice Editor-in-Chief Krystyna Górna Danuta Dyk Małgorzata Kotwicka EDITORIAL ADVISORY BOARD Vincenzo Antonelli Grażyna Bączyk Merita Berisha Regina Bisikiewicz Antonio Cicchella Susumu Eguchi Aleksandra Gaworska-Krzemińska Barbara Grabowska-Fudala Elżbieta Grochans Aleksandra Gutysz-Wojnicka Lotte Kaba-Schönstein Helena Kadučáková Karin Klas Christina Koehlen Maria Kózka Halyna Krytska Anna Ksykiewicz-Dorota Joanna Lewko Mária Machalová Ludmiła Marcinowicz Ewa Mojs Jana Nemcová Grażyna Nowak-Starz Beata Pięta Hildebrand Ptak Joanna Rosińczuk Silvia Scelsi Maria T. Szewczyk Arkadii Shulhai Robert Ślusarz Dorota Talarska Monika Urbaniak Frans Vergeer Ewa Wilczek-Rużyczka Katarína Žiaková Scientific Secretary Barbara Grabowska-Fudala Editorial Secretary Barbara Grabowska-Fudala LUISS Guido Carli di Roma (Italy) Poznan University of Medical Sciences (Poland) University of Prishtina (Kosowo) European Association of Service Providers for Persons with Disabilities (EASPD) University of Bologna (Italy) Graduate School of Biomedical Sciences, Nagasaki University (Japan) Medical University of Gdańsk (Poland) Poznan University of Medical Sciences (Poland) Pomeranian Medical University in Szczecin (Poland) University of Warmia and Mazury in Olsztyn (Poland) Hochschule Esslingen (Germany) Katolícka Univerzita v Ružomberku (Slovakia) Studiengangsleitung Gesundheits- und Krankenpflege, IMC FH Krems (Austria) Evangelische Hochschule Berlin (Germany) Jagiellonian University Collegium Medicum (Poland) Ternopil State Medical University (Ukraine) Medical University of Lublin (Poland) Medical University of Bialystok (Poland) Prešovská Univerzita (Slovakia) Medical University of Bialystok (Poland) Poznan University of Medical Sciences (Poland) Comenius University in Bratislava (Slovakia) Jan Kochanowski University in Kielce (Poland) Poznan University of Medical Sciences (Poland) Evangelische Hochschule Berlin (Germany) Wroclaw Medical University (Poland) Vice president of Aniarti, Director of nursing and health professions department, Children's Hospital G. Gaslini Genoa (Italy) Nicolaus Copernicus University Ludwik Rydygier Collegium Medicum (Poland) Ternopil State Medical University (Ukraine) Nicolaus Copernicus University Ludwik Rydygier Collegium Medicum (Poland) Poznan University of Medical Sciences (Poland) Poznan University of Medical Sciences (Poland) Fontys Hogescholen (Holland) Andrzej Frycz Modrzewski Krakow University (Poland) Comenius University in Bratislava (Slovakia) EDITOR S ADDRESS Polish Nursing The Faculty of Health Sciences Poznan University of Medical Sciences 11 Smoluchowskiego Str., Poznań, Poland phone: , fax: pielegniarstwopolskie@ump.edu.pl

6 PIELĘGNIARSTWO POLSKIE POLISH NURSING THEMATIC EDITORS Katarzyna Gołębiewska Katarzyna Plagens-Rotman Joanna Stanisławska Renata Szpalik Poznan University of Medical Sciences (Poland) Poznan University of Medical Sciences (Poland) Poznan University of Medical Sciences (Poland) Poznan University of Medical Sciences (Poland) STATISTICAL EDITOR Renata Rasińska THE LIST OF THE REVIEWERS Agnieszka Bańkowska Grażyna Bączyk Benedykt Bober Antonio Cicchella Justyna Cwajda-Białasik Józefa Czarnecka Grażyna Czerwiak Joanna Gotlib Grażyna Iwanowicz-Palus Helena Kadučáková Douglas Kemerer Ewa Kobos Halina Król Urszula Kwapisz Włodzimierz Łojewski Mária Machalová Anders Møller Jensen Henryk Mruk Jana Nemcová Iwona Nowakowska Jan Nowomiejski Piotr Pagórski Mariola Pawlaczyk Beata Pięta Wojciech Grzegorz Polak Ottilie Rung Zofia Sienkiewicz Beata Skokowska Ewa Szynkiewicz Dorota Talarska Monika Urbaniak Aleksandra Zielińska Katarína Žiaková Klaudia J. Ćwiękała-Lewis Nicolaus Copernicus University Collegium Medicum (Poland) Poznan University of Medical Sciences (Poland) Seaside Rehabilitation Centre (Poland) University of Bologna (Italy) Collegium Medicum in Bydgoszcz Nicolaus Copernicus University in Toruń Medical University of Warsaw (Poland) Jan Kochanowski University in Kielce (Poland) Medical University of Warsaw (Poland) Medical University of Lublin (Poland) Katolícka Univerzita v Ružomberku (Slovakia) Nursing Clinical Instructor at York County School of Technology (USA) Medical University of Warsaw (Poland) Jan Kochanowski University in Kielce (Poland) Poznan University of Medical Sciences (Poland) Poznan University of Medical Sciences (Poland) Prešovská Univerzita (Slovakia) VIA University College Denmark (Denmark) Poznan University of Economics (Poland) Comenius University in Bratislava (Slovakia) Poznan University of Medical Sciences (Poland) Poznan University of Medical Sciences (Poland) Poznan University of Medical Sciences (Poland) Poznan University of Medical Sciences (Poland) Poznan University of Medical Sciences (Poland) University Medical Center Rotterdam (Holland) The University of Arizona College of Nursing (USA) Medical University of Warsaw (Poland) Poznan University of Medical Sciences (Poland) Nicolaus Copernicus University Collegium Medicum (Poland) Poznan University of Medical Sciences (Poland) Poznan University of Medical Sciences (Poland) Poznan University of Medical Sciences (Poland) Comenius University in Bratislava (Slovakia) Faculty at Health Sciences and Nursing, Phoenix University (USA)

7 SPIS TREŚCI Od redaktora PRACE ORYGINALNE Lucyna Iwanow, Mariusz Panczyk, Aleksander Zarzeka, Ilona Cieślak, Mariusz Jaworski, Joanna Gotlib Próba oceny postaw studentów pielęgniarstwa wobec kształcenia kompetencji komunikacyjnych w zawodzie pielęgniarki Iwona Zaczyk, Magdalena Młocek, Ewa Wilczek-Rużyczka, Magdalena Kwak Agresja chorych w zamkniętych oddziałach psychiatrycznych a wypalenie zawodowe pielęgniarek Anna Cisińska Specyfi ka pracy pielęgniarki środowiska nauczania i wychowania w opinii studentów Aleksandra Kielan, Mariusz Panczyk, Lucyna Iwanow, Dorota Bugajec, Joanna Skonieczna, Dominik Olejniczak, Joanna Gotlib Bariery w dostępie do szkoleń podnoszących kwalifi kacje zawodowe pielęgniarek Agnieszka Ulatowska, Hanna Brzeźniak, Aleksandra Głowacka, Grażyna Bączyk Ocena bólu pooperacyjnego u chorych leczonych chirurgicznie Damian Durlak Analiza stanu wiedzy pielęgniarek w zakresie prewencji chorób układu sercowo-naczyniowego Arleta Teresa Gromada, Ewa Kobos Zachowania zdrowotne mieszkańców wsi w zakresie profi laktyki raka jelita grubego PRACE POGLĄDOWE Grażyna Jarząbek-Bielecka, Dariusz Radomski, Małgorzata Mizgier, Małgorzata Grys, Ewa Jakubek Problem dzieci wykorzystywanych seksualnie z uwzględnieniem dzieci niepełnosprawnych aspekty opieki lekarskiej i pielęgniarskiej INFORMACJE Wskazówki dla autorów

8 CONTENTS Editor s note ORIGINAL PAPERS Lucyna Iwanow, Mariusz Panczyk, Aleksander Zarzeka, Ilona Cieślak, Mariusz Jaworski, Joanna Gotlib Attempt at assessment of nursing students attitudes towards development of nurses communication skills Iwona Zaczyk, Magdalena Młocek, Ewa Wilczek-Rużyczka, Magdalena Kwak Patient aggression on inpatient psychiatric wards and professional burnout among nurses Anna Cisińska The specifi city of teaching and education environment nurse s work in the opinion of students Aleksandra Kielan, Mariusz Panczyk, Lucyna Iwanow, Dorota Bugajec, Joanna Skonieczna, Dominik Olejniczak, Joanna Gotlib Barriers to accessing professional skills improvement training for nurses Agnieszka Ulatowska, Hanna Brzeźniak, Aleksandra Głowacka, Grażyna Bączyk Evaluation of postoperative pain in patients treated surgically Damian Durlak Analysis of nurses knowledge in the area of prevention of cardiovascular diseases Arleta Teresa Gromada, Ewa Kobos Health behaviours of the village dwellers in prevention of colorectal cancer REVIEW PAPERS Grażyna Jarząbek-Bielecka, Dariusz Radomski, Małgorzata Mizgier, Małgorzata Grys, Ewa Jakubek The problem of sexually abused children including disabled children aspects of medical and nursing care INFORMATION Guidance for authors

9 OD REDAKTORA Szanowni Czytelnicy, w imieniu Komitetu Naukowego mam przyjemność zarekomendować Państwu ostatni w 2018 roku numer Pielęgniarstwa Polskiego, który zawiera 7 prac oryginalnych i 1 artykuł poglądowy. Prace te są poświęcone ważnym problemom klinicznym oraz różnym aspektom zawodu pielęgniarskiego i opieki pielęgniarskiej. W szczególności chciałabym zwrócić Państwa uwagę na dwa artykuły, obydwa poświęcone doskonaleniu zawodowemu pielęgniarek. Pierwszy z nich, autorstwa Lucyny Iwanow i wsp., dotyczy postaw studentów pielęgniarstwa wobec kształcenia kompetencji komunikacyjnych pielęgniarek. Drugi, nadesłany przez Aleksandrę Kielan i wsp., przedstawia interesujące wyniki badań na temat barier w dostępie do szkoleń podnoszących kwalifikacje zawodowe pielęgniarek. Mam nadzieję, że te i wszystkie pozostałe prace wzbudzą zainteresowanie wśród personelu medycznego, badaczy, studentów kierunków medycznych i przedstawicieli innych, pokrewnych dziedzin. Jednocześnie pragnę serdecznie podziękować wszystkim Autorom, którzy nadesłali swoje prace do naszego czasopisma i wszystkim Recenzentom, którzy podjęli się wysiłku ich zrecenzowania w mijającym roku. Życzę Państwu radosnych świąt Bożego Narodzenia i szczęśliwego Nowego Roku. Uprzejmie przypominam, że manuskrypty można przesyłać drogą elektroniczną poprzez panel redakcyjny dostępny na ofi cjalnej stronie internetowej czasopisma: Życzę Państwu przyjemnej lektury zimowego wydania naszego czasopisma. Dr hab. Krystyna Jaracz, prof. UM Redaktor Naczelna Dr Barbara Grabowska-Fudala Sekretarz Naukowy POLISH NURSING NR 4 (70) 2018 OD REDAKTORA 331

10 EDITOR S NOTE Dear Readers, on behalf of the Scientifi c Committee, I am pleased to recommend you the last issue of the Polish Nursing in the year It contains 7 original papers and 1 review article. The papers are devoted to signifi cant clinical problems and different aspects of nursing care and the nursing profession. In particular, I would like to draw your attention to two articles, addressing issues related to professional training in nursing. The first one, authored by Lucyna Iwanow and co-authors, deals with attitudes of nursing students towards development of communication skills among nurses. The second one, written by Aleksandra Kielan and co-authors, presents an interesting study on barriers to accessing professional skills improvement training for nurses. I hope that these two and all the remaining papers will find their readership among health professionals, researchers, students of medical universities, as well as representatives of other related fields. Simultaneously, I would like to thank all those Authors who sent their work to our journal and all those Reviewers who have taken the task of evaluating manuscripts in the past year. I wish you, Dear Readers, a merry Christmas and a happy New Year. I would like to kindly remind you that manuscripts can be submitted online, through the editorial system available at the offi cial journal website at I wish you a pleasant reading of the winter issue of our journal. Assoc. Prof. Krystyna Jaracz, PhD Editor in Chief Barbara Grabowska-Fudala, PhD Scientific Secretary 332 POLISH NURSING NR 4 (70) 2018 EDITOR S NOTE

11 Copyright Poznan University of Medical Sciences ATTEMPT AT ASSESSMENT OF NURSING STUDENTS ATTITUDES TOWARDS DEVELOPMENT OF NURSES COMMUNICATION SKILLS PRÓBA OCENY POSTAW STUDENTÓW PIELĘGNIARSTWA WOBEC KSZTAŁCENIA KOMPETENCJI KOMUNIKACYJNYCH W ZAWODZIE PIELĘGNIARKI Lucyna Iwanow, Mariusz Panczyk, Aleksander Zarzeka, Ilona Cieślak, Mariusz Jaworski, Joanna Gotlib Division of Teaching and Outcomes of Education, Faculty of Health Sciences, Medical University of Warsaw, Poland DOI: ABSTRACT Introduction. Communication skills of nurses signifi cantly infl u- ence the effectiveness of nursing care and treatment provided by an interdisciplinary team. A positive attitude of nursing students towards communication skills training for nurses may infl uence their willingness to improve such competences. Aim. The aim of the study was an attempt to assess the attitudes of nursing students towards development of communication skills. Material and Methods. A total of 76 students participated in the study. Mean age was 22.7 years. The Communication Skills Attitude Scale, a standardised questionnaire, was used to conduct the study. It comprised 26 statements rated on a fi ve-point Likert scale. In addition, four questions on self-assessment of communication skills with respect to working with patients, their family members, nurses, and other members of a therapeutic team were added to the questionnaire. Descriptive statistics was used to process scores for particular items on the scale and a key was used to calculate the total score. Results. Nursing students had a positive attitude towards developing communication skills (average total score amounted to 108.9/130). A vast majority of the study participants said that they had to possess good communication skills in order to do their work well (mean score: 4.7/5). Almost all respondents agreed that it was worth acquiring and improving communication skills on medical studies (mean score: 4.7/5). Students self-assessed their communication skills as medium (mean score: 3.72/5). Conclusion. The development of a positive attitude and improvement of communication skills at the very beginning of the career pathway may lead to a situation where nurses have better soft skills and are more willing to develop these competences in the future. The present results showing neutral attitudes of students towards developing communication skills and neutral self-assessment of their competences confi rmed the need to introduce communication issues into the curriculum for a nursing programme. KEYWORDS: soft skills, Communication Skills Attitude Scale, students, nursing, communication with patients. STRESZCZENIE Wstęp. Umiejętności komunikacyjne personelu pielęgniarskiego to kompetencje, które w istotny sposób wpływają na efektywność prowadzonego w zespole interdyscyplinarnym procesu pielęgnacyjnego i terapeutycznego. Pozytywne postawy wobec nauki kompetencji komunikacyjnych w zawodzie pielęgniarki, w grupie studentów pielęgniarstwa, mogą mieć wpływ na chęć rozwijania takich kompetencji. Cel. Celem pracy była próba oceny postaw studentów pielęgniarstwa wobec kształcenia kompetencji komunikacyjnych. Materiał i metody. W badaniu udział wzięło 76 studentów. Średnia wieku wyniosła 22,7 lat. Badania prowadzono przy użyciu standaryzowanego kwestionariusza Communication Skills Attitude Scale. Kwestionariusz składa się z 26 stwierdzeń, ocenianych w pięciostopniowej skali Likerta. Dodatkowo autorzy dołączyli do kwestionariusza cztery pytania dotyczące samooceny umiejętności komunikacyjnych w aspekcie pracy z pacjentem, jego rodziną, personelem pielęgniarskim oraz pozostałymi członkami zespołu terapeutycznego. Uzyskane wyniki dla poszczególnych pozycji skali opracowano metodami statystyki opisowej, a sumaryczną punktację zliczono według klucza. Wyniki. Studenci pielęgniarstwa prezentowali pozytywne postawy wobec nauki kompetencji komunikacyjnych (średni wynik sumaryczny wyniósł 108,9/130). Zdecydowana większość badanych twierdziła, że aby dobrze wykonywać pracę pielęgniarki muszą posiadać dobre umiejętności komunikacyjne (średni wynik 4,7/5). Niemal wszyscy ankietowani byli zdania, że na studiach medycznych warto zdobywać i rozwijać umiejętności komunikacyjne (średni wynik 4,7/5). Studenci ocenili średnio swoje umiejętności komunikacyjne (średni wynik 3,72/5). Wniosek. Kreowanie pozytywnych postaw oraz rozwijanie umiejętności komunikacyjnych na początku ścieżki kariery może skutkować lepiej rozwiniętymi kompetencjami miękkimi wśród personelu pielęgniarskiego oraz większą chęcią do rozwijania tych umiejętności w przyszłości. Prezentowane wyniki wskazujące na neutralne postawy wobec nauki umiejętności komunikacyjnych oraz neutralną ocenę swoich kompetencji przez studentów potwierdzają zasadność uzupełnienia programu nauczania na studiach pielęgniarskich o treści z zakresu komunikacji. SŁOWA KLUCZOWE: kompetencje miękkie, Skala Oceny Postaw Wobec Nauki Umiejętności Komunikacyjnych, studenci, pielęgniarstwo, komunikacja z pacjentem. POLISH NURSING NR 4 (70) 2018 ORIGINAL PAPER 333

12 Introduction Both Polish and world scientifi c literature presents numerous publications emphasising that effective communication between patients and doctors as well as members of a therapeutic team and family members is crucial for providing high-quality care [1 10]. Owing to their nature, soft skills, including communication ones, are amongst the most desired competencies on the labour market [11] [Street Jr., 2013, Designing a curriculum for communication skills training from a theory and evidence-based perspective]. Employees look for employers with an ability to communicate effectively, establish contacts, maintain relations, work in a team, manage other people, as well as influence others, motivate them and develop their potential [8, 11, 12]. Proper communication, both between interdisciplinary team members and between medical personnel and patients as well as their family members is essential for the correct course of treatment. In addition, communication skills of healthcare professionals influence the image of a healthcare entity and increase patient satisfaction with and quality of healthcare provided [6]. In spite of the important role of soft skills, the available literature ind icates that the level of these skills among nurses is insuffi cient [1, 2]. The attention is also drawn to the need for better mutual communication between nurses and doctors as well as other members of a therapeutic team [1, 2, 4, 9, 13]. Available scientifi c reports point to the conclusion that it is necessary to include in the curriculum the training in soft skills as well as development of a positive attitude towards acquiring them [14 16]. It is important that students develop a positive attitude by a properly designed teaching process towards learning communication skills. This may result in the willingness to develop these skills in the future, e.g. by participating in post-graduate training courses. At present, CSAS is the most popular standardised tool used for measuring the attitude towards learning communication skills [17]. Due to good psychometric parameters and an access to numerous language versions, this scale can be considered an international tool, enabling a comparison of results between various countries and students of different medical and health sciences [18 33]. CSAS has been developed by Rees et al. [17] in order to evaluate attitudes of students of medicine towards learning communication skills. The tool was supposed to help to modify the curriculum for medical degree programmes so that there were more courses dealing with soft skills in a broader sense [17]. Molinuevo et al. [19] have adapted CSAS to the needs of nursing students in Catalonia. It is an important feature of CSAS that there are several validated language versions of this scale, which makes it possible to compare results of various studies conducted by different researchers in different countries [17, 27, 29, 32 34]. Since there is no Polish language version of CSAS, the present authors decided to prepare a pilot version of the scale measuring attitudes towards communication skills learning, based on an Anglo-Saxon version of CSAS and adapt it to study attitudes of nursing students. Aim of study The aim of the study was an attempt to assess the attitudes of nursing students towards developing communication skills. Material and Methods The pilot study enrolled a total of 76 nursing students (75 women). Mean age was 22.7 years (median: 22; min. 19, max. 55, SD: 4.14). Students of Warsaw Medical University constituted a vast majority of the entire study group (61 persons). Nine students of Ludwik Rydygier Collegium Medicum in Bydgoszcz (Nicolaus Copernicus University in Toruń) and six students of the University of Rzeszów also took part in the study. 45 respondents were first-cycle degree students, 19 of whom were firstyear students, 13 second-year students, and another 13 third-year students. As many as 31 persons were second-cycle degree students, including 16 first-year students and 15 second-year students. Nearly threequarters of the respondents admitted they had never had any experience with any training in communication skills. The study was conducted in March Participation in the study was voluntary and anonymous. The tool was made available to the respondents on a social networking site in an electronic form using the Google form. The present authors received an opinion of the Ethical Review Board of Warsaw Medical University that an approval for the study with reference to the objective of the present study was not necessary [41]. The study was performed using a survey technique with a standardised questionnaire of Communication Skills Attitude Scale [17]. The questionnaire comprised 26 statements concerning the signifi cance of communication skills in the nursing profession rated on a fivepoint Likert scale (1 strongly disagree, 5 strongly agree). The scale was divided into two subscales: positive (PAS) and negative (NAS). 13 statements expressed an approving attitude towards communication skill in the nursing profession, while the other 13 on the contrary. The attitude towards learning communication skills was assessed (whether it is positive or negative) on the basis of a total score, whereas answers on the 334 POLISH NURSING NR 4 (70) 2018

13 NAS scale were recoded before being added together. The total score available for completing the questionnaire was 130. Four additional questions concerning self-assessment of communication skills were added by the present authors to the CSAS. These questions were rated on a five-point Likert scale as well, with 1 referring to very poor and 5 meaning very good. The respondents were asked to assess their competence in regard to collaboration with patients, family members of patients, other nurses and nursing students as well as other members of a therapeutic team. Descriptive statistics was used to process scores for particular items on the scale and a key was used to calculate the total score. The MicrosoftExcel program was used for calculations. Results Nursing students participating in the study had a positive attitude towards communication skills (average total score amounted to 108.9/130). A vast majority of the respondents agreed that they needed to have good communication skills in order to be able to do their work well (mean score: 4.7/5). Although the students did not agree with a statement that the development of communication skills was easy (mean score: 3.0/5), most of them agreed that it would be useful to acquire them during the course of study (mean score: 4.4/5). Over three-quarters of the respondents said that communication skills signifi cantly influenced the process of building respect for patients among nurses and improve communication between nursing staff and patients. A vast majority of the respondents admitted that the acquisition of communication skills would be useful for teamwork. See Table 1 for detailed results relating to attitudes of students towards the acquisition of communication skills in nursing. Table 1. Attitudes of students towards acquiring communication skills in the profession of nurse Attitude Average Median SD PAS 4. Developing my communication skills is just as important as developing my knowledge of medicine 5. Learning communication skills has helped or will help me respect patients Learning communication skills is interesting Learning communication skills has helped or will help facilitate my teamworking skills 10. Learning communication skills has improved my ability to communicate with patients Learning communication skills is fun Learning communication skills has helped or will help me respect my colleagues Learning communication skills has helped or will help me recognise patients rights regarding confi dentiality and informed consent When applying for medicine, I thought it was a really good idea to learn communication skills 21. I think it is really useful learning communication skills on the medical degree My ability to pass exams will get me through medical school rather than my ability to communicate 23. Learning communication skills is applicable to learning medicine Learning communication skills is important because my ability to communicate is a lifelong skill Average score of the PAS: 51,3/65 NAS 1. In order to be a good practitioner I must have good communication skills I cannot see the point in learning communication skills Nobody is going to fail their medical degree for having poor communication skills I have not got time to learn communication skills I can t be bothered to turn up to sessions on communication skills Communication skills teaching states the obvious and then complicates it Learning communication skills is too easy I fi nd it diffi cult to trust information about communication skills given to me by nonclinical lecturers 17. Communication skills teaching would have a better image if it sounded more like a science subject 19. I don t do not need good communication skills to be a practitioner I fi nd it hard to admit to having some problems with my communication skills I fi nd it diffi cult to take communication skills learning seriously Communication skills learning should be left to psychology students, not medical students Average score of the NAS: 57,6/65 Source: author s own analysis Students self-assessed their communication skills as medium (mean score: 3.7/5). Their ability to communicate with patients was rated highest (4.5/5), followed by the ability to communicate with other nurses (3.8/5), members of an interdisciplinary team (3.7/5), and family members of patients (3,4/5). Attempt at assessment of nursing students attitudes towards development of nurses communication skills 335

14 Discussion The existing healthcare model as well as management of medical facilities put great emphasis on soft skills among nursing staff, understood in their broad sense, communication skills included. A number of publications emphasise the importance of communication among nurses as well as between nurses and their patients and family members of patients [5, 7]. They also indicate that the level of communication between therapeutic team members is unsatisfactory. This is one of the main reasons for medical errors, thus affecting the safety of patients and medical personnel [5, 7, 9, 42, 43]. Despite a positive attitude of the respondents towards learning communication skills revealed in the study, the mean score of all answers amounted to 3.2/5. This demonstrated the neutral attitude towards communication skills. Nursing students participating in a pilot study also assessed their communication skills as neutral (mean score: 3.7/5). The present results confirmed the rationale for introducing elements of teamwork composed of students of different majors as early as at the beginning of their university education. The aim of this is to create a positive attitude and development of communication skills in setting up therapeutic teams. The study group saw the link between competence in communication and the process of building respect in teamwork and in working with patients. It has to be recognised that students agreed with a statement that it was diffi cult to acknowledge gaps in soft skills. The CSAS was initially designed to assess students of medicine but now the scale has been validated also for students of dentistry [32, 38], nutrition [20], school pedagogics, [22] and resident doctors [34]. There is also one language version Catalonian adjusted to students of nursing [19]. The tool has been validated so far in 16 countries on four continents. It is available in 11 language versions. At present, in addition to the original English language version, the following versions were validated in Europe: Norwegian [31], Portuguese [34], Catalonian [19], German [29], Hungarian [40], and Finnish [18]. The present authors did not find any publications in the Polish literature discussing students attitudes towards learning communication skills. However, there is a number of articles relating to issues concerning soft skills among nurses [5 8, 11, 42, 44]. A study by Kekus et al. [5] demonstrated that interpersonal communication constituted one of the basic skills in modern nursing. The authors referred to the World Health Organisation which had showed that good interpersonal communication skills represented one of five core competencies leading to a healthy and happy life. Lipińska et al. [44] emphasised the importance of communication with patients as a fundamental part of care and satisfaction with services provided. It was also demonstrated that most nurses had problems with communicating with terminally ill patients. A study by Surmacka and Motyka [7] on communication problems in clinical practice showed how the need for safety was important for patients. According to hospital patients, this need was often neglected because of communication errors. In addition, it was found that communication skills of medical personnel remained at a very low, unsatisfactory level. The present study revealed that the respondents saw a need to develop communication skills in medical professions. The study participants presented a positive attitude towards learning communication skills in a number of professional activities of nurses, not only directly related to a conversation, but also to building respect for patients and other members of a therapeutic team. The students participating in the study saw the link between the development of communication skills and good learning outcomes and professional skills. The present study is the first one based on the Polish language version of CSAS. In addition, this is one of the few publications in the world analysing attitudes of nursing students. The present study is a pilot that starts a series of articles regarding the use of the Polish language version of the Communication Skills Attitude Scale for nurses and nursing students. Attitudes of students of medical science and health science towards learning communication skills are often analysed in the world literature with the use of CSAS [19, 23 25, 32, 33, 38]. Rees et al. [39], authors of the original tool, examined 225 first-year students of medicine. In addition to the original questionnaire comprising 26 statements, self-assessment questions on communication skills were added to the questionnaire. The median of the results amounted to 3, which means that the students did not have a clearly defined view on communication skills. In the present study the median of answers provided by students on their attitudes towards learning communication skills was 3, which is similar to the one obtained by Rees et al. [39]. Most students (92%) believed that their communication skills needed improvement and that courses in communication at the faculty of medicine were essential. Those skills should be taught during clinical classes when working directly with patients and the remaining members of medical and interdisciplinary teams. Additionally, Rees et al. [39] noticed that gender, language, and ethnic origin influenced differences in the results. Women participating in the study demonstrated fewer negative attitudes towards communication skills than men [39]. 336 POLISH NURSING NR 4 (70) 2018

15 Cleland et al. [23] analysed 467 first-, second-, and third-year students of medicine and compared their attitudes. In this study, additional self-assessment questions on communication skills were also added to the original tool. It was observed that the higher the year of study, the lower the return rate and the more negative attitudes towards communication skills. Moreover, a correlation between a gender and the attitude towards communication skills was also found [23]. As in the study by Rees et al. [39], women adopted a more positive attitude towards communication skills. Additionally, unlike men, women were more neutral in assessing their communication skills. It was recommended to analyse students attitudes over the entire course of study, including postgraduate training, arguing that the present level of professional skills may influence attitudes towards communication skills [23]. Due to a small sample and a female-dominated study group in the present study, it was impossible to perform analysis in terms of the gender and the year of study. A study by Khashab conducted among 470 fourthand fifth-year students of medicine was another one analysing attitudes towards communication skills with the use of CSAS [21]. As in the case of the two aforementioned studies, the author of this one added to the original questionnaire a number of self-assessment questions on communication skills. Additionally, the respondents were asked whether they had participated in communication courses in the past. 95% of the study participants believed that their communication skills needed improvement. However, the respondents showed a different trend than those in the study by Cleland [23]. In the study by Khasab, [21] the higher the year of study, the more positive attitude of students towards communication skills. In addition, no correlations were found between the gender and the attitude towards skills [21]. The present results also demonstrated a need for improvement of communication skills. The mean score of self-assessment of communication skills of students participating in the study amounted to 3.7. Moreover, the respondents could not take a position that learning communication skills exerts an impact on learning medicine (mean score: 3.4/5). Limitations of the study results Interpretation and drawing conclusions on the basis of the present results are subject to certain limitations that need to be taken into account when assessing these outcomes. The study was conducted with a small group of nursing students. Most respondents studied at the same university, hence the study group cannot be considered as representative for the entire population of students of this particular major. This was a pilot study and its results encourage to perform a national study with a representative group of students and practising nurses. Conclusion The development of a positive attitude and improvement of communication skills at the very beginning of the career pathway may lead to a situation where nurses have better soft skills and are more willing to develop these competences. The present results showing neutral attitudes of students towards developing communication skills and neutral self-assessment of their competences confirmed the need to introduce communication issues into the curriculum for a nursing programme. References 1. Kantek F. and Kavla I. Nurse-nurse manager conflict: how do nurse managers manage it? Health Care Manag (Frederick), (2): Baron U., et al. Attitudes of nursing and medicine students towards the nurse s role in therapeutic team. Pielęgniarstwo Polskie, (54): Street Jr. R.L. and H.C.J.M. De Haes. 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16 16. Woloschuk W., Harasym P. and W. Temple. Attitude change during medical school: a cohort study. Medical Education, (5): Rees C., Sheard C. and S. Davies. The development of a scale to measure medical students attitudes towards communication skills learning: the Communication Skills Attitude Scale (CSAS). Med Educ, (2): Koponen J., Pyörälä E. and P. Isotalus. Comparing three experiential learning methods and their effect on medical students attitudes to learning communication skills. Medical Teacher, (3): e198 e Molinuevo B. and Torrubia R. Validation of the Catalan version of the communication skills attitude scale (CSAS) in a cohort of south European medical and nursing students. Educ Health (Abingdon), (1): Power B. and S. Lennie. Preregistration dietetic students attitudes to learning communication skills. Journal of Human Nutrition and Dietetics, (2): Khashab S. Attitudes of Alexandria Medical Students towards Communication Skills Learning. J Egypt Public Health Assoc, (5-6): Ihmeideh F., Al-Omari A. and K. Al-Dababneh. Attitudes toward Communication Skills among Students -Teachers in Jordanian Public Universities. Australian Journal of Teacher Education, (4): Cleland J., Foster K. and M. Moffat. Undergraduate students attitudes to communication skills learning differ depending on year of study and gender. Medical Teacher, (3): Shankar R., et al. Student attitudes towards communication skills training in a medical college in Western Nepal. Educ Health (Abingdon), (1): Harlak H., Dereboy C. and A. Gemalmaz. Validation of a Turkish translation of the Communication Skills Attitude Scale with Turkish medical students. Educ Health (Abingdon), (1): Harlak H., et al. Communication skills training: effects on attitudes toward communication skills and empathic tendency. Education for Health, (2): Fazel I. and T. Aghamolaei. Attitudes toward learning communication skills among medical students of a university in Iran. Acta Medica Iranica, (9): Marambe K., Edussuriya D. and K. Dayaratne. Attitudes of Sri Lankan medical students toward learning communication skills. Education for Health, (3): Busch A., et al. Do medical students like communication? Validation of the German CSAS (Communication Skills Attitude Scale). GMS Z Med Ausbild, (1): Alotaibi F. and A. Alsaeedi. Attitudes of medical students toward communication skills learning in Western Saudi Arabia. Saudi Med J, (7): Anvik T., et al. Assessing medical students attitudes towards learning communication skills which components of attitudes do we measure? BMC Medical Education, (4): Laurence B., et al. Adaptation of the Communication Skills Attitude Scale (CSAS) to dental students. Journal of Dental Education, (12): Ahn S., Yi Y. and D. Ahn. Developing a Korean communication skills attitude scale: comparing attitudes between Korea and the West. Med Educ, (3): Loureiro E., SeveroM. and M. Ferreira. Attitudes of Portuguese medical residents towards clinical communication skills. Patient Educ Couns, (8): Anvik T., et al. Medical students cognitive and affective attitudes towards learning and using communication skills a nationwide cross-sectional study. Medical Teacher, (3): Laureiro E., et al. Third year medical students perceptions towards learning communication skills: Implications for medical education. Patient Education and Counseling, : Molinuevo B., et al. A Comparison of Medical Students, Residents and Tutors Attitudes towards Communication Skills Learning. Education for Health, (2): Nor N., Yusof Z. and M. Shahidan. University of Malaya dental students attitudes towards communication skills learning: implications for dental education. Journal of Dental Education, (12): Rees C. and C. Sheard. Evaluating first-year medical students attitudes to learning communication skills before and after a communication skills course. Medical Teacher, (3): Toth I., et al. Attitudes of medical students towards communication skills studies. Orvosi Hetilap, (38): Komisja Bioetyczna Warszawskiego Uniwersytetu Medycznego. Available from: pl/content/szczeg%c3%b3%c5%82owe-informacje-orazwzory-dokument%c3%b3w. 42. Motyka M. Rola aktywnego słuchania w komunikacji terapeutycznej z pacjentem. Problemy Pielęgniarstwa, (2): Ray J. and A. Overman. Hard facts about soft skills. Am J Nurs, (2): Lipińska M., Maj K. and U. Romanowska. Komunikowanie się z chorym u kresu życia w opinii pielęgniarek. Pielęgniarstwo XXI wieku, (41): The manuscript accepted for editing: The manuscript accepted for publication: Funding Sources: This study was not supported. Confl ict of interest: The authors have no confl ict of interest to declare. Address for correspondence: Lucyna Iwanow Żwirki i Wigury Warszawa phone: lucyna.iwanow@wum.edu.pl Division of Teaching and Outcomes of Education, Faculty of Health Sciences, Medical University of Warsaw 338 POLISH NURSING NR 4 (70) 2018

17 Copyright Poznan University of Medical Sciences PATIENT AGGRESSION ON INPATIENT PSYCHIATRIC WARDS AND PROFESSIONAL BURNOUT AMONG NURSES AGRESJA CHORYCH W ZAMKNIĘTYCH ODDZIAŁACH PSYCHIATRYCZNYCH A WYPALENIE ZAWODOWE PIELĘGNIAREK Iwona Zaczyk 1, Magdalena Młocek 2, Ewa Wilczek-Rużyczka 3, Magdalena Kwak 4 1 Department of Emergency Medicine, Institute of Health, The State Higher Vocational School in Nowy Sącz 2 The Józef Babiński Specialist Hospital in Cracow 3 Chair of Health Psychology, The Andrzej Frycz Modrzewski Cracow University 4 Department of Clinical Nursing and Health Psychology, Institute of Health, The State Higher Vocational School in Nowy Sącz DOI: ABSTRACT Introduction. Nurse is a member of the therapeutic team that has the longest and the closest contact with a patient. This fact is of particular importance when we have to do with an aggressive patient. Aggression is one of the fundamental behaviour destabilising the entire process of treatment as well as disrupting the nurse patient relationship. The burnout syndrome is one of the most serious consequences of aggression experienced at work and is becoming an increasingly recognised problem both in Poland and abroad. Aim of study. Determining the occurrence level of aggression and burnout as well as establishing relationships between these variables experienced by the group of psychiatric nurses. Materials and Methods. The study covered 74 nurses working at the hospital in the south of Poland. The study used the MBI questionnaire (Maslach Burnout Inventory) and an authorial questionnaire. Research fi ndings. The study showed that nurses had to deal with various kinds of aggression in their work. The surveyed nurses showed occupational burnout. The relationship between the prevalence of professional burnout and the experience of aggression has been confi rmed. Conclusions. There is a relationship between the aggression experienced by nurses in the workplace and the occurrence of occupational burnout mainly in the dimension of emotional exhaustion and depersonalization. Therefore, it is recommended for psychiatric nurses to participate in workshops focusing on different ways of dealing with occupational burnout and aggression in the workplace. KEYWORDS: aggression, professional burnout, psychiatric nurses. STRESZCZENIE Wprowadzenie. Pielęgniarka jest członkiem zespołu terapeutycznego, który najdłużej i najbliżej spotyka się z pacjentem. Fakt ten nabiera szczególnego znaczenia, gdy mamy do czynienie z pacjentem agresywnym. To właśnie agresja jest jednym z podstawowych negatywnych zachowań destabilizujących proces leczenia oraz zakłócających relację pielęgniarka pacjent. Jednym z poważniejszych następstw agresji doświadczanej w pracy jest zespół wypalenia zawodowego (burnot syndrome), który staje się coraz częściej rozpoznawanym problemem zarówno w Polsce jak i za granicą. Cel pracy. Określenie występowania agresji i wypalenia zawodowego oraz wykazanie związków między tymi zmiennymi w grupie pielęgniarek psychiatrycznych. Materiał i metody. Badaniami objęto 74 pielęgniarki psychiatryczne pracujące w szpitalu w południowej Polsce. W pracy wykorzystano kwestionariusz MBI (Maslach Burnout Inventory) oraz kwestionariusz ankiety własnej. Wyniki. Przeprowadzone badania wykazały, że badana grupa pielęgniarek ma w swojej pracy do czynienia z różnego rodzaju agresją. Badane pielęgniarki w dużym stopniu są wypalone zawodowo. Analizując relacje wypalenia zawodowego i agresji w grupie pielęgniarek psychiatrycznych, potwierdzono związek między występowaniem wypalenia a doświadczaniem agresji. Wnioski. Istnieje związek pomiędzy agresją doznawaną przez pielęgniarki w miejscu pracy a występowaniem wypalenia zawodowego, głównie w wymiarze wyczerpanie emocjonalne i depersonalizacja, w związku z tym zalecany jest udział pielęgniarek psychiatrycznych w warsztatach dotyczących sposobów radzenia sobie z wypaleniem zawodowym i agresją. SŁOWA KLUCZOWE: agresja, wypalenie zawodowe, pielęgniarki psychiatryczne. Introduction Aggression is the form of action that directs dissatisfaction or anger towards oneself (auto-aggression), other people (verbal or physical aggression) or mundane objects [1]. Aggressive behaviour is defined as actions or intentions causing pain, damage or loss of values which are considered important and priceless by an individual [2]. According to the literature, there are various reasons POLISH NURSING NR 4 (70) 2018 ORIGINAL PAPER 339

18 for aggressive behaviour. The aetiology of aggressive behaviour includes biological, psychological factors as well as environmental and social circumstances. There are also different models used to explain the phenomenon of patient aggression. Anderson and Bushman suggested a general model of aggression with the particular emphasis being placed on the importance of the human factor and situational picture responsible for aggressive behaviour. According to the above-mentioned authors, the human factor may include among others: personality traits, sex, beliefs, long-term goals while situational picture is understood as environment and situations which are to increase aggressive behaviour [3]. In turn, Axer and Beckett refer to the concepts of stress and the primary appraisal. According to them, the patient who assesses a particular situation as a threat has a gradually increased tension that leads to aggressive behaviour [4]. Every incident involving aggression entails serious consequences as it is connected with the risk of bodily injury to both medical staff and an aggressive patient. The consequences are not only restricted to physical injuries but they embrace a whole range of psychological burdens and disorders which trigger anxiety, unwillingness to handle aggressive patients, reluctance to work. Various types of aggressive behaviour observed while treating patients with mental disorders constitute a serious problem that disturbs the treatment process, but also destabilises relations between patient and healthcare professionals [5-6]. A very important element of the research on patient aggression is the connection between these types of behaviour and the occurrence of the professional burnout syndrome [7]. Some studies also show a reverse phenomenon, in which the already existing burnout is a factor that contributes to aggression in the workplace [8]. There are different definitions of professional burnout, but according to the most popular one presented by Maslach and Jackson professional burnout is a psychological syndrome of emotional distress, depersonalisation and lowered sense of personal accomplishment, which may occur in individuals who work with other people in a certain manner [9]. The relationship between aggression and burnout may be explained by a three-phased relation stressor stress outcome (burnout). As suggested by Bedi, it is aggression that constitutes one of the stressors leading to the psychological response in the form of stress triggering the professional burnout syndrome [10]. Since the very beginning of the research on professional burnout, nurses have been the occupational group that has been placed in the centre of the researchers interest. As research on burnout progressed, the obtained results distinctly showed that there were certain professional groups more affected by burnout and nurses were always among them [11]. What is more, it can be assumed that the working conditions in which nurses function nowadays, and will continue to function in the near future, are to intensify this problem [12]. In case of this profession, the factors encouraging the occurrence of the burnout syndrome include: day-to-day contact with health problems, low possibility to control the working environment, pressure for continuous vigilance, hierarchical organisational structure, need for contact with different people involved in the same problem [13]. Material and Methods The group of 74 psychiatric nurses were interviewed by using two research tools. The vast majority of the respondents were women (90,5%) aged 16 to 60. The average length of service was fourteen years. The largest group of the respondents were persons with secondary education 67.6%, while 21.6% had higher education. The overwhelming majority of the surveyed nurses did not have supplementary education (87.8% ). The research was carried out on a voluntary basis. The nurses employed in the closed psychiatric wards were asked to fill in an anonymous questionnaire. The authors used a self-created questionnaire which included 30 questions, of which 29 were closed ones and only one was open. In the first question nurses were supposed to determine whether they found their working environment stressful. A few of other questions referred to the occurrence of passive and active aggression in their workplace. The questions 9 to 11 contained information on procedures and communication techniques to be applied in case of exposure to aggressive behaviour. Further questions (12 to 30) covered the subject of active aggression occurred as well as the consequences it might entail. The last two questions of the above-mentioned questionnaire dealt with strategies and ways of coping with stress. The second research tool used during the study was The Maslach Burnout Inventory (MBI). It is the most commonly employed and standardised measure of burnout. It is used in case of nearly 90% of research on this phenomenon. The very initial version of this tool was developed by Maslach and Jackson in The questionnaire had later been modified a few times until the present version was obtained. The questionnaire that is available in Poland is its version adapted by T. Pasikowski. The Maslach Burnout Inventory is a self-test consisting of 22 statements about feelings. It assesses three scales of burnout, namely emotional exhaustion 9 statements, depersonalization 5 statements and personal accomplishment 8 statements. The responses are provided accord- 340 POLISH NURSING NR 4 (70) 2018

19 ing to the 6-point scale and the answer can range from never to every day [14 15]. Research findings The degree of risk associated with aggression on the part of patients The study showed that the surveyed group of nurses experienced not only mild acts of aggression in the form of verbal and passive aggressive behaviour. A considerable group of the surveyed nurses fell victims to physical aggression involving high level of harm in the form of pushing, pinching, beating, kicking and even attacking with the use of various tools. Almost all of the respondents experienced verbal aggression (see Figure 1) 100% of the nurses encountered demands, often unjustified while acts such as threats, calling names, bulling were confirmed by more than 90% of the surveyed. As for the active physical aggression, the research results clearly indicate that the higher degree of aggression the lower number of people who have experienced it (see Figure 2). As many as 93.3% of the respondents were witnesses to vandalism to a hospital ward, and 80.3% were involved in the situation where an act of aggression was aimed at somebody else. 71.7% of the surveyed nurses admitted that they had to face sexual violence, 67.6% were jarred, pinched, scratched, 59% were kicked, pummelled, and 33.8% of the respondents were attacked by patients using different tools. There were even rape attempts, which was confirmed by 4% of the nurses. Apart from being psychologically traumatised, nurses also complained of physical pain, bruises and minor injuries such as scratches. The victims of patients aggressive behaviour encounter serious consequences of such acts (Figure 3). Figure 2. The percentage of respondents who experienced active physical aggression Source: author s own analysis Figure 3. The percentage of respondents who complained of physical injuries as a result of the experienced physical aggression Source: author s own analysis The situation which involved aggressive behaviour a victim had to face an aggressor down is incredibly difficult itself as it often leaves a victim with physical injuries as well as entails serious psychological and social consequences on a victim, who in this case is a member of nursing staff. 73% of the surveyed nurses reported fear and anxiety while dealing with an aggressive patient due to the aggression experienced (Figure 4). Figure 1. The percentage of respondents who have experienced verbal and passive aggression Source: author s own analysis Figure 4. The percentage of respondents who reported psychosocial symptoms as effects of experienced aggression Source: author s own analysis Patient aggression on inpatient psychiatric wards and professional burnout among nurses 341

20 Surprising was the fact, that the surveyed nurses most frequently received support from colleagues, family members and occasionally from their superiors. Although some of the respondents experienced serious psychological consequences, only few of them sought professional help. Most often they consulted their GP and only one nurse decided to see a psychologist (Figure 5). Figure 7. The level of a depersonalization indicator (DEP) Source: author s own analysis Figure 5. The percentage of respondents commenting on particular forms of support obtained Source: author s own analysis The prevalence of particular burnout indicators in the group under research The level of emotional exhaustion varies signifi cantly among respondents. The largest group of the surveyed 54.1% is characterised by the average level of that burnout indicator while the high level was declared by 25.7% of the respondents. The low level of emotional exhaustion was observed in 20.3% of the surveyed which makes them the least numerous group in comparison to those mentioned above (Figure 6). The results of the conducted study for the last burnout indicator, that is the level of the lowered sense of personal accomplishment, seem to be extremely worrying. The analysis of the study results showed that none of the respondents managed to obtain more than 31 points, which were required to obtain at least the average level of this dimension. It implies that all of the surveyed present the high level of professional burnout in the dimension of the lowered sense of personal accomplishment, and thus, also all of the surveyed nurses are characterised by the low sense of personal accomplishment, which in turn has a negative impact on their job satisfaction. The relationship between professional burnout and aggression experienced by respondents The relationship was assessed using the Spearman s rank correlation coeffi cient and the signifi cance level of 0,05 (Table 1). Table 1. The relationship between professional burnout and aggression experienced by respondents in the workplace Figure 6. The level of the emotional exhaustion indicator (EEX) Source: author s own analysis As for depersonalization, the obtained results proved to be higher and more alarming when compared with emotional exhaustion. None of the respondents obtained the result confirming the low level of that indicator. Almost two thirds of the surveyed nurses 63.5% were characterised by the average level of its severity, and the remaining group of nurses over a third of all the respondents (36.5%) confirmed the high level of professional burnout in terms of depersonalization (Figure 7). Agression experienced by nurses in the workplace Spearman s rank correlation coeffi cient EEX DEP PAR Patient threatens the respondent without using words 0.368* 0.324* Patient speaks badly, provides false information, or blackens the respondent 0.259* 0.149* Patient threatens, or announces aggressive actions towards the respondent 0.295* Patient destroys medical equipment, vandalises objects nearby in the presence of the respondent 0.376* 0.379* 0.320* Patient beats, kicks, hits, or becomes aggressive towards another patient, co-worker or 0.291* 0.328* colleague on duty Incidents of sexual harassment of the respondent by a patient 0.251* 0.290* 0.238* * statistical signifi cance at the 0,05 level EEX emotional exhaustion, DEP depersonalization, PAR personal accomplishment Source: author s own analysis 342 POLISH NURSING NR 4 (70) 2018

21 The carried out study and its statistical analysis clearly show the following: The EEX burnout indicator correlates positively with: situations when a patient threatened the respondent without using words situations when a patient spoke badly, provided false information, or blackened the respondent situations when a patient threatened, or announced aggressive actions towards the respondent situations when a patient destroyed medical equipment, vandalised objects nearby in the presence of the respondent situations when a patient beat, kicked, hit, or became aggressive towards another patient, co-worker or colleague on duty incidents of sexual harassment of the respondent by a patient This means that as the frequency of the above situations increases, the EEX burnout indicator grows. The DEP burnout indicator correlates positively with: situations when a patient threatened the respondent without using words situations when a patient destroyed medical equipment, vandalised objects nearby in the presence of the respondent situations when a patient beat, kicked, hit, or became aggressive towards another patient, co-worker or colleague on duty incidents of sexual harassment of the respondent by a patient This means that as the frequency of the above situations increases, the DEP burnout indicator grows. The lowered sense of personal accomplishment PAR correlates positively with: situations when a patient destroyed medical equipment, vandalised objects nearby in the presence of the respondent incidents of sexual harassment of the respondent by a patient This means that as the frequency of the above situations increases, the level of lowered sense of personal accomplishment (PAR) grows. Discussion Both aggression and professional burnout constitute serious problems on psychiatric wards. Aggression itself has serious consequences that range from physical pain to enormous mental suffering [7, 16 18]. The analysis of research results has indicated that the surveyed nurses deal with various forms of verbal aggression but also active physical aggression involving the use of tools and sexual violence. The research findings have confirmed what was stated in the published literature on the subject. Esteban-Llor et al. as well as Berent et al. state that nurses working on psychiatric wards encounter patient aggressive behaviour and according to our study none of the respondents negates the occurrence of such situations [18 19]. It has also been confirmed by Grudzień et al. in their research almost all of the respondents handled an aggressive patient (99.1%) [2]. Delaney et al. obtained similar results in their study, namely: according to the authors, 88% of the interviewed nurses working on the psychiatric wards deal with both verbal and physical patient aggression. The level of the experienced aggression is generally high and the most popular form of aggressive behaviour is verbal abuse. The above conclusions are based on authors own research, according to which verbal aggression was confirmed by 90% of the respondents, active physical aggression not involving the use of tools 59.5%, and aggression involving the use of tools 33.8% [20]. Also, according to the research carried out by Gascon et al. 50% of the surveyed experienced physical aggression while as many as 84.7% had to face verbal and passive aggression. The most common types of aggressive behaviour included speaking with a raised voice and obscenities [7]. However, the same was not confirmed by Adamowski et al. who conducted research on aggressive patients being hospitalised on psychiatric wards. They proved that the most frequent kind of patient aggressive behaviour towards others was physical violence (67% of the respondents) and second most frequent was verbal aggression (53% of the respondents) [21]. The questionnaire results show that the part of respondents is not familiar with communication techniques and does not obey principles of conduct towards an aggressive patient. Therefore, it may be assumed that they do have problems approaching such a person. Duxbury, who was looking for causes of patient aggression, proved that incorrect communication is one of the main causes of aggression reported by patients themselves [22]. Meanwhile, Sariusz-Skąpska in her study pointed out that the type and quality of nurse-patient communication had an impact on the aggressive behaviour of the mentally ill. She claims that all the diffi culties in communication with the patent, lack of suffi cient information on treatment goals or stages of diagnosis very often lead to conflict situations [5]. Our research shows that the surveyed nurses are burnt-out. The average and high level of burnout have been observed in its all analysed dimensions. The high level of emotional exhaustion was confirmed by 25.7% of the respondents, and the average level by 54.1% of the respondents. As for the dimension of depersonalisation, the high level of burnout was stated by 36.5%, and the average level Patient aggression on inpatient psychiatric wards and professional burnout among nurses 343

22 of burnout by 63.5% of the surveyed. What is more, all respondents showed the high level of the lowered sense of personal accomplishment. The link between the experienced aggression and the prevalence of professional burnout has been shown in the present study. According to Tsirigotis K. et al. physical and verbal aggression carried out by patients against medical staff is the contributing factor to their burnout. Such acts of aggression should be treated as human rights abuses [23]. The analysis of the relationship between burnout and aggression in the group of nurses under research has also confirmed the link between the occurrence of emotional exhaustion and the experienced aggression in the form of the threatening facial expression, gestures, without using words and verbal aggression acts such as rumours, slander, threats involving the use of force. It has also been shown that being a witness of the situation involving the use of force towards another person increases the level of professional burnout in the dimension of emotional exhaustion. The same is true for cases involving incidents of sexual abuse. The high level of depersonalization is linked to aggression in the form of non-verbal threats, vandalism, beating another person in the presence of the respondent and sexual harassment. Similar findings were observed in the study by Bedi et al., who also confirmed the relationship between different types of aggressive behaviour and the two dimensions of occupational burnout, namely: emotional exhaustion and depersonalisation [10]. In turn, Viotti et al. proved the link between verbal aggression and all the burnout dimensions [24]. The research conducted by Bernaldo-De-Quiros et al. clearly indicated a higher degree of professional burnout among people who encountered verbal and physical aggression than among people who never experienced such behaviour [25]. As for the level of lowered personal accomplishment, the connection between the occurrence of the high level of professional burnout and aggression in the form of destruction, vandalism as well as incidents of sexual harassment of the respondent by the patient is observed. Roldan et al. have shown in their study that active aggression contributes to occupational burnout in the dimension of the lowered sense of personal accomplishment [8]. Conclusions 1. The surveyed nurses experienced a different kind of aggressive behaviour in their workplace from various forms of verbal aggression to even active physical violence involving the use of tools and sexual violence The relationship between the experienced aggression in the workplace and the occurrence of professional burnout among the surveyed nurses has been observed, mainly in the dimensions: emotional exhaustion and depersonalization. The prevailing level of professional burnout observed among the surveyed was average or high depending on its dimension under research. The respondents who experience aggressive behaviour and professional burnout associated with it tend to seek help and support from people in their immediate environment, such as family members, colleagues rather than professional therapists. It is recommended for psychiatric nurses to participate in workshops and courses focusing on different ways of dealing with occupational burnout and aggression in the workplace. 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23 13. Lewandowska A, Litwin B. Wypalenie zawodowe jako zagrożenie w pracy pielęgniarki. Rocz PAM. 2009; 55 (3): Wilczek-Rużyczka E, Zaczyk I. Wypalenie zawodowe polskich pielęgniarek metaanaliza badań. Hygeia Public Health. 2015; 50(1): Pasikowski T. Polska adaptacja kwestionariusza Maslach Burnout Inventory. Sęk H. (red.): Wypalenie zawodowe przyczyny i zapobieganie. Wyd. PWN, Warszawa Jansen GJ, Dassen T W N, Burgerhof J G M, Middel B. Psychiatric Nurses Attitudes Towards Inpatient Aggression Scale (ATAS). Aggressive Behav. 2006; 32(1): Berring LL, Pederson L, Buus N. Coping with Violence in Mental Health Care Settings: Patient and Staff Member Perspectives on De-escalation Practices. Achives of Psychiatric Nursing. 2016; 30: Llor-Esteban B, Sanchez-Munoz M, Jimenez-Barbero J A. User violence towards nursing professionals in mental health services and emergency units. The Europen Journal of Psychology. 2017; 9: Berent D, Pierchała O, Florkowski A. Agresja pacjentów wobec personelu medycznego izby przyjęć szpitala psychiatrycznego. Psychiatria i Psychoterapia. 2009; 5: Delaney J, Cleary M, Jordan R. An exploratory investigation into the nursing management of aggression in acute psychiatric settings. J Psychiatr Ment Health Nurs. 2001; 8(1): Adamowski T, Piotrowski P, Tryzyna M, Kiejna A. Ocena częstotliwości i rodzaju agresji u pacjentów hospitalizowanych z powodu zachowań agresywnych. Psychiatr Pol. 2009; 43(6): Duxbury J. Causes and management of patient aggression and Violence: staff and patient perspectives. J Adv Nurs. 2005; 50(5): Tsirigotis K, Gruszczyński W. Zaburzenia nerwicowe u pielęgniarek oddziałów psychiatrycznych. Probl Pielęg. 2010; 18(4): Viotti S, Gilardi S, Guglielmetti C, Converso D. Verbal Aggression from Care Recipiens as a Risk Factor among Nursing Staff: A Study on Burnout in the JD-R Model Perspective. BioMed Research International. 2015; 7: Bernaldo-De-Quiros M, Piccini A T, Mar Gomez M. Psychological consequences of aggression in pre-hospital emergency care: Cross sectional survey. Int J Nurs Stud. 2015; 52: Artykuł przyjęty do redakcji: Artykuł przyjęty do publikacji: Źródło fi nansowania: Praca nie jest fi nansowana z żadnego źródła. Konfl ikt interesów: Autorzy deklarują brak konfl iktu interesów. Address for correspondence: Iwona Zaczyk Kościuszki 2 G Nowy Sącz Phone: (0-18) iwonazaczy@interia.pl Department of Emergency Medicine, Institute of Health, The State Higher Vocational School in Nowy Sącz Patient aggression on inpatient psychiatric wards and professional burnout among nurses 345

24 Copyright Poznan University of Medical Sciences THE SPECIFICITY OF TEACHING AND EDUCATION ENVIRONMENT NURSE S WORK IN THE OPINION OF STUDENTS SPECYFIKA PRACY PIELĘGNIARKI ŚRODOWISKA NAUCZANIA I WYCHOWANIA W OPINII STUDENTÓW Anna Cisińska Nursing Education Department with Practical Workshops Medical University of Lodz DOI: ABSTRACT Introduction. The basic legal acts specifying provisions of the Act on healthcare services fi nanced from public funds are regulations on work and duties of the nurse in the teaching and education environment (a school hygienist): Regulation of the Minister of Health of 28 August 2009 on the organization of preventive health care for children and adolescence and the Regulation of the Minister of Health of 24 September 2013 on the guaranteed services in the fi eld of primary care. Aim. The aim of this study was to present the specifi city of teaching and education environment nurse s work in the opinion of nursing students. Material and Methods. The study was conducted in the winter semester of the academic year 2016/2017 among third-year students of the Faculty of Health Sciences, Department of Nursing and Midwifery, Medical University of Lodz. Among the respondents there were 86 women and 6 men. The study used the method of the author s own diagnostic survey. The questionnaire consisted of 12 questions (open and closed), concerning, among others, perception and evaluation of nurses work in the educational environment interest in professional work in the medical school and evaluation of knowledge and skills, gained in the course of classes in medical school. Results. Striking is the fact that the vast majority of respondents 78.3% did not express interest in working as a school nurse. Conclusions. The organization of preventive childcare and care of the youth within the primary health care system needs to be modifi ed. KEYWORDS: nurse, environment and education, student. STRESZCZENIE Wstęp. Podstawowymi aktami prawnymi, uszczegóławiającymi zapisy Ustawy o świadczeniach opieki zdrowotnej fi nansowanych ze środków publicznych, są rozporządzenia regulujące pracę i zadania pielęgniarki w środowisku nauczania i wychowania (higienistki szkolnej): Rozporządzenie Ministra Zdrowia z dnia 28 sierpnia 2009 roku w sprawie organizacji profi laktycznej opieki zdrowotnej nad dziećmi i młodzieżą oraz Rozporządzenie Ministra Zdrowia z dnia 24 września 2013 r. w sprawie świadczeń gwarantowanych z zakresu podstawowej opieki zdrowotnej. Cel. Celem pracy było przybliżenie specyfi ki pracy pielęgniarki środowiska nauczania i wychowania w opinii studentów pielęgniarstwa. Materiał i metody. Badanie zostało przeprowadzone w semestrze zimowym w roku akademickim 2016/2017 wśród studentów III roku Wydziału Nauk o Zdrowiu Oddział Pielęgniarstwa i Położnictwa Uniwersytetu Medycznego w Łodzi. Wśród ankietowanych było 86 kobiet i 6 mężczyzn. W badaniu zastosowano metodę sondażu diagnostycznego (ankiety) własnego autorstwa. Kwestionariusz składał się z 12 pytań (otwartych i zamkniętych) dotyczących m.in. percepcji i oceny pracy pielęgniarki w środowisku nauczania i wychowania, zainteresowania pracą zawodową w medycynie szkolnej oraz ewaluacją wiedzy i umiejętności, kształconych w toku zajęć z przedmiotu medycyna szkolna. Wyniki. Zastanawiający jest fakt, że zdecydowana większość badanych 78,3% nie wyraziła zainteresowania pracą jako pielęgniarka szkolna. Wnioski. Organizacja opieki profi laktycznej nad dziećmi i młodzieżą szkolną w ramach systemu podstawowej opieki zdrowotnej wymaga modyfi kacji systemowych. SŁOWA KLUCZOWE: pielęgniarka, środowisko nauczania i wychowania, uczeń. Introduction The basic legal acts specifying the provisions of the Act on health care services financed from public funds [1] are regulations on work and duties of a nurse in the teaching and education environment (school hygienist): Regulation of the Minister of Health of 28 August 2009 on the organization of preventive health care for children and adolescence [2] and the Regulation of the Minister of Health of 24 September 2013 on the guaranteed services in the field of primary care [3]. 346 POLISH NURSING NR 4 (70) 2018 ORIGINAL PAPER

25 Under these regulations, the nurse cares for students from grades 1 (i.e. from the age of 6) to the last grade of the upper secondary school (that is, usually until 18 19). Soon, as a result of the implemented reform of the education system in Poland, the naming change should be expected in connection with the elimination of lower secondary schools, the name upper secondary schools will disappear. The basic duties of a nurse who takes care of students include: performing screening tests, which are the initial identifi cation of undiagnosed diseases, disorders or defects; management of post-screening proceedings in relation to students with a positive test result in order to confirm or rule out the suspicion of disorders revealed in this test; active counselling for students with health problems; caring for students with chronic diseases and disabilities, including the implementation of nursing services, treatments and medical procedures necessary to perform on the student during his/her stay at school, only on the basis of a medical order and in consultation with the primary care doctor, on whose list of benefi ciaries there is a student providing pre-medical help in case of a sudden illness, injury and poisoning; advising the school head regarding safety conditions for pupils, the organization of meals and sanitary conditions at school; oral health education; conducting group fluoride prophylaxis among primary school students (grades I-VI) in areas where fluoride levels in drinking water do not exceed 1 mg / l by supervised tooth brushing with fluoride preparations 6 times a year, every 6 weeks ; participation in planning, implementation and evaluation of health education [4]. In addition, the nurse is obliged to respect students rights to information, privacy and intimacy, keep medical records and improve qualifi cations in the field of preventive care for children. The education of nursing students takes into account the above-mentioned areas of teaching and education environment nurse s work in both theoretical and practical aspects. The study of the effectiveness of the teaching process allows its further moderation and improvement, which is the main goal of this research. It provides valuable information about the perception of the teaching content within the subject, but also illustrates the state of students awareness: their ideas about nurse s work, the assessment of career prospects, as well as the intellectual maturity of young people to do the job of a nurse. Aim of the study The aim of this study was to present the specifi city of teaching and education environment nurse s work in the opinion of nursing students. Material and Methods The study was conducted in the winter semester of the academic year 2016/2017 among third-year students of the Faculty of Health Sciences Department of Nursing and Midwifery, Medical University of Lodz. Among the respondents there were 86 women and 6 men. The study used the method of a diagnostic survey of his own authorship. The questionnaire consisted of 12 questions (open and closed), concerning, among others perception and evaluation of teaching and education environment nurse s work, interest in professional work in the medical school and the evaluation of knowledge and skills, gained in the course of classes in medical school. Results The 92-person group of respondents were students of the last year of undergraduate studies in nursing. According to the traditions of the profession, women constituted 93.4%; while men made up only 6.5% of the group. The study covered a group of the third year students who completed the cycle of classes in basic health care school medicine and the education stage at the undergraduate level, enabling them to do the job of a nurse. The questionnaire opened with the question about the willingness to take up a job of a nurse in the teaching and education environment. It is interesting to note that the vast majority of respondents 78.3% did not express interest in this kind of work (Figure 1). Figure 1. The students interest in working as a nurse in the teaching and education environment Source: author s own analysis The specifi city of teaching and education environment nurse s work in the opinion of students 347

26 Some respondents do not associate their future with the profession of a nurse at all; for others, there are more attractive specialties, and consequently jobs in the profession. The table below shows the answers to the question in what types of medical units they would like to work as nurses (Table 1). From the list of potential workplaces, the respondents indicated three according to the selection order (1 indicates the place of the first choice, 3 the place indicated as last one). In this way, we have obtained a kind of ranking of jobs according to students of the 3rd year of nursing. students per nurse (13.05), the scope of responsibility (9.7%) heightened by the fact that a school nurse had to take a lot of decisions or actions on her own, without the possibility of an immediate consultation with another qualified person or a supervisor (Figure 3). Table 1. The most attractive jobs to do the job of a nurse n % n % n % SOR 29 31, , A hospital ward 49 53, ,2 6 6,5 Dialysis unit 5 5, , ,9 POZ Clinic 2 2,2 9 9,8 7 7,6 Specialist clinic 4 4, ,1 16 7,4 School / educational facility , ,9 Rest-home , ,8 Source: author s own analysis Figure 2. The advantages of doing the job of a nurse in a school environment Source: author s own analysis The place of the first choice was usually the hospital ward (without defining the specialty), indicated by more than half of the respondents; every third student would choose a hospital emergency department. Signifi cantly, no person indicated the school. Even in the places of the second and third choice, the school was the last choice. It turns out that the work of a nurse in teaching and education environment does not look attractive, although it might seem otherwise as it does not involve physical effort. Although most people do not perceive the work of a nurse at school as attractive, we have found the answer to the question which type of school/educational institution the respondent considered the most attractive place of work for a nurse in the teaching and education environment. 25% of respondents indicated primary school, the same number (25%) secondary school, 16% kindergarten. For every third student (33.7% of respondents) the type of school did not matter. In the next question of the survey, students enumerated the school advantages as a workplace: contact with children (40.2%), help for children (26%), independence (7.7%), time and work characteristics (6.6%). The following diagram illustrates the answers (Figure 2). When asked to indicate the disadvantages of nurse s work in the teaching environment, the respondents raised such issues as: a small scope of rights (17.3%), noise (15.2%), workload due to the large number of Figure 3. Disadvantages of doing the job of a nurse in a school environment Source: author s own analysis In the further part of the survey respondents assessed the current model of health care at schools. In this case, there was a symmetrical division of opinions: 45% of the respondents said that the current system of care at schools was suffi cient, while according to 42.4% of respondents it was not (Figure 4). Figure 4. Is the current model of health care in schools suffi cient? Source: author s own analysis 348 POLISH NURSING NR 4 (70) 2018

27 The question about the assessment of nurses work at schools in which the respondents studied was aimed at expressing a subjective opinion on this topic based on experience and observations. The educational value of this question consists in encouraging to reflection on the social dimension of this profession, which is assessed both professionally and socially. Patients are not always able to assess professionalism in the light of specialist knowledge and professional skills of nurses, but they pay attention to the attitude, personal culture and interpersonal competences. All these factors affect the quality of work. Often, it is on their basis that opinions about individual health care workers are formed. The question s purpose was to make students aware of the important role of the psychological aptitude that can be shaped and improved. At the same time, it encourages reflection on what nurse s work at school should look like. In the case of primary schools, 60.9% of respondents expressed a positive assessment of nurse s work, in the case of lower secondary schools 54.3%, in relation to upper secondary schools 46.7%. Unambiguously negative assessments appeared in over a dozen percent of surveys, the other participants of the study did not have a good opinion on this matter. The structure of responses indicates the important role of psychological preparation of candidates for the profession during the studies. The development of public relations skills is also needed from a social point of view. A nurse working at school not only performs strictly medical tasks, but also participates in the educational process of students. The way in which her work and personality are perceived by children and youth shapes the attitude of the young generation to health care institutions. Empathy, sensitivity, tactfulness, and the ability to make contact are indispensable in the described part of the work. The assessment of nurses work at schools a few years ago is included in students answers. However, this is a reliable assessment because it is expressed by people with professional preparation. Questions about the assessment of theoretical and practical classes are of signifi cant importance for the evaluation of classes with students, preparing them for work in the teaching and education environment. Most of the respondents feel substantively prepared to carry out duties and responsibilities of the nurse at school. As the most interesting element of practical classes, 46.7% indicated screening tests (Figure 5). The study also looked at how far school medicine classes were perceived as useful in non-professional life. 2/3 of respondents believe that the knowledge and skills taught during the course of the subject will be useful outside of professional duties (13% of students indicated the answer definitely yes, 53.3% rather yes ). The opposite opinion presents a group of over a dozen respondents: 14.1% think that classes will be rather not useful in non-professional life, and 3.3% are defi - nitely convinced about it. Figure 5. Answers to the question: Did the classes in the course of your studies prepare you / substantively to do the job of a nurse in the teaching and education environment? Source: author s own analysis Discussion In the available literature, similar studies showing the specifi city of school nurse s work in the opinion of students were not found. In Polish and foreign literature, publications that stress the role of a nurse working in the teaching and education environment prevail [5 6]. Leading in this field are the experiences and postulates of the American Pediatric Academy, which promotes the concept of developing professional medical care at schools and the so-called school clinics [7]. Nurses working at schools and in educational institutions constitute a relatively small group in the professional background of nurses. According to the Ministry of Health, about 8,000 specialized nurses (including 689 school hygienists) look after 5.2 million pupils, attending 28 thousand. primary, junior high and high schools [8 10]. The research shows that candidates for the nursing profession do not associate their future with work in the teaching and education environment. Only 1.1% of respondents are interested in this kind of work. These results correspond to the situation in the country [11]. The analysis of the National Association of Nurses of School Medicine also shows that qualified nursing staff, starting their professional activity, is reluctant to take up employment in teaching and education environment. For this reason, and because of the age structure of the described group of health care workers (high percentage of school nurses and hygienist in pre-retirement and retirement age), there are fears that in a few years there may be a problem of providing preventive health care for students [12]. The range of tasks of nurses working in particular types of schools and educational institutions has an individual specifi city. It is conditioned by the age of stu- The specifi city of teaching and education environment nurse s work in the opinion of students 349

28 dents/pupils. There are other responsibilities for nurses in the field of supervision over personal hygiene for a child in the kindergarten or in the lowest grades of primary school, and other ones in the case of teenagers in high schools or technical schools. From the authors own research it results that students experience greater uncertainty in contact with younger children. Yet another is the work pattern of nurse s work in special schools, which are attended by children with physical or mental disabilities. In this case, not only activities resulting from standards in preventive health care are necessary, but also close cooperation with the child s specialists and guardians [13]. The profession of a nurse is connected with constant contact with people of various age groups and requires the ability to cooperate and readiness to help. The core of nurses work in the teaching and education environment are children and youths especially those requiring the attention of the recipient of the medical market. As regards the care of pupils, nurse responsibilities include in particular screening tests. These include, inter alia, periodic anthropometric measurements, tests of visual acuity and hearing, assessment of posture, measurement of blood pressure [14]. The implementation of the above-mentioned tasks allows the observation of children s development and diagnosis of health problems. This is a particularly important aspect of the nurse s work because of the objective priority: the initial identifi cation of possible disorders and problems [15]. The number of disabled students seems to increase, as evidenced by the observed increase in the percentage of children with disorders within the musculoskeletal system, sight or hearing. Data from the Health Protection Information Systems Center (CSIOZ) show that changes in the spine, chest, pelvis, lower and upper limbs constitute a total of 45 55% of total postural defects [16]. Considering the advantages of work in the profession, the respondents indicated the possibility of the early detection of specifi c health problems in children, which is part of the professional mission of providing help and results from the pro-social motives of choosing a career in nursing. Nurses at school are the only qualified medical staff and have a special role in the teaching and education environment due to the scope of responsibility. High qualifi cations and effectiveness in action, both in planned activities, resulting from the scheduled tasks, screening or health promotion, as well as in emergency situations related to health risk and life emergency are required from this professional group. In the light of the current legal status, doing the job of a nurse at school or in the educational establishment requires the completion of specialization training or a qualifi cation course in the field of nursing in the education or teaching environment. The right to work in school preventive care is also provided by a nurse holding a master s degree in nursing and at least three years of work experience in primary care. A school nurse can also be a school hygienist [17]. According to the Ministry of Health, the interest in raising qualifi cations as part of postgraduate education in school medicine is relatively small. In the years , only 134 nurses were qualified as nurses in the field of nursing in the education and teaching environment and the qualifi cation courses were completed by 3748 people [18]. What affects the low popularity of the described specialization? The profession of a school nurse seems marginalized and underestimated. Over the last three decades, the scope of duties and powers has gradually decreased. Despite the scientifi c and technical progress and raising the health awareness of the society, one can get the impression that the needs of medical care in schools are greater. It should be mentioned here that the nurse should perform at school not only strictly medical tasks, mentioned earlier, but also actively participate in programming the educational and preventive work of the school and implement tasks in the field of health education [19, 20]. Currently, school nurses can be completely overlooked in the organization of pedagogical work related to the state of health. An example is the situation in one of the Lodz junior high schools, where in the preventive program the task of conducting classes on the period of girls puberty was entrusted not to a qualified nurse, but a representative of the company - a distributor of hygiene articles [21]. Considering other factors, discouraging students and nursing graduates to work as nurses in the teaching and education environment, the phenomenon of noise is also worth analyzing. For experienced nurses, it does not seem to be a major problem, however, after completing practical classes at school, students indicated that noise was a serious disadvantage that negatively affected the health and well-being of employees and the students themselves [22]. The tests carried out in Polish and foreign schools showed noise as an unfavorable factor. According to analyzes of the National Institute of Hygiene, corridors constitute the loudest places at schools; in case of primary schools, the measurements gave an average score of 83 db, which is almost equal to the traffi c noise, while in upper secondary schools 76 db. A similar problem of high noise level is also found in English, German or Swedish schools [23]. According to the students opinion, another disadvantage of nurse s work at school is too many pupils per nurse. This indicator is based on the principles developed by the School Medicine Department of the Mother 350 POLISH NURSING NR 4 (70) 2018

29 and Child Institute. When determining the number of students on preventive health care by a nurse, the type of school is taken into account, and in case of schools attended by students with disabilities their number and a degree of disability. Since January 1, 2011, at schools in which the number of pupils ranges from to , a nurse or a school hygienist should be at work not less than 3 times a week, minimum 4 hours a day. At schools with students, a nurse should be present at least twice a week for 4 hours a day. In smaller schools, a nurse should be available once a week for 4 hours [17]. The existing recommendations although they operate with minimum values in practice are becoming the norm that sets the working time of nurses in most public schools. This is mainly due to economic reasons. As a consequence, the status quo means that the nurse must take care of several schools to ensure full-time employment. It is also connected with the necessity to commute between institutions, which is especially troublesome in smaller towns. The described situation also does not provide comfort in dealing with students, and is particularly problematic for schools the absence of a school nurse causes that medical duties must be carried out by teachers. Among other disadvantages of the profession, affecting its perception on the labor market, the respondents indicated a relatively low remuneration compared to other groups. This problem has been causing negative emotions for a long time. It should be added that financing the services of nurses in school medicine is based on the capitalization rate, which is the lowest among basic health care services. A higher pay is provided to nurses who take care of students in special and integration schools, in special educational centers there the rate of admission is higher than the standard rate and depends on the degree of the child s disability [24]. Conclusions 1. The presented results prove that the majority of surveyed students do not associate professional plans with nursing care and educational environment. 2. In the process of educating candidates for the nursing profession, one should give the right rank to school medicine, shaping along with professional competences the psychological aptitude. 3. The organization of preventive care for children and schoolchildren as part of the primary care system requires system modifi cations, the effect of which should be the increase of availability of nursing care at schools, improvement of the quality of the health care system for young Poles and effective pro-health education. References 1. Ustawa z dnia 27 sierpnia 2004 r. o świadczeniach opieki zdrowotnej finansowanych ze środków publicznych (Dz. U. 2004, nr 210; poz. 2135). 2. Rozporządzenie Ministra Zdrowia z dnia 28 sierpnia 2009 r. w sprawie organizacji profi laktycznej opieki zdrowotnej nad dziećmi i młodzieżą (Dz. U. RP 2009, nr 139; poz. 1133). 3. Rozporządzenie Ministra Zdrowia z dnia 24 września 2013 r. w sprawie świadczeń gwarantowanych z zakresu podstawowej opieki zdrowotnej (Dz. U. RP 2013, poz.1248). 4. Faleńczyk K., Barczykowska E., Kujawa W. Organizacja Podstawowej Opieki Zdrowotnej nad Dziećmi i Młodzieżą. W: Barczykowska E., Faleńczyk K (red.). Metoda studium przypadku w pielęgniarstwie pediatrycznym wybrane zagadnienia z opieki nad dzieckiem w podstawowej opiece zdrowotnej, Wrocław: Wydawnictwo Continuo; Holmes BW, Sheetz P, Allison M i wsp. Role of the School Nurse in Providing School Health Services, American Academy of Pediatrics (AAP), 2016; 137 (6), Thomas J, Jones M. Health promotion and the role of the school nurse: a systematic review, Journal of Anvanced Nursing (JAN), 2000: 32 (5), Health Problems at School, dostęp www. pielęgniarki.info.pl/article/view/id/4345, dostęp Główny Urząd Statystyczny, Oświata i wychowanie w roku szkolnym 2015/16, Warszawa 2016, Centrum Systemów Informacyjnych Ochrony Zdrowia, Biuletyn Statystyczny Ministerstwa Zdrowia, Warszawa 2016, Boczek K. Dlaczego nikt nie chce zostać pielęgniarką szkolną, Służba Zdrowia, 2014; Wojciechowska M, Piejak M. Problemy w realizacji świadczeń pielęgniarki szkolnej w zakresie profilaktycznej opieki zdrowotnej udzielanej w środowisku nauczania i wychowania, Szczecin 2012; Oblacińska A, Ostręga W. Standardy i metodyka pracy pielęgniarki i higienistki szkolnej, Warszawa: Instytut Matki i Dziecka; Jodkowska M., Woynarowska B. Testy przesiewowe u dzieci i młodzieży w wieku szkolnym, Warszawa: Instytut Matki i Dziecka; Kocka K, Kochaniuk H, Bartoszek A i wsp. Najczęstsze problemy zdrowotne dzieci w wieku szkolnym na przykładzie szkoły podstawowej i gimnazjum w Lublinie, Medycyna Ogólna i Nauki o Zdrowiu. 2013; 4: dostęp Zimna T., Rola pielęgniarki szkolnej w opiece profilaktycznej uczniów, dostęp r. 18. Zabezpieczenie społeczeństwa w świadczenia pielęgniarskie i położnicze, Ministerstwo Zdrowia Departament Pielęgniarek i Położnych, Warszawa 2015, Beverly J, Bradley. The School Nurse as health educator, Journal of School Health, 1997; 67 (1): Tucker S, Lanningham Foster L. Nurse-Led School-Based Child Obesity Prevention, The Journal of School Nursing, 2015; 31 (6): Szkolny Program Profilaktyki w Publicznym Gimnazjum nr 33 w Łodzi. 22. Augustyńska D, Radosz J. Hałas w szkołach-przegląd badań, Bezpieczeństwo Pracy Nauka i Praktyka, 2009; 9: Augustyńska D, Radosz J. Wpływ hałasu szkolnego na uczniów i nauczycieli oraz jego profilaktyka, Bezpieczeństwo Pracy Nauka i Praktyka, 2009;10: The specifi city of teaching and education environment nurse s work in the opinion of students 351

30 24. Cisińska A. Rola i zadania pielęgniarki szkolnej w świetle obowiązujących przepisów, Ošetrovatel stvo bez hraníc ÍV. Lukáš Kober (red.), Dana Zrubcová, Andrea Bratová; Tatranská Kotlina: Slovenská komora sestier a pôrodných asistentiek; 2014; Artykuł przyjęty do redakcji: Artykuł przyjęty do publikacji: Źródło fi nansowania: Praca nie jest fi nansowana z żadnego źródła. Konfl ikt interesów: Autorzy deklarują brak konfl iktu interesów. Address for correspondence: Anna Cisińska Jaracza Łodz phone: anna.cisinska@umed.lodz.pl Nursing Education Department with Practical Workshops Medical University of Lodz 352 POLISH NURSING NR 4 (70) 2018

31 Copyright Poznan University of Medical Sciences BARRIERS TO ACCESSING PROFESSIONAL SKILLS IMPROVEMENT TRAINING FOR NURSES BARIERY W DOSTĘPIE DO SZKOLEŃ PODNOSZĄCYCH KWALIFIKACJE ZAWODOWE PIELĘGNIAREK Aleksandra Kielan 1, Mariusz Panczyk 2, Lucyna Iwanow 2, Dorota Bugajec 1, Joanna Skonieczna 1, Dominik Olejniczak 1, Joanna Gotlib 2 1 Public Health Division, Faculty of Health Science, Medical University of Warsaw 2 Division of Teaching and Outcomes of Education, Faculty of Health Science, Medical University of Warsaw DOI: ABSTRACT Introduction. Nurses are obliged by law to constantly update their knowledge and professional skills. Awareness of barriers to accessing training is necessary to provide favourable conditions for postgraduate education for nurses. The study aimed to analyse opinions and experiences of nurses concerning barriers to accessing professional skills improvement courses and trainings. Material and Methods. The study enrolled a total of 1244 nurses taking specialisation examinations organised by the Postgraduate Training Centre for Nurses and Midwives in Warsaw. The study was conducted during the fall examination session in 2014 using a diagnostic survey carried out via an original questionnaire comprising 7 questions with a fi ve-point Likert scale concerning the assessment of barriers to accessing training. An additional part with sociodemographic data was also included in the questionnaire. Results. The higher the level of education of nurses, the more important were fi nancial barriers to accessing training. A barrier arising from the distance between the place of training and the place of residence was recognised as having the largest impact by nurses providing home care for elderly and ill patients as part of their professional work. The signifi cance of obligations related to the care of child/children or other persons constituted a more important barrier to accessing training for charge nurses than for departmental nurses (57.3 and 26.0%, respectively). Bad work environment and a lack of approval for persons developing their skills were identifi ed as important barriers to accessing training signifi cantly more often by charge nurses (64.0%) than by the remaining nurses. Conclusions. The adaptation of working environment and use of measures motivating and enhancing nurses to participate in trainings should take account of the needs of nurses. Therefore, there is a need for each individual assessment of needs and diffi culties a nurse can encounter in accessing postgraduate training. KEYWORDS: barriers, qualifi cations, nursing staff, education. STRESZCZENIE Wstęp. Pielęgniarki mają ustawowy obowiązek stałego aktualizowania swojej wiedzy i umiejętności zawodowych. Stwarzanie odpowiednich warunków sprzyjających kształceniu podyplomowemu pielęgniarek wymaga znajomości przeszkód w dostępie do szkoleń. Celem badania była analiza opinii i doświadczeń pielęgniarek na temat barier w dostępie do kursów i szkoleń podnoszących kwalifi kacje zawodowe. Materiał i metody. W badaniu brało udział 1244 pielęgniarki uczestniczki egzaminów specjalizacyjnych orgaznizowanych przez Centrum Kształcenia Podyplomowego Pielęgniarek i Położnych w Warszawie. Badanie przeprowadzono w sesji jesiennej w 2014 roku metodą sondażu diagnostycznego, z użyciem autorskiego kwestionariusza składającego z 7 pytań na 5-stopniowej skali Likerta dotyczących oceny barier w dostępie do szkoleń. Ankietę uzupełniono o dodatkową część pozwalającą na zbieranie danych socjodemografi cznych. Wyniki. Im wyższy poziom wykształcenia pielęgniarek, tym większe było znaczenie bariery fi nansowej w dostępie do szkoleń. Najsilniejszy wpływ bariery wynikającej z oddalenia miejsca szkolenia od miejsca zamieszkania był dostrzegany przez pielęgniarki, które w ramach pracy zawodowej sprawują opiekę domową nad osobami starszymi lub chorymi. Znaczenie obowiązków wynikających z opieki nad dzieckiem/dziećmi lub innymi osobami jako istotna bariera w dostępie do szkoleń była znacznie silniejsza u pielęgniarek odcinkowych niż pielęgniarek oddziałowych (57,3 vs 26,0%). Znaczenie niesprzyjającej atmosfery w pracy i braku akceptacji dla osób doszkalających się jako istotna bariera w dostępie do szkoleń była znacznie większa u pielęgniarek odcinkowych (64,0%) niż w pozostałych grupach. Wnioski. Dostosowanie warunków w miejscu pracy oraz stosowanie mechanizmów motywujących i zachęcających pielęgniarki do udziału w szkoleniach powinno uwzględniać ich potrzeby. Konieczna jest więc każdorazowa indywidualna ocena potrzeb i trudności jakie może napotkać pielęgniarka w dostępie do szkoleń podyplomowych. SŁOWA KLUCZOWE: bariery, kwalifi kacje, personel pielęgniarski, edukacja. POLISH NURSING NR 4 (70) 2018 ORIGINAL PAPER 353

32 Introduction The Nurses and Midwives Act of July 15, 2011 imposes on nurses and midwives an obligation to constantly update their knowledge and professional skills and gives them an entitlement to professional development on a variety of postgraduate training programmes [1]. Professional development is also regulated by the Code of Professional Conduct of Nurses and Midwives of the Republic of Poland [2]. The postgraduate education system in Poland as of December 17, 1998 comprises the following forms of training: specialised courses (also called specialisation ), qualifying courses, specialist courses, and skills improvement courses. Their aim is to provide nurses with knowledge of and skills in a particular field in order to be able to provide health services and exercise professional activities while providing nursing, preventive, diagnostic, treatment, and rehabilitation services as well as improving and updating their knowledge and skills. Each nurse and midwife with the right to perform their profession is allowed to enrol in a specialist and skills improvement course. Professional experience of at least two years in the preceding five years is required to start a specialisation and experience of at least 6 months is required in the case of a qualifying course [1]. Ongoing changes and rapid development of modern medicine force all healthcare professionals to constantly update their knowledge. In addition, nurses and midwives have gained new powers and competencies, which has increased their responsibility, autonomy, and professionalism. Recent years have seen a growing interest of nurses in improving their knowledge by attending various forms of trainings. This results from growing awareness of statutory need for training, availability of a broad range of educational offer, and co-financing of trainings from the state budget [3 5]. A systematic review by Santos [6] demonstrated that there were few studies on the effect of selected factors on the diffi culty in getting access to professional skills improvement training for nurses. Nevertheless, the available world literature focused on this issue showed that nurses continued to face barriers to accessing postgraduate education [7 17]. These include several major restrictions: the lack of time for professional development, the structure and nature of work, financial barriers, lack of superiors approval, insuffi cient training dates, the fact that the employer does not require further training of employees, as well as transportation diffi culties [5, 6]. The lack of time is, according to nurses themselves, the most crucial factor. Nurses often devote their free time to participate in training [13, 18, 19]. This affects work-life balance [13, 20, 21]. In addition to the barriers mentioned above, the literature enumerates disincentives for nurses to make an effort to improve their professional qualifi cations [11]. These factors are largely the same as the barriers mentioned above. A critical literature review by Schweitzer and Krassa [11] listed the following factors: family responsibilities, travel distance, and inability to get time away from work, lack of quality or interesting topics, lack of benefits connected with continuing education, lack of support from administration, and peer opinions and attitudes. There is only a few Polish studies that aimed at specifying the influence of potential barriers on nurses participation in postgraduate training courses [5, 22 24]. Additionally, no major national studies relating to the present issue have yet been performed. For the above reasons, the authors tried to assess and analyse the opinions and experiences of nurses taking their final specialisation examinations concerning the barriers to accessing trainings and courses that improve their professional qualifi cations. Material and Methods A voluntary and anonymous cross-sectional study was carried out during specialisation examination at the Postgraduate Training Centre for Nurses and Midwives in Warsaw during the fall examination session from September to November The study enrolled a total of 1244 person, including 1165 women (93.2%) and 17 men (1.4%); the remaining persons did not reply to the question about gender. The mean age of the study participants amounted to 42.7± 6.37 years (min. 26, max. 58, median: 43). The largest proportion of the study participants lived in towns with low and medium population density (26.3% each). Nearly one in four respondents (19.8%) lived in large cities. The mean job tenure of the respondents was 20.3 years (min. 2, max. 37). Nearly one-third of the total (32.3%) had secondary medical education and a similar proportion had graduated from the first-cycle programme (31.5%). The remaining study participants had a Master s degree in Nursing. Nearly half of the total (48.8%) worked in town hospital departments and 23.4% of the respondents worked in teaching hospitals. Senior nurses constituted the largest group of study participants (38.3%), followed by operating room nurses (21.4%) and charge nurses (10.5%). A diagnostic poll method with a survey technique was used in the study. The survey was anonymous and voluntary. The questionnaire comprised seven questions in which the respondents were supposed to rate on a five-point Likert scale how a specifi c barrier hinders their access to training (Table 1). In addition, the 354 POLISH NURSING NR 4 (70) 2018

33 questionnaire comprised a personal data form consisting of six questions related to sociodemographic data. obligations related to the care of child/ children or other persons Table 1. Potential barriers to accessing professional skills improvement training for nurses 1. fi nancial barriers 2. insuffi cient dates of available courses 3. lack of replacement 4. distance between the place of training and the place of residence is too long 5. obligations related to the care of child/children or other persons 6. lack of available trainings in a particular discipline 7. bad work environment, lack of approval for persons developing their skills Source: author s own analysis The STATISTICA version 13.1 (StatSoft ) software package was used for analysis. Descriptive statistics and mathematical statistics were applied. Chi 2 test of independence (the strength of association was measured with Cramér s V coeffi cient) and the γ correlation coeffi cient were used to demonstrate a correlation between a dependent variable (barriers to accessing training improving professional skills of nurses) and independent variables (such as: age, job tenure, place of residence, education level, place of work, and position at work). For all analyses, the a priori level of signifi cance was established at Results The assessment of the signifi cance of individual barriers to accessing training showed that according to the study participants the lack of adequate financial resources (average 4.3/5) and lack of replacement for an employee on training (average 3.7/5) constituted the greatest diffi culties. The least important obstacles comprised the one associated with the duties related to the care of child/children or other persons (average 3.1). It needs to be emphasised that all seven barriers were rated above the value of 3.0, which means that the answers rather yes and definitely yes were most common (Table 2). Table 2. Assessment of signifi cance of particular barriers to accessing training Barrier to accessing training Mean SD Median Min Max fi nancial barriers insuffi cient dates of available courses lack of replacement distance between the place of training and the place of residence is too long lack of available trainings in a particular discipline bad work environment, lack of approval for persons developing their skills SD standard deviation Source: author s own analysis There was a correlation between the financial barriers and the place of residence of the study participants. The larger the town, the smaller the signifi cance of this barrier for the respondents (γ = ; Z = ; p = 0.001). However, the signifi cance of financial barriers to accessing training grew along with the increase in the level of education (γ = 0.159; Z = 3.813; p = 0.000). In addition, a weak correlation was observed between the age and the signifi cance of this barrier to the respondents (γ = 0.091; Z = 2.518; p = 0.012). A weak positive correlation was found between the place of residence of the respondents and the signifi - cance of the barrier related to the distance between the place of training and the place of residence (γ = 0.076; Z = 2.695; p = 0.007). The larger the town, the smaller the signifi cance level of the distance between the place of training and the place of residence (γ = ; Z = ; P = 0.000). In addition, the largest impact of this barrier was observed among home care nurses (chi 2 = ; p = 0.02; V = 0.087). There was a signifi cant correlation between the importance of the barrier related to the duties associated with the care of child/children or other persons and age (γ = ; Z = ; p = 0.000) as well as job tenure (γ = ; Z = ; p = 0.000). The signifi cance of this barrier for nurses decreased with age and job tenure. In addition, the larger the town of residence, the smaller the signifi cance of this barrier (γ = ; Z = ; p = 0.006). The importance of obligations related to the care of child/children or other persons constituted a more important barrier to accessing training for charge nurses than for departmental nurses (57.3 and 26.0%, respectively) (chi 2 = ; p = 0.003; V = 0.116). The importance of bad work environment and the lack of approval for persons developing their skills was far more signifi cant for charge nurses as compared with the remaining groups (chi 2 = ; p = 0.012; V = 0.106). No statistically signifi cant correlations were found between the independent variables and diffi culties consisting in insuffi cient dates of available courses and the lack of replacement for employees on training. Barriers to accessing professional skills improvement training for nurses 355

34 Discussion A new system of education provides nurses in Poland with new prospects for their professional development. It allows for gaining independence as well as for continuous improvement and broadening of medical knowledge. However, numerous studies have demonstrated that nurses continue to face barriers to accessing training that would improve their professional competencies [25]. The present results showed that financial barriers as well as the distance between the place of residence and the place of training constituted the most signifi cant diffi culties in improving professional qualifi cations for nurses studying at the Postgraduate Training Centre for Nurses and Midwives in Warsaw, with home care nurses being most affected by this obstacle. Responsibilities related to the care of child/children or other persons as well as bad work environment and lack of approval for persons developing their skills had a signifi cant influence on the decision-making process. Both barriers were of particular importance for charge nurses. A study by Cisoń-Apanasewicz et al. [22] demonstrated that financial reasons (62.1%) were mentioned in the first place as a barrier or obstacle to participating in training, followed by the lack of motivation to undertake professional development (34.8%). Other reasons included the lack of interest of employers in professional development, overloading with work responsibilities, and the lack of training programmes [6]. Similar results were obtained in a study by Nowicki et al. [25]. Financial reasons (71.4%) and the lack of time (55.8%) were indicated by a vast majority of nurses participating in the study as the major barriers to undertaking training [25]. The lack superior s approval also seems to pose a considerable problem (32.5%). Other reasons here included insuffi cient training dates (15.6%), transportation diffi culties (7.8%), and the lack of requirements on the part of employers (2.6%) [25]. In a study by Kobos et al. [23] respondents pointed to circumstances at work as the main barrier to undertake training. The lack of clear rules applying to the training leave was the most important concern, which was encountered by 76.0% of the study participants. Similarly to other studies, the following issues were also mentioned: financial barriers and the lack of financial support from employers (74.0%), as well as little interest of employers in improving skills by employees (62.0%). The working pattern, particularly a 12-hour shift system, night or weekend work (65.0%) as well as physical and mental tiredness from work constituted another barrier for the respondents. Approximately 60% of the study participants were not sure whether it was profitable to undertake training and for over half of the total expenditure arising during the course was important [23]. According to respondents participating in a study by Tomaszewska et al. [24], financial barriers and high costs of postgraduate training were among factors that limited the professional development of nurses (80.0%). Over half of the study participants said that the access to training was limited by managerial staff of healthcare institutions (66.0%) and nursing management staff (55.0%). Nearly 60% of all pointed to the diffi culty in gaining access to conferences, courses, and workshops, without providing reasons. The remaining answers suggested a link between the diffi culties and other work-related circumstances, such as the lack of time, burnout, the lack of motivation to development, the lack of the training leave and the lack of career advancement opportunities as well as the lack of financial motivation [24]. A study by Shahhosseini and Hamzehgardeshi [17] conducted among Iranian male and female nurses demonstrated that they faced similar barriers to professional development to those in Poland. The barriers were divided into three basic groups: personal barriers, interpersonal barriers, and structural barriers. The first group comprised time constraints, household chores, emotional stress, and poor physical health. Interpersonal barriers included little support from colleagues, no family support, negative experiences with previous trainings and poor cooperation between staff members. Structural barriers comprised the largest number of obstacles, including occupational obligations, course costs, distance, insuffi cient training dates, the lack of organisational support, the lack of information on skills improvement programmes and the lack of access to them, the lack of support from superiors, the lack of appropriate skills improvement courses and their poor quality, as well as the need for vocational training [17]. Similarly, time constraints, professional obligations, the lack of opportunity to participate in training, course costs, and negative experiences with previous trainings such as inexperienced teachers and the lack of order in classrooms were mentioned by Chinese nurses participating in a study by Ni et al. [9] as five most important obstacles to attend skills improvement courses. Conclusions 1. Securing external funding could effectively decrease diffi culties in that regard encountered by nurses willing to improve their qualifi cations. 2. Offering training and courses in smaller towns would facilitate access and decrease costs. 3. There is a real demand for training among managerial staff of healthcare institutions focusing on the need for improving qualifi cations of nurses and motivating them to develop their skills. 356 POLISH NURSING NR 4 (70) 2018

35 4. References Better access to the training leave, interest in training showed by employers, as well as career advancement and financial bonuses may constitute signifi cant incentives for improving qualifi cations. 1. Ustawa z dnia 15 lipca 2011 r. o zawodach pielęgniarki i położnej (Dz.U nr 174 poz. 1039). 2. Kodeks etyki zawodowej pielęgniarki i położnej Rzeczypospolitej Polskiej. Dostęp: krajowy-zjazd-pielegniarek-i-poloznych/kodeks-etyki-zawodowej-pielegniarki-i-poloznej-rzeczypospolitej-polskiej/, [dostęp: ] Bogusz R, Majchrowska A. Motywy podejmowania kształcenia podyplomowego w zawodzie pielęgniarskim. Pielęgniarstwo XXI wieku. 2012;3(40): Iwanow L. Analiza opinii pielęgniarek położnych na temat dostępnych form oraz tematyki kursów i szkoleń podnoszących kwalifikacje zawodowe. Warszawski Uniwersytet Medyczny; Kadłubowska M, Bąk E, Turbiarz A, Kolonko J. Podnoszenie kwalifikacji zawodowych w opinii studentów licencjackich studiów pomostowych. Problemy Pielęgniarstwa. 2010;18(2): Santos MC. Nurses barriers to learning: an integrative review. Journal for Nurses in Staff Development. 2012;28(4): Hamzehgardeshi Z, Shahhosseini Z. A cross-sectional study of facilitators and barriers of Iranian nurses participation in continuing education programs. Global Journal of Health Science. 2013;6(2): Chong MC, Sellick K, Francis K, Abdullah KL. What influences malaysian nurses to participate in continuing professional education activities? Asian Nursing Research. 2011;5(1): Ni C, Hua Y, Shao P, Wallen GR, Xu S, Li L. Continuing education among Chinese nurses: a general hospital-based study. Nurse Education Today. 2014;34(4): Penz K, D Arcy C, Stewart N, Kosteniuk J, Morgan D, Smith B. Barriers to participation in continuing education activities among rural and remote nurses. Journal of Continuing Education in Nursing. 2007;38(2):58 66; quiz 7 8, Schweitzer DJ, Krassa TJ. Deterrents to nurses participation in continuing professional development: an integrative literature review. Journal of Continuing Education in Nursing. 2010;41(10):441 7; quiz Nolan M, Owens RG, Nolan J. Continuing professional education: identifying the characteristics of an effective system. Journal of Advanced Nursing. 1995;21(3): Brekelmans G, F. Poell R, van Wijk K. Factors influencing continuing professional development: A Delphi study among nursing experts. European Journal of Training and Development. 2013;37(3): Hegney D, Tuckett A, Parker D, Robert E. Access to and support for continuing professional education amongst Queensland nurses: 2004 and Nurse Education Today. 2010;30(2): Wessels SB. The deterrents to CPE effectiveness in the accounting profession: a factor analytic study. Journal of Business & Economics Research (JBER). 2011;3(6). 16. Channa ZI. Barriers to Participation in non-formal CNE Programs among Hospital Nurses in Pakistan. Annals of Pakistan Institute of Medical Sciences. 2013;9(4): Shahhosseini Z, Hamzehgardeshi Z. The Facilitators and Barriers to Nurses Participation in Continuing Education Programs: A Mixed Method Explanatory Sequential Study. Global Journal of Health Science. 2015;7(3): Gibson JM. Using the Delphi technique to identify the content and context of nurses continuing professional development needs. Journal of Clinical Nursing. 1998;7(5): Gould D, Drey N, Berridge EJ. Nurses experiences of continuing professional development. Nurse Education Today. 2007;27(6): Grossman J. Continuing competence in the health professions. The American Journal of Occupational Therapy. 1998;52(9): Lawton S, Wimpenny P. Continuing professional development: a review. Nursing Standard. 2003;17(24): Cisoń-Apanasewicz U, Gaweł G, Ogonowska D, Potok H. Opinie pielęgniarek na temat kształcenia podyplomowego. Problemy Pielęgniarstwa. 2009;17(1): Kobos E, Leńczuk-Gruba A, Idzik A, Sienkiewicz Z. Rola zakładu pracy w dokształcaniu i doskonaleniu zawodowym w kontekście barier edukacyjnych dostrzeganych przez pielęgniarki. Problemy Pielęgniarstwa. 2010;18(2): Tomaszewska M, Cieśla D, Czerniak J, Dykowska G. Możliwości doskonalenia zawodowego pielęgniarek-potrzeby a rzeczywistość. Problemy Pielęgniarstwa. 2008;16(1-2): Nowicki G, Chilimoniuk B, Goniewicz M, Górecki M. Możliwości i bariery rozwoju zawodowego pielęgniarek w opinii uczestników specjalizacji w dziedzinie pielęgniarstwa ratunkowego. Problemy Pielęgniarstwa. 2012;20(4): The manuscript accepted for editing: The manuscript accepted for publication: Funding Sources: This study was not supported. Confl ict of interest: The authors have no confl ict of interest to declare. Address for correspondence: Mariusz Panczyk Żwirki i Wigury 61, Warsaw, Poland phone.: +48 (22) mariusz.panczyk@wum.edu.pl Division of Teaching and Outcomes of Education, Faculty of Health Science, Medical University of Warsaw Barriers to accessing professional skills improvement training for nurses 357

36 Copyright Poznan University of Medical Sciences EVALUATION OF POSTOPERATIVE PAIN IN PATIENTS TREATED SURGICALLY OCENA BÓLU POOPERACYJNEGO U CHORYCH LECZONYCH CHIRURGICZNIE Agnieszka Ulatowska 1, Hanna Brzeźniak 2, Aleksandra Głowacka 1, Grażyna Bączyk 1 1 Department of Nursing Practice, Faculty of Health Sciencies, Poznan Uniwersity of Medical Scienties, Poland 2 Department of Psychiatrics, The Regional Hospital for Mental Diseases Dziekanka in Gniezno, Poland DOI: ABSTRACT Introduction. Pain is an unpleasant sensation in the body. In the case of postoperative pain, it is associated with a damaged tissue. The basic post-operative action is to deal with the pain. It begins with proper monitoring of the pain intensity and then using treatments to relieve the pain. Aim. The aim of the study is to assess postoperative pain after surgical procedures: cholecystectomy and removal of varices of lower limbs by means of grading scales. Material and Methods. The tests were carried out in the surgical department of the Vivax medical center in Gniezno. Subjects were tested after removal of the gall bladder (42 patients) and after removal of varices of the lower limbs (40 patients). The study group consisted of patients aged 18 to 75 years. A questionnaire consisting of 8 questions and a grading scale for the assessment of postoperative pain was used to conduct the study. The assessment of pain intensity was monitored immediately after surgery, then after 4, 8 and 12 hours after surgery. Results. The following relationships have been shown: between the assessment of postoperative pain immediately after surgery and gender including the type of surgery; between the assessment of postoperative pain in respective hours after surgery (4, 8, 12 hours) and the type of surgery; between the assessment of postoperative pain immediately after surgery, at the respective hours after surgery (4, 8, 12 hours) and the type of anesthesia used. Conclusions. 1) Pain intensity in patients after surgical procedures increased until 12 hours after surgery and then slightly decreased. 2) The type of anesthesia used had an effect on the intensity of pain. 3) Age, gender and time after surgery had an effect on the intensity of pain. KEYWORDS: postoperative pain, pain assessment. STRESZCZENIE Wstęp. Ból jest nieprzyjemnym odczuciem dla organizmu. W przypadku bólu pooperacyjnego związany jest on z uszkodzeniem tkanek. Podstawowym działaniem pooperacyjnym jest walka z bólem. Rozpoczyna się ona prawidłowym monitorowaniem natężenia bólu, a następnie stosowaniem metod przeciwbólowych. Cel. Celem pracy jest ocena bólu pooperacyjnego po zabiegach chirurgicznych: cholecystektomii i usunięciu żylaków kończyn dolnych za pomocą skali numerycznej. Materiał i metody. Badania wykonano w oddziale zabiegowym ośrodka medycznego Vivax w Gnieźnie. Badano pacjentów po usunięciu pęcherzyka żółciowego (42 pacjentów) i po usunięciu żylaków kończyn dolnych (40 pacjentów). Grupę badaną stanowili chorzy w wieku od 18 do 75 lat. Do przeprowadzenia badania wykorzystano kwestionariusz ankiety składający się z 8 pytań oraz skalę numeryczną do oceny bólu pooperacyjnego. Ocenę natężenia bólu monitorowano bezpośrednio po zabiegu operacyjnym, następnie po upływie 4, 8 i 12 godzin od zakończenia operacji. Wyniki. Wykazano następujące zależności: pomiędzy oceną bólu pooperacyjnego bezpośrednio po zabiegu a płcią oraz rodzajem zabiegu; pomiędzy oceną bólu pooperacyjnego w poszczególnych godzinach po zabiegu operacyjnym (4, 8, 12 godzinie) a rodzajem zabiegu; pomiędzy oceną bólu pooperacyjnego bezpośrednio po zabiegu i w określonych godzinach po operacji (4, 8, 12 godzinie) a rodzajem zastosowanego znieczulenia. Wnioski. 1) Natężenie bólu u chorych po zabiegach chirurgicznych rosło maksymalnie do 12 godzin po zabiegu, a następnie nieznacznie obniżało się. 2) Rodzaj stosowanego znieczulenia miał wpływ na natężenie bólu. 3) Wiek, płeć, czas po zabiegu miały wpływ na natężenie bólu. SŁOWA KLUCZOWE: ból pooperacyjny, ocena bólu. Introduction Postoperative pain caused by surgical tissue damage is classified as acute pain. The term acute pain refers to pain of a relatively short duration, which should disappear with the healing of the tissues or the end of the harmful stimulus. The International Association for the Study of Pain defines pain as an unpleasant sensory and emotional experience related to actual or potential tissue damage or described in terms of such damage. This definition exposes not only the sensory experience, but also the emotional component of pain. Tissue injury leading to the occurrence of pain causes a process 358 POLISH NURSING NR 4 (70) 2018 ORIGINAL PAPER

37 called nociception, which consists of four elements: transduction, transmission, modulation and perception. At the transduction stage, the damaging stimulus is exchanged in the primary nerve endings, also known as nociceptors, into an electrical signal. Nociceptors are found throughout the body, both in somatic tissues and visceral organs. At the transmission stage, the electrical signal is sent via the nerve pathways to the central nervous system. The nervous pathways include the basic sensory afferents (mainly A-delta and C fiber) that terminate in the spinal cord. Then, the pain information is transmitted through the spinal-thalamic pathways to the cerebral cortex. The modulation-process that enhances or inhibits the pain signal occurs mainly in the posterior corners of the spinal cord. Perception the last stage of the nociception process takes place when the pain signal reaches the cerebral cortex. The first three stages of nociception are important for the sensory and differential aspects of pain. The fourth-perception stage is part of the patient s experience of a subjective and emotional nature [1, 2, 3]. Post-operative pain caused by intraoperative tissue damage occurs when intraoperative analgesia ceases to function and its source is damaged surface tissues (skin, subcutaneous tissue, mucous membranes) as well as deeper structures (muscles, fascia, ligaments, periosteum). In the case of a large injury, apart from superfi cial and deep somatic pain, there also appears a visceral component of postoperative pain, caused both by the smooth muscle contraction caused by squeezing, stretching of visceral structures, and inflammatory changes, pulling or tensing the mesentery [4]. The basic step in the choice of the method of anesthesia is to determine whether a given surgical procedure can be properly and safely performed with the use of central regional anesthesia or whether it is necessary to use general anesthesia. One of the techniques of regional anesthesia is subarachnoid anesthesia. The blockage of spinal nerve roots is obtained by administering a local anesthetic to the spinal canal / subarachnoid space, in the lower part of the lumbar spine. In the case of regional anesthesia, where only a part of the body is anesthetized, the consciousness remains. Conversely, under general anesthesia, a druginduced reversible state of unconsciousness, with the abolition of pain and possible defense reactions of the body is achieved. Supporting or completely replacing the patient s breathing with artifi cial ventilation is always necessary [5]. An example of frequently performed procedures under regional anesthesia is the surgical treatment of lower limb varicose veins. Depending on the presence of reflux and its location as well as the extent of varicose veins, the operation may consist in partial or complete removal of the saphenous vein or scabbard, ligation of perforating veins or removal or obliteration of individual varicose veins [6]. On the other hand, general anesthesia is used when the surgical site excludes the possibility of using regional techniques. An example of a procedure that requires the use of general anesthesia is cholecystectomy performed both by the classic method and the laparoscopic method. The intensity of postoperative pain depends to a large degree on the extent of the surgical trauma and the treatment method used. It should also be emphasized that the intensity of acute post-operative pain may be an important predictor of chronic pain development. Long-lasting peripheral nociceptive stimulation from the surgical wound results in central sensitization and chronic pain [7]. This can be prevented by inhibiting the receptor mechanisms by means of analgesics with a different mechanism of action. To monitor the effectiveness of analgesic therapy, it is recommended to use verified methods of pain intensity measurement (e.g. 11-point numerical scale NRS) [8]. The intensity of pain should be assessed at regular, short intervals, both at rest and during activity. The level of the pain intensity should be recorded in the patient s medical records [4]. Research objective The aim of the study is to assess postoperative pain after surgical procedures such as cholecystectomy performed under general anesthesia and removal of varicose veins in subarachnoid anesthesia using a numerical scale. This scale assesses the intensity of postoperative pain using the points awarded. 0 points means no pain, 5 points moderate pain, 10 points unbearable pain. The detailed goals are an assessment of postoperative pain using the above-mentioned scale, taking into account the factors: age, sex, type of surgery, type of anesthesia used. In addition, the pain intensity after surgery was determined: immediately after surgery, and 4, 8, 12 hours after surgery. Material and Methods The study group consisted of 82 people hospitalized for the purpose of surgical treatment, in the surgical ward of the non-public medical center VIVAX in Gniezno. Two groups of patients were identified among the patients. One was patients after cholecystectomy 42 (51.52%), the second after removal of varicose veins 40 (48.78%) (Table 2). Women accounted for over half of the respondents 52 (63.41%). The examined patients were divided into age groups: years 21 people (25.61%), years 33 people (40.24%) and over 55 years 28 people (34.15%) (Table 1). The study group was also divided in terms of the type of anesthe- Evaluation of postoperative pain in patients treated surgically 359

38 sia used. General anesthesia was used in 42 (51.52%) patients and spinal anesthesia in 40 (48.78%) patients. (Table 2). The first pain measurement took place immediately after the procedure, the next one after 4, 8 and 12 hours after the operation was completed using the numerical scale. To assess the pain, a numerical scale was used where: 0 points means no pain, 5 points moderate pain, 10 points unbearable pain. In addition, information on age, gender, type of surgery and anesthesia was collected. Results Table 1. Characteristics of the study group in the scope of socio-demographic variables Age Variable Variable characteristics N % years years above 55 years male Sex female Source: author s own research The study included 82 people. The most numerous group were the respondents aged people (40.24% of the total number of respondents). The largest group were the respondents aged people (25.61%). The majority of respondents are women 52 (63.41% of all respondents) (Table 1). Table 2. Characteristic of the examined group in terms of the type of surgical procedure and the applied anesthesia Type of surgery and anesthesia N % removal of the gallbladder removal of varicose veins General anesthesia spinal anesthesia Source: author s own research A more numerous group of patients were patients after cholecystectomy performed under general anesthesia 42 persons (51.22%), the remaining subjects were patients after removal of varices of lower limbs under spinal anesthesia 40 people (48.78%) (Table 2). Table 3. Evaluation of postoperative pain using a numerical scale Evaluation of postoperative pain by means of a numerical scale at specifi c intervals after surgery Average Statistics Standard deviation immediately after surgery 0.46 ± hours after surgery 2.93 ± hours after surgery 3.39 ± hours after surgery 3.39 ±1.30 Source: author s own research Immediately after the procedure, the patients experienced pain at the level of 0.46 ± 1.07 points. After 4 hours from the procedure, the postoperative pain reached the intensity 2.93 ± 2.19 points. Subsequent post-operative pain measurements were taken at 8 and 12 hours after surgery. After 8 hours its intensity was 3.39 ± 1.55 points, and after 12 hours 3.39 ± 1.30 points (Table 3). Table 4. Relationship between the assessment of postoperative pain and the age of patients Pain assessment using a numerical scale in intervals after surgery pain assessment immediately after surgery pain assessment 4 hours after surgery pain assessment 8 hours after surgery pain assessment 12 hours after surgery Age Source: author s own research Number of people Average Standard deviation years ± years ± 1.18 above 55 years ± years ± years ± 2.07 above 55 years ± years ± years ± 1.41 above 55 years ± years ± years ± 1.37 above 55 years ± 1.20 p Analyzing the occurrence of postoperative pain at various time intervals from the end of the operation and in terms of age, it should be stated that: immediately after the procedure, patients over the age of 55 years rated pain at the level of 0.54 ± 1.04 points. In contrast, patients between years 0.45 ± 1.18 points. The youngest patients years assessed pain intensity at 0.3 ± 0.97 points. Statistically (p = 0.882). After 4 hours, the pain intensity was repeated. Patients over 55 years of age assessed pain at the level of 3.32 ± 1.98 points. At the age of years at the level 2.3 ± 2.07 pts. Patients aged at the level 3.39 ± 2.53 pts. Statistically (p = 0.162). The next measurement of postoperative pain intensity was made after 8 hours from the end of the operation. Patients over 55 years rated their pain intensity 3.6 ± 1.66 points. Subjects in the age group years, assessed the pain level 3.24 ± 1.41 points. Postoperative pain in patients aged was at the level of 3.29 ± 1.62 points. Statistical signifi cance (p = 0.569). When measuring the intensity of pain after 12 hours from the end of the surgical procedure the results were as follows: subjects over the age of 55 experienced pain at the level of 3.61 ± 1.20 points. Patients aged ± 1.37 points The pain felt by patients aged was estimated at 2.90 ± 1.20 points. Statistically (p = 0.135) (Table 4). 360 POLISH NURSING NR 4 (70) 2018

39 Table 5. Relationship between the assessment of post-operative pain and the gender of patients Pain assessment using a numerical scale at intervals after an operation pain assessment immediately after surgery pain assessment 4 hours after surgery pain assessment 8 hours after surgery pain assessment 12 hours after surgery Sex Source: author s own research Number of people Average Standard deviation female ± 0.46 male ± 1.53 female ± 2.24 male ± 2.13 female ± 1.60 male ± 1.45 female ± 1.25 male ± 1.38 p Immediately after the operation, the pain experienced by women amounted to 0.15 ± 0.46 points. In men, the pain at the same time was set at ± 1.53 points. Statistically (p = 0.000). After 4 hours from the end of the surgery, women experienced pain of ± 2.24 points, while men 2.74 ± 2.13 points. Statistically (p = 0.547). After 8 hours from the end of the operation, women reported pain at 3.27 ± 1.60 points, men at 3.60 ± 1.45 points. Statistically (p = 0.353). Another measurement of postoperative pain intensity was made after 12 hours from the end of the operation. In women, it was 3.27 ± 1.25 points, while in men 3.60 ± 1.38 points. Statistically (p = 0.270) (Table 5). Table 6. Relationship between the assessment of postoperative pain and the type of surgery Pain assessment using a numerical scale at intervals after surgery pain assessment immediately after surgery pain assessment 4 hours after surgery pain assessment 8 hours after surgery pain assessment 12 hours after surgery Type of surgery removal of the gallbladder removal of varicose veins removal of the gallbladder removal of varicose veins removal of the gallbladder removal of varicose veins removal of the gallbladder removal of varicose veins Source: author s own research Number Standard Average of people deviation ± ± ± ± ± ± ± ± 1.32 p The type of surgery was included in the assessment of postoperative pain. The subjects underwent surgery to remove both the gall bladder and varicose veins. Immediately after the surgery, patients after cholecystectomy reported pain at the level of 0.90 ± 1.36 points, while patients after removal of varicose veins 0.00 ± 0.00pts. Statistically (p = 0.000). 4 hours after removal of the gallbladder, patients reported pain of 3.60 ± 2.19 pts, and after removing varicose veins 2.23 ± 1.99 points. Statistically (p = 0.004). At the next measurement of the intensity of post-operative pain, after 8 hours the pain felt by patients after cholecystectomy was 3.83 ± 1.54 pts. Subjects after the operation of varicose veins had pain at ± Statistically (p = 0.007). Twelve hours after the end of the procedure, the patients performed another assessment of postoperative pain intensity. In the case of subjects after removal of the gall bladder, the pain reached the result 3.67 ± 1.24 points. Among patients after removal of varicose veins, the pain was at the level of 3.10 ± 1.32 points. Statistically (p = 0.048) (Table 6). Table 7. Relationship between the assessment of post-operative pain and the type of anesthesia used Pain assessment using a numerical scale at intervals after surgery pain assessment immediately after surgery pain assessment 4 hours after surgery pain assessment 8 hours after surgery pain assessment 12 hours after surgery Type of anesthesia Source: author s own research Number Standard Average of people deviation General anesthesia ± 1.36 spinal anesthesia ± 0.00 General anesthesia ± 2.19 spinal anesthesia ± 1.99 General anesthesia ± 1.54 spinal anesthesia ± 1.42 General anesthesia ± 1.24 spinal anesthesia ± 1.32 p Postoperative pain was evaluated in terms of the type of anesthesia used. In the presented studies, patients were subjected to two types of anesthesia. In the case of gall bladder removal, general anesthesia was used, while subarachnoid varicose veins were removed. Postoperative pain monitoring immediately after the procedure, patients under general anesthesia reported pain at the level of 0.9 ± 1.36 points, while among patients who underwent spinal anesthesia, the pain was estimated at 0.00 ± 0.00 pts. Statistically (p = 0.000). Four hours after surgery was completed, another postoperative pain assessment was made. Patients after surgery under general anesthesia, assessed pain at 3.60 ± In the case of patients who underwent subarachnoid anesthesia, the pain intensity was ± 1.99 points. Statistically (p = 0.004). With the next mea- Evaluation of postoperative pain in patients treated surgically 361

40 surement of the intensity of post-operative pain, after 8 hours of surgery, subjects undergoing general anesthesia reported pain at 3.83 ± 1.54 points. In contrast, patients undergoing subarachnoid anesthesia at ± 1.42 points. Statistically (p = 0.007). At 12 hours after the operation, the pain that worried patients after surgery under general anesthesia was ± 1.24 points. In the case of patients after the procedure performed under spinal anesthesia, the pain was at the level of 3.10 ± 1.32 points. Statistically (p = 0.048) (Table 7). Discussion The proper measurement of pain severity is an indispensable element of effective treatment of post-operative pain, allowing to assess both the dynamics of pain over time and the effectiveness of the treatment [9]. Although many articles by eminent Polish experts have been published recently on the treatment of post-operative pain, the number of publications on the detailed assessment of post-operative pain is still small [10, 11]. In this research, the severity of postoperative pain was assessed using the numerical pain assessment scale in two groups of patients. The first group consisted of patients after cholecystectomy, the second one was examined after surgical treatment of varices of the lower limbs. These tests were carried out immediately after surgery, and then after 4, 8 and 12 hours after surgery. Statistical analysis showed that the level of pain in both groups immediately after surgery was low and amounted to 0.46, after 4 hours the mean level of pain was 2.94, while after 8 and 12 hours the level of pain was maintained at the same level and amounted to 3.9. Obtained results in the scope of the first two measurements indicate that postoperative analgesia was effective. However, the measurement result in two consecutive time points of 3.9 suggests the need for the systematic pain assessment at shorter intervals. The study also examined the influence of such variables as: age, sex, type of surgery and the type of anesthesia used for the degree of pain perception in the NRS scale. Comparing the level of pain at individual time points, there was no signifi cant relationship between the age of patients and the degree of pain experienced. There were no signifi cant differences in the severity of pain in individual measurements, comparing the group of women and men. Only in the immediate postoperative period did men experience a signifi cantly higher level of pain compared to women. In the study of Przychodzka et al., There were no signifi cant differences in the assessment of pain between men and women [12]. Also in the studies of Juszczak et al., in which the quality of nursing care in the aspect of postoperative pain was assessed in 291 patients undergoing surgical interventions, there was no relationship between the age and sex of the subjects and the assessment of the quality of nursing care in the aspect of postoperative pain. [13]. In the scientifi c literature on the treatment of post-operative pain, it is emphasized that the most painful is pain in patients after thoracotomy and abdominal surgeries, while treatments on the coatings and limbs are usually burdened with much smaller painful ailments. The location of the procedure, its extent, the degree of traumatization of tissues, the direction of skin incision and the use of specifi c analgesia techniques in the perioperative period signifi cantly affect the degree of pain perception [4]. The analysis of author s own studies showed signifi cant differences in pain assessment between cholecystectomy patients compared to patients after removal of varicose veins. In the patients after cholecystectomy, the mean highest pain level was 3.83 during the measurement performed 8 hours after surgery, while in patients after removal of varicose veins, the highest value in the NRS score of 3.10 was found 12 hours after surgery. This means that the type of surgery affected the severity of pain. However, the surge in the point value on the NRS scale is surprising at particular time points in both groups. Interpreting the results obtained, one should bear in mind the differences in the patients responses to the analgesic therapy used. In the specialist literature, there are reports indicating that there are individual differences between respondents in responding to analgesia. Patients may differ in terms of the observed response to treatment due to the variability of pain over time, exposure to psychological or physical stress as well as due to physiological differences or different bioavailability of the drug [14]. However, without specifying additional factors, it is diffi cult to conclude on the basis of the results obtained on the NRS scale that some of the respondents responded to treatment and others did not. The above data from the literature, however, draw attention to the necessity of conducting an accurate pain assessment and providing individualized treatment. The presented studies also showed that during the postoperative treatment the size of the surgical injury only slightly correlates with the level of pain assessed by the NRS scale. Less extensive surgical procedures are not associated with a complete lack of post-operative pain. Mędzrzycka-Dąbrowska et al. emphasizes that the assessment of pain performed by the nurse should be focused primarily on satisfying the individual needs of the patient and not on realizing predetermined assumptions about the level of pain that the type of surgery may cause [15]. The cholecystectomy treatment was performed under general anesthesia, whereas the procedure of removal of varicose veins was carried out under aortic anesthesia. Analysis of the 362 POLISH NURSING NR 4 (70) 2018

41 obtained data showed a signifi cant difference in the NRS scale at individual time points in both groups. The cumulative analysis comparing the use of subarachnoid anesthesia to general anesthesia showed lower NRS scores in patients undergoing anesthesia. Assessing the results of our research, it can be concluded that both the type of surgery and the type of anesthesia had an effect on the severity of pain measured by the NRS scale. Similarly, in the studies conducted by Tomaszek, the relationship between the severity of pain and the type of surgery was demonstrated. [16]. Therefore, it seems appropriate to conduct and publish pain assessments in surgically treated patients. Research results can have a positive impact on the quality of nursing care in terms of pain. The Juszczak et al study did not show the influence of the type of anesthesia and the type of surgery on the quality of nursing care in the aspect of post-operative pain [13]. Similarly, the Grochans study did not show a signifi cant relationship between the type of surgery and the type of anesthesia and the severity of pain. [17]. Bączyk et al. emphasized the importance of the quality of nursing care in the treatment of postoperative pain. [18]. Our research confirmed that pain monitoring using standardized measurement tools is an important element in maintaining good analgesic effects. Also in the study of Słomian et al. it was proved that numerical, analogue and verbal scales were perceived by nurses and doctors as effective tools for fi ghting postoperative pain. The study involved 150 patients in the postoperative period, in whom the intensity of pain before and after anesthesia was measured, using the scale and verbal description of the patient s pain sensations. The results of the study showed a correlation between the assessment using the scale and the patient s own assessment. In both cases, there was a reduction in pain after the pharmacotherapy. [19]. The use of appropriate assessment tools provides the patient with the possibility of transporting a subjective pain sensation to objective parameters by describing pain in a measurable way [15, 20]. Our studies using the NRS scale may contribute to a better understanding of pain sensations in patients after cholecystectomy and in patients after surgical treatment of varicose veins, but do not contribute to explaining the influence of the analgesia methods used on the subjective pain assessment in both groups. There is therefore a need for further research to explain the effect of both the type of analgesia and other additional factors affecting the achievement and maintenance of the satisfactory post-operative pain control Conclusions 1. The following factors influenced the intensity of postoperative pain: type of surgery and anesthesia used, age, sex, time from the end of the procedure. Patients at the age of 55 and above reported the most severe pain after 8 hours after the operation was completed. Taking into account the gender of the subjects, men experienced the strongest pain at 8 and 12 hours after surgery. The highest intensity of postoperative pain was noted in patients after laparoscopic cholecystectomy after 8 hours from the end of the operation. Taking into account the type of anesthesia used, patients suffering from general anesthesia experienced stronger pain. The highest pain level was 8 hours after the procedure. The highest intensity of postoperative pain was recorded after 8 hours from the end of the procedure. Pain monitoring is an important element of nursing care in the post-operative period. This has an impact on the use of an effective analgesic therapy, counteracting complications and the success of the whole convalescence process. References 1. Bączyk G., Kapała W. Podstawy kliniczne oraz pielęgnowanie chorych w okresie przed i pooperacyjnym w chirurgii ogólnej, ortopedii traumatologii. Poznań 2012,27 54, , Suchorzewski M. Ból i jego leczenie; Rozdz. w: Anestezjologia i Intensywna opieka. Klinika i pielęgniarstwo, Red. Wołowicka L., Dyk D. Warszawa PZWL 2008; Sherwood RE., Williams C.G., Prough D.S. Podstawy anestezjologii, leczenia bólu i płytkiej sedacji.w: Popiela T (red). Sabiston chirurgia. Urban Partner. Wrocław 2008; Wordliczek J., Misiołek H., Zajączkowska R., Dobrogowski J. Uśmierzanie bólu pooperacyjnego. W: Wordliczek J., Dobrogowski J. (red). Leczenie bólu. PZWL Warszawa 2017; , Wundere G.L., Debrand-Passard A. Pielęgniarstwo operacyjne. Urban Partner Wrocław. 2010; Ciostek P., Noszczyk W. Przewlekła choroba żylna. W: Szmidt J., Kużdżała J. (red). Podstawy chirurgii. Medycyna Praktyczna. Kraków 2009; Asthley E., Doraisswami M. Ból pooperacyjny.w: Bromley L., Brandner B. (red). Ból ostry. medipage. Warszawa 2013; Kruszyna T. Uśmierzanie bólu pooperacyjnego. Med. Prakt. Chir. 2016; 2: Juszczak K. Pielęgniarska ocena stanu chorego z bólem pooperacyjnym. Piel Chirurg Angiol. 2012;4: Wordliczek J., Dobrogowski J. Uśmierzanie bólu pooperacyjnego. Med Prakt Chir. 2011; Misiołek H., Cettler M., Woroń J., Wordliczek J., Dobrogowski J., Mayzner-Zawadzka E. Zalecenia postępowania w bólu pooperacyjnym AD Ból. 2014;15, 2: Przychodzka E., Lorencowicz R., Turowski K., Jurczuk Andrzejczuk R. Ból w okresie przed i pooperacyjnym u pacjentów chirurgicznych. Zdrow Dobros 2013; 5: Evaluation of postoperative pain in patients treated surgically 363

42 13. Juszczak K., Jaracz K., Kuberska I. Subiektywna ocena jakości opieki pielęgniarskiej w aspekcie bólu pooperacyjnego u chorych poddawanych interwencji chirurgicznej. Piel Chir Angiol. 2016; 4: Dworkin R.H., McDermott M.P., Farrar J.T., Oconnor A.B., Senn S. Interpretowanie reakcji pacjenta na leczenie w badaniach klinicznych dotyczących leczenia przeciwbólowego: implikacje dla genotypowania, fenotypowania i zindywidualizowanego leczenia bólu. Ból. 2015;16,1: Mędzrzycka-Dąbrowska W., Ogrodniczuk M., Dąbrowski S. Udział pielęgniarki w procesie monitorowania terapii bólu pooperacyjnego część II. Anestezjologia i Ratownictwo. 2014; 8: Tomaszek L. Ocena stopnia nasilenia bólu u dzieci po zabiegach torakochirurgicznych. Probl Pielęg 2009, 17, 3: Grochans E., Hyrcza V., Kuczyńska M., Szkup-Jabłońska M., Jurczak A., Karakiewicz B. Subiektywna ocena bólu pooperacyjnego u chorych po wybranych zabiegach chirurgicznych, Pielęg Chir Angiol 2011; 2: Bączyk G., Ochmańska M., Stępień S. Subiektywna ocena jakości opieki pielęgniarskiej w zakresie bólu pooperacynego u chorych leczonych chirurgicznie. Probl Pielęgn ;7,: Słomian R., Wruble A.W., Rosen G., Rom M. Determination of clinically meaningful leveis of pain reduction in patients experiencing acute. Pain Manag Nurs 2006; 7: Ulatowska A., Bączyk G., Lewandowska H. Przegląd piśmiennictwa na temat bólu pooperacyjnego oraz jakości opieki pielęgniarskiej. Piel Chir Angiol. 2012; 1:7 1 The manuscript accepted for editing: The manuscript accepted for publication: Funding Sources: This study was not supported. Confl ict of interest: The authors have no confl ict of interest to declare. Address for correspondence: Agnieszka Ulatowska Dąbrowskiego Poznań, Poland phone: agnesia74@poczta.fm Department of Nursing Practice, Faculty of Health Sciencies, Poznan Uniwersity of Medical Scienties, Poland 364 POLISH NURSING NR 4 (70) 2018

43 Copyright Poznan University of Medical Sciences ANALYSIS OF NURSES KNOWLEDGE IN THE AREA OF PREVENTION OF CARDIOVASCULAR DISEASES ANALIZA STANU WIEDZY PIELĘGNIAREK W ZAKRESIE PREWENCJI CHORÓB UKŁADU SERCOWO-NACZYNIOWEGO Damian Durlak Faculty of Health Sciences, Radom College DOI: ABSTRACT Introduction. The knowledge of cardiovascular diseases is important because of an increasing number of patients suffering from this group of diseases. It is expected that nurses will not only provide professional health care, but will also educate patients and shape their healthy habits. Aim. of the research was to assess the knowledge of nurses about cardiovascular diseases. The research was focused on the main risk factors and methods of prevention of cardiovascular diseases. Material and Methods. In the research an individual survey was conducted among a group of nurses, who were working in their profession. People interviewed were asked a series of open and closed questions concerning correct biochemical and physiological parameters of the human body and cardiovascular diseases. Results. The results present that 64.49% of respondents know modifi able factors infl uencing development and course of cardiovascular diseases. People surveyed have shown poor knowledge of the correct cholesterol level in blood and blood pressure, there were respectively 28.80% and 20.80% of correct answers. The Pearson correlation coeffi cient has shown a moderate correlation (-0.44) between the place of residence and fi nished courses. There has been a weaker correlation between the age, seniority and place of residence and correct answers. Conclusions. Results show that it is needed to constantly refresh and deepen nurses knowledge. The Surveyed group had knowledge about risk factors and cardiovascular diseases, acquired their knowledge from proven sources lectures, laboratories and practical classes. It is still needed to refresh the knowledge about biochemical and physiological parameters of the human body. KEYWORDS: cardiovascular diseases, nurses, prevention, knowledge. STRESZCZENIE Wstęp. Wiedza na temat chorób układu sercowo-naczyniowego jest szczególnie istotna ze względu na rosnącą liczbę przypadków pacjentów chorych na tę grupę chorób. Od pielęgniarek oczekuje się obecnie nie tylko fachowej opieki pielęgnacyjnej, ale również przekazywania wiedzy i kształtowania prawidłowych postaw zdrowotnych pacjentów. Cel. Celem pracy była ocena wiedzy pielęgniarek i pielęgniarzy w zakresie chorób układu sercowo-naczyniowego. W badaniu skupiono się na głównych czynnikach ryzyka i metodach profi laktyki schorzeń tego układu. Materiał i metody. W badaniu wykorzystano jako technikę badawczą ankietę indywidualną, narzędzie badawcze kwestionariusz ankiety. Badanie przeprowadzono na grupie pielęgniarek i pielęgniarzy aktywnych zawodowo. Osoby ankietowane odpowiadały na szereg pytań otwartych i zamkniętych, dotyczących prawidłowych parametrów biochemicznych i fi zjologicznych organizmu człowieka, a także chorób układu sercowo-naczyniowego. Wyniki. Uzyskane odpowiedzi wykazały, że 64,49% respondentów zna czynniki modyfi kowalne, mające wpływ na rozwój i przebieg chorób układu sercowo-naczyniowego. Ankietowane osoby wykazały się niską wiedzą dotyczącą prawidłowego stężenia cholesterolu i ciśnienia tętniczego krwi, gdzie prawidłowych odpowiedzi udzieliło odpowiednio 28,80% i 20,80% osób. Wyliczony współczynnik korelacji Pearsona wskazał na umiarkowanie silną korelację między miejscem zamieszkania a posiadanymi kursami na poziomie około -0,44, przy znacznie słabszej korelacji między wiekiem, stażem pracy i miejscem zamieszkania a prawidłowymi odpowiedziami na pytania. Wnioski. Wyniki badania wskazują na potrzebę odświeżania i pogłębiania wiedzy wśród pielęgniarek i pielęgniarzy. Badana grupa posiadała wiedzę na temat czynników ryzyka i chorób układu sercowo-naczyniowego, zdobywała swoją wiedzę ze sprawdzonych źródeł z wykładów, ćwiczeń lub zajęć praktycznych. Potrzebne jest odświeżanie wiedzy dotyczącej parametrów biochemicznych i fi zjologicznych organizmu człowieka. SŁOWA KLUCZOWE: układ sercowo-naczyniowy, pielęgniarki, profi laktyka, wiedza. POLISH NURSING NR 4 (70) 2018 ORIGINAL PAPER 365

44 Introduction Cardiovascular diseases constitute a serious social and economic problem both in Poland and worldwide. Despite the fact that the number of incidences of cardiovascular diseases has begun to drop within the last decades, it is assessed that they are still the most important health problem in the world in the 21 st century. Currently, even every fourth person identifies a cardiovascular ailment in themselves [1]. Such a situation requires a change in undertaking complex solutions: monitoring risk factors, early diagnosis and undertaking treatment, and preventing repeated acute incidents [2]. Fighting with the epidemic of these diseases is inseparably connected with effi cient, complex, and possibly individual education of patients that motivates for a change in health behaviour, for self-control, and self-care, and favouring an effi cient cooperation with a doctor, nurse, and other professionals working for the benefit of health [3]. For several dozens of years, research into a decrease of threats connected with cardiovascular diseases has been conducted. A signifi cant role in this scope is played by prevention and education on cardiovascular diseases, risk factors, and the possibilities of eliminating them on a wide scale [4]. A classic definition of prevention assumes that it includes any activities undertaken in order to prevent the appearance and development of undesirable behaviour, conditions or phenomenon in a given population [5]. Health education ought to be supported with effi cient activities in order to develop behaviour focused on disease prevention to make the society aware that health is a capital, which is worth investing in [6]. Health education ought to transform human attitudes and behaviour to fi ght with new threats, and shape responsibility for one s own health and the health of other people from the nearest surroundings [7]. What is expected from a contemporary nurse is not only a professional nursing care, but also the right actions towards patients, whose aim is to convey knowledge on health and the conditions of maintaining it; and in the situation of a disease, knowledge on this disease and the ways of handling its consequences [8]. A nurse ought to be ready to help to make decisions connected with maintaining patient s health, shaping his/her positive attitudes, and behaviour towards health. In order for educational activities to be effi cient, a nurse ought to use various methods and forms of education, and should also gain supplemental education, because knowledge is subject to constant modifi cations [9]. The Aim of research The relevant level of knowledge among nurses is a signifi cant element of the proper and effi cient education of patients. For this reason, the assessment of knowledge on the risk factors and the prevention of cardiovascular diseases among female and male nurses has been chosen as the main aim of this research. Apart from that, the knowledge of female and male nurses on the proper biochemical and physiological parameters of a human organism has also been subject to an assessment. The aim of the research was not to compare the knowledge of nurses working in specifi c wards, but to assess the knowledge of the whole occupational group working in the same hospital. Material and Methods An anonymous survey questionnaire was used in the research (an individual questionnaire). The examined group consisted of female and male nurses actively working in the profession. The place where the research was conducted was Mazovian Specialized Hospital in Radom. The group surveyed consisted of nurses working mainly in internal, cardiology and other wards placed in this hospital. The survey was conducted within the period of time from 10 th December 2016 till 20 th March The questionnaire included 15 open and closed (single and multiple choice) questions as well as an instruction and information about the anonymity of the people researched. The people surveyed answered questions concerning: 1. the risk factors of cardiovascular diseases, 2. the cardiovascular diseases that appear in the society most frequently, 3. factors influencing the development and course of cardiovascular diseases, 4. modifiable factors influencing the development and course of cardiovascular diseases, 5. non-modifiable factors influencing the development and course of cardiovascular diseases, 6. the correct blood pressure, 7. the value of blood pressure that is typical for hypertension, 8. the correct concentration of total cholesterol in blood serum, 9. the correct concentration of cholesterol LDLfraction in blood serum, 10. the correct concentration of cholesterol HGLfraction in blood serum, 11. the correct concentration of glucose in blood, 12. the characteristics of an anti-atherosclerotic diet, 13. the elements of a pro-health lifestyle influencing the elimination of risk factors of cardiovascular diseases, 14. the main sources of knowledge of the researched nurses on cardiovascular diseases, 366 POLISH NURSING NR 4 (70) 2018

45 15. the record data: age, sex, place of residence, seniority, possessed specializations, and specialized courses completed. Results 125 female and male nurses at the age from 23 to 65 years old took part in the research. In the research group, 75% female and male nurses possessed specialized courses; additionally, 68,8% of the respondents possessed at least one specialization (Table 1). In terms of an age division, the most numerous group (39%) composed of people included in the age range of years old, and the least (8%) of the respondents were at the age of years old. Not all the people surveyed answered the question concerning the age, which resulted in the total of indications of all age ranges that was lower than 125. A definite majority of the respondents were women (91%). The most numerous group from among the people taking part in the survey possessed seniority within the limits of years (43%). The smallest number of people possessed work experience below 5 years (8%). This corresponds to the age groups of the respondents, where the most numerous group was characterized by a relatively high age. The biggest percentage of completed courses was observed among people aged above 50 years old. None of the respondents below 30 years old completed a course. The results obtained in the questionnaire research allowed to assess the knowledge of the researched group of the female and male nurses. The percentage values provided in the analysis mean a fraction of questionnnaires with a given answer marked or provided. In the first analyzed question, the female and male nurses could choose several factors from among the menioned risk factors of cardiovascular diseases. On the basis of the results of the conducted research, most of the nurses stated that the main cause for the risk of cardiovascular diseases was smoking cigarettes 24.53%, an improper diet 21.87% and stress (Figure 1). In the opinion of the respondents, genetics and age did not constitute the risk factors of cardiovascular diseases. As many as 8.80% of the respondents gave no answer, which can testify to the ignorance of risk factors of cardiovascular diseases. Table 1. Record data of the researched nurses Independent Number % Categories variables of indications of indications Age and more Sex Woman Man 11 9 Courses Professional Specializations development No courses or specializations Less than 5 years years Seniority years years and more years 1 13 Nurses with specialization years by age years and more years 0 0 Nurses with years 9 23 courses by age years and more Source: authors own analysis Figure 1. Answers on the appearance of cardiovascular diseases risk factors obtained among the researched female and male nurses Source: authors own analysis On the basis of the research conducted on the knowledge of cardiovascular diseases most commonly appearing in the society, 25.41% of the respondents indicated heart attack as the disease dominating in our society. High percentage of people surveyed mentioned coronary disease 23.78%, 16.22% indicated atherosclerosis and 14.59% hypertension; while 15.47% of the researched female and male nurses did not mention any cardiovascular disease (Figure 2). Analysis of nurses knowledge in the area of prevention of cardiovascular diseases 367

46 Figure 2. Answers on the cardiovascular diseases most frequently appearing in the society obtained among the researched female and male nurses Source: authors own analysis Only 20.60% of the total number of respondents thought that both the modifiable and non-modifiable factors influenced the development and course of diseases (Figure 3). It is worrying that as many as 76.20% of the respondents gave no answer to this question despite a much higher percentage of answers in a pilot study. According to the results, 1.60% of the respondents thought that only the modifiable factors influenced the development and course of cardiovascular diseases. The same percentage of the respondents indicated only non-modifiable factors. Due to a high percentage of blank answers, this question was excluded from further analysis. Figure 4. Answers on the modifi able factors infl uencing the development and course of cardiovascular diseases obtained among the questioned female and male nurses Source: authors own analysis. A large group of the respondents left the questions concerning the correct blood pressure and the right concentration of total cholesterol in blood unanswered (Figure 5 and Figure 6). It can indicate a lack of relevant knowledge concerning these parametres. Due to a high percentage of blank answers, these questions were excluded from further analysis. Figure 5. Answers on the correct blood pressure Source: authors own analysis. Figure 3. Answers on the factors infl uencing the occurrence, development and course of cardiovascular diseases obtained among questioned female and male nurses Source: authors own analysis. As a result of the conducted research, it was stated that a definite majority of the respondents showed knowledge of modifiable factors influencing the development and course of cardiovascular diseases (Figure 4). The most commonly chosen factors were: no physical activity 9.52%, obesity 9.12%, smoking tobacco and overweight 8.88%. As many as 29.28% of the respondents indicated none of the many listed risk factors that were subject to modifi cation. Figure 6. Answers on the correct concentration of total cholesterol in blood Source: authors own analysis. From the analysis of the research results, it follows that the respondents know the elements of a pro-he- 368 POLISH NURSING NR 4 (70) 2018

47 alth lifestyle and their influence on eliminating the risk factors of cardiovascular diseases (Figure 7). Most of the respondents indicated the following answers: an anti atherosclerotic diet 27.73%, a diet with limiting table salt and taking medicines systematically in case of chronic diseases 10.04%, taking care of maintaining the correct body weight 9.96%. In order to check the correlations between the variables analyzed in the research, the value of the Pearson s correlation coeffi cient was specified. The analysis showed a moderately strong, negative correlation between the place of residence and possessed courses on the level of about (Table 2). However, place of residence showed a weaker correlation with possessed specializations. The relations between the age, seniority, sex, the place of residence, and correct answers to selected questions were characterized by quite a weak correlation. It can be concluded that the age and seniority of the responding female and male nurses did not have a direct influence on giving the correct answers to the questions mentioned. Table 2. Values of the Pearson s correlation coeffi cient among selected variables Figure 7. Answers on the a pro-health lifestyle and its infl uence on eliminating the risk factors of cardiovascular diseases Source: authors own analysis The obtained research results allowed for differentiating the sources from which the female and male nurses researched acquired knowledge on cardiovascular diseases (Figure 8) % of the respondents acquired information on cardiovascular diseases during lectures and classes. Practical classes were indicated by 11.84% of the respondents. As many as 58.88% of the respondents gave no answer. Figure 8. Answers on the sources of information on the subject of cardiovascular diseases in the opinion of the responding female and male nurses Source: authors own analysis Age Seniority Sex Place of residence Possessed courses Possessed specializations Correct answer to the question about the correct blood pressure Correct answer on the a blood pressure value with hypertension Correct answer on the correct concentration of total cholesterol Correct answer on the correct concentration of LDL- cholesterol Correct answer on the correct concentration of HGL- cholesterol Correct answer on the correct concentration of glucose Source: authors own analysis Discussion The signifi cance of relevant health education was also discerned in other research determining the state of patients knowledge [10]. Professionals dealing with people suffering from cardiovascular diseases should constantly update their knowledge both in the scope of new medical discoveries and from the point of view of conveying knowledge. Pro-health education ought to be carried out particularly carefully in rural areas where the responding people demonstrated the poorest knowledge concerning cardiovascular diseases [11]. However, even at such places like Beijing, research has shown that there is still a need for more intensive education among nurses about cardiovascular diseases risk reduction, as less than 58% of respondents correctly answered questions concerning this topic [12]. Female and male nurses in Poland are characterized by a relatively high level of knowledge, which is also reflected by surveys conducted in terms of knowledge in the scope of relevant blood pressure and factors affecting it [13]. The research authors emphasized the signifi cance of female nurses development of knowledge both before and after graduating from a higher education institution. The Analysis of nurses knowledge in the area of prevention of cardiovascular diseases 369

48 involvement of nursing staff in educating society and preventing diseases can contribute to a better prevention of cardiovascular diseases signifi cantly. The results of a survey conducted among American nurses reflect the results obtained in this research. Plenty of nurses gain knowledge on the subject of possible therapies from practice and scientifi c articles, on smaller degree relying on education [14]. The correlation between age, seniority, and the correct answers was relatively low. In the researched group, the level of knowledge was similar independently of the values of these factors, which can indicate that nurses update their knowledge even many years after completing education. In other research groups, the results indicated a higher level of knowledge among people with seniority over 5 years comparing to people working shorter than 5 years [15]. However, the quality of nursing care was adequate in both groups. It has been shown that additional courses related to cardiovascular disease prevention significantly improved knowledge of graduate nursing students [16]. The subject of pro-health education and prevention of cardiovascular diseases is vast. The presented research constitutes one possible approach to specifying the need for further education of nursing staff. It also constitutes a basis for further research, for example, among people practicing other medical professions. A summary of research from other European countries is possible for comparing the knowledge and attitude towards pro-health education of nurses depending on age and the place of work. Conclusions The results of the research indicate that the majority of the responding female and male nurses possess the knowledge on the risk factors and prevention of cardiovascular diseases. The best-known risk factors of cardiovascular diseases known to female and male nurses are smoking cigarettes, an improper diet, alcohol consumption, no physical activity, and obesity, which corresponds to the factors given in the subject literature. The female and male nurses know the most frequent cardiovascular diseases; and they know the factors influencing the development and course of these diseases. They possess knowledge on the pro-health lifestyle eliminating the risk factors of cardiovascular diseases; they gain knowledge during lectures and classes given by lecturers, and during practical classes. It results from the analysis of record data that age affects professional development among the female and male nurses. The higher the seniority of female and male nurses is, the more completed courses and specializations they have. Due to a big number of blank answers, it can be concluded that there is a need for a constant refreshment of knowledge of the female and male nurses that are professionally active, in the scope of biochemical and physiological parameters of the human body. It is possible to discern a need for further education of the female and male nurses in a form of a specialized block within the framework of education at higher education institutions, in order to equip them with relevant skills and information that are necessary for educating patients with the disorders of the cardiovascular system, as well as planning personal professional development by the female and male nurses through various development forms that will facilitate their improving qualifi cations. References 1. Gromadzka-Ostrowska J., Włodarek D., Toeplitz Z. Edukacja prozdrowotna. Warszawa: SGGW; Kaszuba D., Nowicka A. Pielęgniarstwo kardiologiczne. Warszawa: PZWL; Sierakowska M., Wrońska I. Edukacja zdrowotna w praktyce pielęgniarskiej. Warszawa: PZWL; Yu E., Rimm E., Qi L. I wsp.. Diet, Lifestyle, Biomarkers, Genetic Factors, and Risk of Cardiovascular Disease in the Nurses Health Studies. Waszyngton: American Journal of Public Health; / Szymańska J. Programy profilaktyczne Podstawy profesjonalnej psychoprofilaktyki. Warszawa: Ośrodek Rozwoju Edukacji; Rutkowska B. Podstawowe działania pielęgniarki w edukacji pacjenta. Podstawy Pielęgniarstwa t.2. Lublin: Czelej; Kubica A., Sinkiewicz W., Szymański P., Bogdan M. Edukacja zdrowotna w chorobach układu krążenia możliwości i zagrożenia. Gdańsk: Folia Cardiologica Excerpta; / Svavarsdottir M., Siguroardottir A., Steinsbekk A. Knowledge and skills needed for patient education for individuals with coronary heart disease: The perspective of health professionals. Londyn: European Journal of Cardiovascular Nursing; Lizak D., Goździalska A., Seń M., Jaśkiewicz J., Satora R. Promocja zdrowia i edukacja zdrowotna obowiązek czy wyzwanie dla pracowników ochrony zdrowia w XXI wieku?. W: Działania opiekuńcze w profilaktyce i terapii. Gożdzialska J., Jaśkiewicz J., Dębska G. Kraków: Oficyna Wydawnicza AFM; Stromberg A. The crucial role of patient education in heart failure. European Journal of Heart Failure; Brescia: Nowicki G., Ślusaska B., Brzezicka A. Analiza stanu wiedzy o czynnikach ryzyka chorób układu sercowo-naczyniowego wśród osób pracujących. Gdańsk: Problemy Pielęgniarstwa; / Wu Y., Deng Y., Zhang Y. Knowledge, attitudes, and behaviors of nursing professionals and students in Beijing toward cardiovascular disease risk reduction; Research in Nursing & Health; Grabowska H., Narkiewicz K., Grabowski W., Grzegorczyk M., Gaworska-Krzemińska A., Świetlik D. Ocena masy ciała oraz jej wpływ na wartość ciśnienia tętniczego w opinii licencjatów pielęgniarstwa. Gdańsk: Problemy Pielęgniarstwa; / POLISH NURSING NR 4 (70) 2018

49 14. Sohn P., Loveland C., Nurse practitioner knowledge of complementary alternative health care: foundation for practice; Journal of Advanced Nursing; Arathy S., A study to assess the knowledge and practices among cardiac nurses about patient safety after cardiac catheterization; Pakistan Journal of Medical and Health Sciences; / Engler M., Engler M., Davidson D., Slaughter R. Cardiovascular disease prevention: knowledge and attitudes of graduate nursing students; Journal of Advanced Nursing; The manuscript accepted for editing: The manuscript accepted for publication: Funding Sources: This study was not supported. Confl ict of interest: The authors have no confl ict of interest to declare. Address for correspondence: Damian Durlak Rapackiego 23 m Radom phone: dam.durlak@gmail.com Faculty of Health Sciences, Radom College Analysis of nurses knowledge in the area of prevention of cardiovascular diseases 371

50 Copyright Poznan University of Medical Sciences HEALTH BEHAVIOURS OF THE VILLAGE DWELLERS IN PREVENTION OF COLORECTAL CANCER ZACHOWANIA ZDROWOTNE MIESZKAŃCÓW WSI W ZAKRESIE PROFILAKTYKI RAKA JELITA GRUBEGO Arleta Teresa Gromada 1, Ewa Kobos 2 1 student of Nursing Division, Faculty of Health Sciences, Medical University of Warsaw, Poland 2 Department of Social Nursing, Faculty of Health Sciences, Medical University of Warsaw, Poland DOI: ABSTRACT Introduction. Colorectal cancer is one of the most common cancers in the world. Risk factors include genetic predispositions, infl ammatory bowel diseases and the lifestyle. Colorectal cancer is still late diagnosed. The village residents have a more diffi cult access to preventive activities, which may have an impact on their health behaviours. The aim. Analysis of villagers behaviours in prevention of colorectal cancer. Material and Methods: 160 inhabitants participated in the study. The criteria for participation in the study were the age below 40 and the lack of diagnosed colorectal cancer. The research tool was an original questionnaire consisting of a metric and a scale of health behaviours classifi ed in fi ve areas. Results. Participants of the study undertook health behaviours most frequently in the area of drug avoidance (M = 1.79), and the least frequently in the area of physical activity (M = 2.86) and nutrition (M = 2.68). People with more risk factors, professionally active people, as well as better educated people were more likely to have prophylactic examinations (p < 0.05). The older the participants were, the less frequently they used stimulants (p = ). Women show more frequent health behaviours in the following categories: nutrition, stimulants (p = ) and prophylactic tests (p < ). Conclusions: The village dwellers with a higher number of risk factors implement signifi cantly less frequently health behaviours in the prevention of colorectal cancer. Participants take up physical activity and undergo preventive examinations rarely. It is necessary to create the infrastructure for physical activity and information campaigns for the rural community. They should be particularly targeted at unemployed residents of rural areas, men and elderly people. KEYWORDS: colorectal cancer, prophylaxis, health behaviours. STRESZCZENIE Wstęp. Rak jelita grubego jest jednym z najczęściej występujących nowotworów na całym świecie. Do czynników ryzyka można zaliczyć predyspozycję genetyczną, choroby zapalne jelit oraz styl życia. Rak jelita grubego jest wciąż zbyt późno rozpoznawany. Mieszkańcy wsi mają utrudniony dostęp do działań profi laktycznych, co może rzutować na ich zachowania zdrowotne. Cel. Analiza zachowań zdrowotnych mieszkańców wsi w zakresie profi laktyki raka jelita grubego. Materiał i metody. Badaniem objęto 160 mieszkańców wsi. Kryteriami włączenia do badania był wiek > 40 r.ż. oraz brak zdiagnozowanego nowotworu jelita grubego. Za narzędzie badawcze posłużył autorski kwestionariusz ankiety składający się z metryczki oraz skali zachowań zdrowotnych sklasyfi kowanych w 5 obszarów. Wyniki. Badani najczęściej podejmowali zachowania zdrowotne w zakresie unikania używek (M = 1,79), najrzadziej w zakresie aktywności fi zycznej (M = 2,86) i żywieniowe (M = 2,68). Osoby, u których wykazano więcej czynników ryzyka, aktywne zawodowo, a także osoby bardziej wykształcone częściej wykonywały badania profi laktyczne (p < 0.05). Im starsi byli ankietowani tym rzadziej korzystali z używek (p = 0,0001). Kobiety wykazują częstsze zachowania zdrowotne w kategoriach: żywienie, używki (p=0,0008) oraz badania profi laktyczne (p < 0,0001). Wnioski. Mieszkańcy wsi z większą liczbą czynników ryzyka istotnie rzadziej realizują zachowania zdrowotne w profi laktyce raka jelita grubego. Ankietowani rzadko podejmują aktywność fi - zyczną i rzadko wykonują badania profi laktyczne. Niezbędne jest tworzenie infrastruktury dla aktywności fi zycznej oraz tworzenie kampanii informacyjnych przeznaczonych dla społeczności wiejskiej. Należy szczególnie kierować je do niepracujących mieszkańców wsi, mężczyzn oraz starszych osób. SŁOWA KLUCZOWE: rak jelita grubego, profi laktyka, zachowania zdrowotne. Introduction Colorectal cancer (CRC) is one of the most common cancers in the world. It is estimated that it is the third cancer in terms of incidence in the male population and the second in the female population [1]. The incidence of colorectal cancer among men in Poland in 372 POLISH NURSING NR 4 (70) 2018 ORIGINAL PAPER

51 2015 amounted to 10271, and among women to men died of colorectal cancer in Poland in 2015 and 2144 of rectal cancer in Poland. These values were 3547 and 1374 respectively in women [2]. It is estimated that 15,500 men and 9100 women will develop colorectal cancer in Poland in 2025 [3]. The etiology of CRC is not fully known yet. There are many different factors that contribute to its development, as well as factors that counteract it [4, 5, 6]. Environmental factors and lifestyle play the greatest role in colorectal cancer pathogenesis [5, 6]. Genetic factors are responsible for only 5 10% of cases of disease. They are mainly related to the occurrence of family adenocarcinomas: adenocarcinoma polyposis and Lynch syndrome. 20% of cases of CRC occur in persons with colorectal cancer in the family [4, 5, 7]. Moreover, other family cancers, such as breast cancer, endometrial and ovarian cancer, increase the risk of developing CRC [8, 9]. Bowel cancer may also develop on the basis of nonspecifi c inflammatory bowel diseases, such as Crohn s disease or ulcerative colitis [4, 6]. Other important risk factors include diabetes or insulin resistance, smoking, alcohol consumption, obesity (especially abdominal obesity), red meat and animal fat diets, lack of physical activity, and age over 50 [4, 6, 8, 9, 10, 11, 12, 13]. People with type 2 diabetes mellitus or insulin resistance are at risk of hyperinsulinemia, at least at the beginning of the disease. It has been shown that both endogenous and exogenous insulin stimulate the process of carcinogenesis. Moreover, chronic hyperglycaemia also influences the development of various tumors, mainly through intensifi cation of cellular processes during carcinogenesis [10, 14, 15]. People who consume red meat every day are three times more likely to develop colorectal cancer than those who limit their consumption of red meat to 500 g a week. Various compounds such as aromatic hydrocarbons and heterocyclic amines are formed during the processing and treatment of meat. They show high mutagenic properties. Frequent consumption of products rich in animal fats leads to an increase in deoxycholic acid in the large intestine. It has been proved that it has an impact on the development of neoplastic lesions [4, 5, 13, 16]. There is a correlation between the increase in BMI and the occurrence of colorectal adenomas. Studies show that the risk of colorectal cancer increases by as much as 24% for each increase in BMI by 5 kg/m 2 in men and by 9% in women [6, 11, 13]. Further risk factors are alcohol consumption and smoking [4, 5, 6, 9, 12, 13]. Acetaldehyde, which is a metabolite of alcohol, damages cell DNA and disrupts repair mechanisms. Moreover, frequent consumption of alcohol reduces the folic acid concentration in the body, which protects against the occurrence of neoplastic lesions [4, 5, 6, 9, 13]. Among other things, tobacco smoke has an effect on increased expression of 5-lipoxygenase, growth of the vascular endothelium. This contributes to the risk of colorectal cancer. This risk applies to both active and passive smokers [4, 6, 9, 12]. Protective factors include the consumption of marine fish, the daily supply of at least g of fibre, the daily consumption of at least 400 g of low-starch fruit and vegetables, the consumption of garlic and dairy products [5, 13, 17]. Research on fish consumption as a prevention for colorectal cancer is inconsistent. There are reports that frequent consumption of marine fish reduces the risk of colorectal cancer by up to 12%. A benefi cial role is attributed to polyunsaturated omega-3 acids, which protect against CRC by inhibiting cycloxygenase-2. Moreover, fish contain large amounts of selenium and vitamin D, which may also have a protective function [13, 18]. Dietary fiber increases the volume of faecal matter and binds water in the intestines. Its soluble fractions slow down the passage of food from the stomach to the intestine. Conversely, the insoluble fractions shorten the intestinal passage. Moreover, pectins contained in fiber have detoxifying properties [13]. It is likely that garlic has a protective function. One of the compounds found in garlic, ayoen, stops the multiplication of leukemic cancer cells. Sulphur compounds influence the activity of macrophages and T lymphocytes. Furthermore, garlic has proven bactericidal properties, which may have an anticancer effect [5, 13]. Dairy products contain calcium, which has a protective effect. It is likely to prevent the adverse and carcinogenic effects of bile acids. It is also possible that calcium inhibits cell proliferation, which inhibits the carcinogenesis process. The highest risk reduction of CRC occurrence was achieved with the supply of more than 2000 mg/day of calcium [13, 19]. It is of preventive importance to perform daily exercise for at least half an hour [5, 17, 20]. Regular exercise reduces the risk of CRC from 30 50%. First of all, the intensity of the effort is important, it depends less on the total amount of calories burned. The highest risk reduction occurs at a very intensive effort of 18 MET x hrs/week [20]. Symptoms of CRC appear quite late, only at an advanced stage. That is why, in addition to primary prevention, secondary prevention is so important. In Poland, any insured person may have a free colonoscopy between the ages of 55 and 64 with a personal invitation and between the ages of 50 and 65 without an invitation if they have not had a colonoscopy in the last 10 years. People aged can also register for the examination free of charge if their first-degree relative is diagnosed with colorectal cancer. In addition, an examination of Health behaviours of the village dwellers in prevention of colorectal cancer 373

52 a person between 25 and 49 years old may be carried out free of charge if their family has been diagnosed with hereditary polypropathy-free malignant colorectal cancer. This should be confirmed in the genetic clinic. For people who have a low to moderate risk of developing CRC a faecal occult blood test every year, a colonoscopy every 10 years, a sigmoidoscopy and a contrastive barytic infusion every 5 years is recommended. Recommendations for people at higher risk are different. Persons with hereditary glandular polyposis in the family should have an annual sigmoidoscopy from years of age. In patients with hereditary non-polypoid colorectal cancer in the family, colonoscopy should be performed every 1 2 years starting from years of age or 10 years earlier than the earliest diagnosis of the disease in the family. In the case of inflammatory bowel diseases, colonoscopy should be performed 7 8 years after the diagnosis of the disease and repeated every 2 years [17, 21, 22]. The research conducted so far among the inhabitants of Polish villages shows that their knowledge of colorectal cancer [23] and its prophylaxis [24] is insuffi - cient. The village residents notice diffi culties in accessing preventive examinations and give low marks to the health education conducted in this area [23]. One study also found that 34% of the rural population have low health behaviour rates [25]. Another study on the knowledge of the screening program showed that less than half of the respondents from towns with a population of up to 50,000 have ever heard of the program, and the same number declared that they intend to use it [26]. Aim of the study Analysis of health behaviours of the village dwellers in terms of prevention of colorectal cancer. Material and Methods The research was carried out in February 2018 among the inhabitants of rural areas in the Mokobody commune (Mazowieckie Voivodeship). Participation in the survey was anonymous and voluntary. According to the guidelines of the Bioethical Commission of the Medical University of Warsaw, the consent of this Commission is not required so as to conduct the survey. In order to collect the research material, an original questionnaire was used, consisting of a metric and a scale of health behaviours classified in 5 areas: nutritional behaviours, mental health behaviours, physical activity, stimulants, preventive examinations. The scale of health behaviour included four categories of responses: always or almost always, often, sometimes, never or almost never. The fewer points the respondents received on the scale, the higher the frequency of undertaking health behaviours. The criteria for inclusion in the study were: age above 40 years and no diagnosed colorectal cancer. 165 people took part in the study, 160 questionnaires were qualified for analysis. Statistical analyses were conducted using the PQStat statistical package version The Spearman rank correlation coeffi cient, the Mann- Whitney U test, Friedman U test and the Dunn-Bonforti post-hoc test were used. The test probability at the level of p < 0.05 was considered signifi cant, while the level of p < 0.01 was considered highly signifi cant. In the study group 56.87% were women and 43.13% were men. The mean age of the respondents was 61 (SD = 12.8). The largest group of respondents (49.37%) were people aged 40 59, the smallest group (9.37%) aged 80 or more. The basic vocational education was 38.75%, primary or lower secondary education 35%, secondary education 21.87%, higher education 4.38%. Due to their professional status, the largest group were pensioners (45%). Only 14.37% of the respondents worked in the agricultural holding and outside it, people combining work in the agricultural holding and outside it constituted 13.75% of the respondents, disabled pensioners 11.25% % were overweight, 28.75% obese, 26.87% had healthy body weight. A small percentage of respondents had prophylactic examinations for colorectal cancer. The colonoscopy was performed in 14.37% of respondents, 11.87% of the respondents performed the test for occult blood in faeces, the test for rectum was performed in 10.62% of respondents, the test for genetic predispositions to colorectal cancer was performed in 2.50%. Results Comparing the results obtained in different categories of health behaviours, highly significant (p < 0.01) differences in the frequency of their taking were found. The lowest values were obtained in the category of stimulants (M = 1.79), i.e. in this respect the respondents showed the best health behaviours. The highest values were shown in physical activity (M = 2.86), i.e. these behaviours were implemented the least frequently. Detailed data on particular health behaviours are presented in Table 1. While analysing the influence of selected variables on the frequency of taking up health behaviours in particular categories, a correlation between the frequency of implementation of nutritional behaviours, preventive examinations and use of stimulants and the number of CRC risk factors present in the respondents was found (Table 2). The more risk factors the respondents demonstrated, the less frequently they undertook pro-health dietary behaviours (p = ). Moreover, the more risk factors the respondents had, the worse they presented their health behavior on the drug scale, i.e. the more frequently they used drugs (p < ). Conversely, the more risk factors, the more frequently the respondents 374 POLISH NURSING NR 4 (70) 2018

53 showed health behaviours in the scope of preventive examinations (p = ). Analyses show that the higher education the respondents had, the lower the frequency of implementation of health behaviours in the field of mental health (p = ). On the other hand, they had more frequent prophylactic examinations (p < ). The age of the respondents was important in undertaking health behaviours in the field of stimulants (p = ) and prophylactic examinations (p = ). The older the respondents were, the less they used stimulants, the less they did preventive checkups. Tabela 1. Częstotliwość podejmowanych zachowań zdrowotnych przez mieszkańców wsi Table 1. Frequency of health behaviors undertaken by village dwellers Kategorie zachowań zdrowotnych/ Categories of health behaviors M SD Min. Med. Maks. Zachowania żywieniowe/nutritional behaviors Zdrowie psychiczne/mental health Aktywność fi zyczna/physical activity Używki/Stimulants Badania profi laktyczne/preventive examinations Ogółem/Total M średnia arytmetyczna/mean, SD odchylenie standardowe/ standard deviation, Min minimum/minimum, Med mediana/median, Maks maksimum/maksimum Źródło: opracowanie własne Source: author s own analysis Tabela 2. Korelacje między zachowaniami zdrowotnymi, a wiekiem, wykształceniem i ilością czynników ryzyka Table 2. Correlations between health behaviors and age, education and the number of risk factors Kategorie zachowań zdrowotnych/ Categories of health behaviors Zachowania żywieniowe/ Nutritional behaviors Zdrowie psychiczne/ Mental health Aktywność fi zyczna/ Physical activity Wiek w latach/ Age Poziom wykształcenia/ Level of education Czynniki ryzyka/ Risk factors r p r p r p Używki/Stimulants < Badania profi laktyczne/ Preventive examinations < Ogółem/Total r wartość testu korelacji rang Spearmana/value of the Spearman rank correlation test, p wartość prawdopodobieństwa/ probability value Źródło: opracowanie własne Source: author s own analysis The gender of the respondents is differentiated by frequency of taking up health behaviours in the categories of nutrition, preventive examinations and stimulants (Table 3). Tabela 3. Częstotliwość podejmowania zachowań zdrowotnych wśród mieszkańców wsi w zależności od płci Table 3. Frequency of undertaking health behaviors among village dwellers depending on gender Kategorie zachowań zdrowotnych/ Categories of health behaviors Zachowania żywieniowe/ Nutritional behaviors Zdrowie psychiczne/ Mental health Aktywność fi zyczna/ Physical activity Używki/ Stimulants Badania profi laktyczne/ Preventive examinations Ogółem/Total Płeć/Gender M SD Min. Med. Maks. kobiety/ women mężczyźni/ men Test U Manna- -Whitneya Z= p= kobiety/ women Z= p= mężczyźni/ men kobiety/ women mężczyźni/ men Z= p= kobiety/ women Z= mężczyźni/ men p= kobiety/ women mężczyźni/ men Z= p< kobiety/ women Z= mężczyźni/ men p= M średnia arytmetyczna/mean, SD odchylenie standardowe/ standard deviation, Min minimum/minimum,med mediana/median, Maks maksimum/maksimum, Z wartość testu U Manna-Whitneya/value of the U Manna-Whitneya test, p wartość prawdopodobieństwa/probability value Źródło: opracowanie własne Source: author s own analysis Women signifi cantly more often carry out health behaviours in the field of nutrition (p = ), avoidance of stimulants (p = ), and more frequently carry out health behaviours in the field of preventive examinations (p = ). In general, the frequency of taking up health behaviours in the prevention of CRC is not gender differentiated. Analyzes showed that professionally active people were less likely to avoid stimulants (p = ), while they were more likely to undergo preventive examinations (p = ) (Table 4). In general, the frequency of taking up health behaviours in the prevention of CRC is not professional status differentiated. Health behaviours of the village dwellers in prevention of colorectal cancer 375

54 Tabela 4. Częstotliwość podejmowania zachowań zdrowotnych wśród mieszkańców wsi w zależności od aktywności zawodowej Table 4. Frequency of undertaking health behaviors among village dwellers depending on professional activity Kategorie zachowań zdrowotnych/ categories of health behaviors Zachowanie żywieniowe/ Nutritional behaviors Zdrowie psychiczne/ Mental health Aktywność fi zyczna/ Physical activity Używki/Stimulants Badania profi laktyczne/ Preventive examinations Ogółem/Total Aktywność zawodowa/ Professional activity M SD Min. Med. Maks. Test U Manna-Whitneya aktywny/active Z= nie aktywny/inactive p= aktywny/active Z= nie aktywny/inactive p= aktywny/active Z= nie aktywny/inactive p= aktywny/active Z= nie aktywny/inactive p= aktywny/active Z= nie aktywny/inactive p= aktywny/active Z= nie aktywny/inactive p= M średnia arytmetyczna/mean, SD odchylenie standardowe/standard deviation, Min minimum/minimum, Med mediana/median, Maks maksimum/maksimum, Z wartość testu U Manna-Whitneya/value of the U Manna-Whitneya test, p wartość prawdopodobieństwa/probability value Źródło: opracowanie własne Source: author s own analysis Discussion The aim of the study was to analyze the health behavior of the village residents in terms of prevention of colorectal cancer. Little attention is paid in the literature to research on this subject. In many studies, the evaluation of the level of knowledge about colorectal cancer and its prophylaxis in both rural and urban population was the subject of research [23, 24, 25, 26]. The available studies show that 64.2% of the rural population have a low level of knowledge about colorectal cancer [25]. Moreover, their level of knowledge of colorectal cancer and its prevention is worse than that of city dwellers [24, 25]. Therefore, the question arises whether the village dwellers, having low knowledge of colorectal cancer and its prevention, show low frequency of behaviours aimed at prevention of colorectal cancer. Results of research carried out by Kuprewicz et al. showed a low rate of health behaviours in 34% of the rural population, compared to 25.8% in urban areas, and a low level of knowledge in 58.9% of the respondents, including 53.9% in urban areas and 64.2% in rural areas [25]. According to authors own research, the average frequency of presented health behaviours by the village residents is 2.52 on a scale of 1 4, where the value of 1 means that the researched undertakes given behaviour always or almost always, the value of 4 never or almost never. Respondents therefore show an average rate of health behavioural uptake. In their own research, the village dwellers rarely took up health behaviours related to physical activity, nutrition and prophylactic examinations. Comparing these results to the data obtained in the study by Kuprewicz et al. the results of both studies are consistent as regards the lowest rates of dietary behavioural intake (M = 2.68) and the highest in terms of mental health (M = 2.10). In their own research, the respondents made less use of prophylactic examinations (M = 2.54), avoided smoking more frequently and reduced alcohol consumption (M = c1.79). A low level of physical activity in own surveys may result from the fact that only about 14% of respondents work in an agricultural holding and almost as many combine this work with off-farm work. The specifi c nature of farm work is undoubtedly linked to greater daily physical activity. In the study group there were 57.5% of economically inactive people, including as many as 45% of pensioners. Inactive people may have limited physical activity, not only for health reasons, but also because of limited access to infrastructure to facilitate physical activity in non-household settings. Most respondents have never or hardly ever attended organised physical activity classes. In the research conducted by Markowska et al. respondents with a family history of cancer risk had a better understanding of colorectal cancer compared to other cancer groups. The Commission will continue to monitor the implementation of the Directive to ensure that respondents who did not have such a risk are informed [24]. It results from authors own research that the occurrence of risk factors for CRC varied the health behaviours of the village residents in both positive and negative directions. People with a higher number of risk factors more often took up health behaviours from the prophylactic examination group, and less frequently 376 POLISH NURSING NR 4 (70) 2018

55 from the group of nutritional behaviours and stimulants. This may be due to the fact that it is more diffi cult for the respondents to change their bad eating and drinking habits, but it is easier for them to report for preventive examinations. It should also be mentioned that in the scope of preventive research, the most common behavior was reported by women to the gynaecologist for control visits, while the least frequent was the use of the prevention programme of early detection of CRC in the POZ outpatient clinic. Economic activity can be a factor in taking preventive behaviour. In their own examinations, the active persons showed better results in preventive examinations in comparison to inactive persons, which may be indirectly connected with the necessity of carrying out periodic preventive examinations recommended by the employer. According to Markowska s research, the most knowledgeable respondents about colorectal cancer were also those who were professionally active [24], which may translate into higher frequency of taking prophylactic measures. In their own research, women present signifi cantly better results in 3 out of 5 categories of health behaviours. The influence of gender on taking up health behaviours was also confirmed by the results of research carried out by Kuprewicz et al. Most women have a high level of health behaviour compared to men. Compared to the authors own research, the results also confirmed that men showed more antihealth behaviours with respect to drugs (alcohol consumption and smoking), women signifi cantly more often performed prophylactic examinations and presented better nutritional behaviours [25]. In the studies aimed at determining the knowledge about colorectal cancer, women show greater knowledge and are more willing to perform the studies [25, 26]. According to authors own analyses, a small percentage of the respondents had a colonoscopy, a test for latent blood in faeces and a test per rectum, despite the fact that the study involved people aged over 40, half of them aged 40-60, and another half aged less than 60 years old. As mentioned above, the participation of patients in the colorectal cancer prevention programme was the lowest among the indicated prophylactic studies. In research conducted by various authors, only 50% of the rural population have ever heard of the program [23, 26]. In authors own research, about 30% of the respondents declared that they rather planned to perform preventive examinations this year, 45% did not intend to do so. Such a low declaration of participation in prophylactic examinations may also be related to the low availability of screening tests for the village dwellers indicated by Dmowska-Pycka and Adamiak [23]. and the lack of professional education in cancer prevention. Only 14 22% of the rural population learn about screening from a doctor and a nurse [23, 26]. Low awareness of the possibilities of prophylactic examinations among the rural population and limited availability of such examinations may result from a low number of applications for screening tests. Medical personnel should therefore pay special attention to the rural population in terms of health education in the prevention of colorectal cancer. Conclusions 1. The village dwellers with a higher number of risk factors for colorectal cancer are signifi cantly less likely to implement health behaviours to prevent colorectal cancer. 2. The village residents over 40 years of age have low physical activity in the prevention of colorectal cancer. It is essential to create infrastructure for physical activity in a rural environment. 3. A small percentage of the village residents over 40 years of age perform prophylactic examinations for early detection of colorectal cancer. It is reasonable to create information campaigns for the rural community. 4. Actions promoting health behaviours in prevention of colorectal cancer should be specifi cally addressed to the unemployed rural population, men and elderly people. References 1. Didkowska J, Wojciechowska U. Zachorowania i zgony na nowotwory złośliwe w Polsce. Krajowy Rejestr Nowotworów, Centrum Onkologii Instytut im. Marii Skłodowskiej Curie. Dostępne na stronie dostęp z dnia 10/03/ Didkowska J, Wojciechowska U, Olasek P. Nowotwory złośliwe w Polsce w 2015 roku. Warszawa: Krajowy Rejestr Nowotworów, Zakład Epidemiologii i Prewencji Nowotworów; Didkowska J, Wojciechowska U, Zatoński W. Prognozy zachorowalności i umieralności na wybrane nowotwory złośliwe w Polsce do 2025 roku. Warszawa: Centrum Onkologii Instytut; Haggar FA, Boushey RP. Colorectal cancer epidemiology: incidence, mortality, survival, and risk factors. 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56 8. Król SK, Kapka-Skrzypczak L. Nowotwory jelita grubego jako poważny problem w Polsce i na świecie kwestie medyczne i środowiskowe. Med Środow. 2011; 14 (4): Klimczak A, Kubiak K, Cybulska M, Kula A, Dziki Ł, Malinowska K. Etiologia raka jelita grubego oraz bariera antyoksydacyjna ustroju. Pol Merk Lek. 2010; XXVIII (165): Amarowicz M, Urbańczuk M, Schab K. Wpływ cukrzycy na wzrost ryzyka występowania choroby nowotworowej. W: Zdunek B, Olszówka M (red.). Najnowsze badania z zakresu chorób nowotworowych. Lublin: Wydawnictwo Naukowe TYGIEL; 2016: Adamowicz K, Wrotkowska M, Zaucha JM. Związek częstości występowania raka jelita grubego z BMI. Przegl Epidemiol. 2015; 69: Wei PL, Lin SY, Chang YJ. Cigarette smoking and colorectal cancer: from epidemiology to bench. J Exp Clin Med. 2011; 3(6): Kałędkiewicz E, Doboszyńska A. Dietoprofilaktyka raka jelita grubego. Onkol Prak. Klin. 2012; 8, 5: Matykiewicz, Głuszek J. Cukrzyca typu 2 a nowotwory. Stud Med. 2009; 15: Peeters PJHL, Bazelier MT, Leufkens HGM, Vries F, Bruin ML. The risk of colorectal cancer in patients with type 2 diabetes: associations with treatment stage and obesity. Diabetes Care. 2015; 38: Zandonai AP, Sonobe HM, Sawada NO. The dietary risk factors for colorectal cancer related to meat consumption. Rev Esc Enferm USP. 2012; 46(1): Siepsiak M, Połom A, Adrych K. Profilaktyka raka jelita grubego. Farm Współ. 2015; 8: Wu S, Feng Bi, Li Kai, Zhu X, Liang S, Liu X et al. Fish consumption and colorectal cancer risk in humans: a systematic review and meta-analysis. The American Journal of Medicine. 2012; 6(125): Gałaś A, Sochacka-Tatara E, Augustyniak M, Jan Kulig J, Jędrychowski W. Podaż wapnia i fosforu w etiologii raka jelita grubego badania krakowskie. Probl Hig Epidemiol. 2013; 94(1): Gilbert A, Czarkowska-Pączek B, Deptała A. Wysiłek fizyczny w prewencji i leczeniu raka jelita grubego. Prz Lek. 2013; 70(11): Burt RW, Barthel JS, Dunn KB, David DS, Drelichman E, Ford JM. NCCN clinical practice guidelines in oncology. Colorectal cancer screening. J Natl Compr Canc Netw. 2010; 8(1): Ministerstwo Zdrowia. Profilaktyka raka jelita grubego. Dostępne na stronie narodowy-program-zwalczania-chorob-nowotworowych/profilaktyka-raka-jelita-grubego/ dostęp z dnia 26/02/ Dmowska-Pycka A, Adamiak K. Wiedza mieszkańców wsi na temat raka jelita grubego. Pielęg XXI w. 2015; 1(50): Markowska A, Górka J, Grochans E, Szkup M. Ocena wiedzy wybranych grup społecznych na temat profilaktyki raka jelita grubego. Medycyna Ogólna i Nauki o Zdrowiu. 2016; 22(4): Kuprewicz A, Krajewska-Kułak E, Trochimowicz L. Wiedza na temat raka jelita grubego i preferowane zachowania zdrowotne mieszkańców miasta i wsi. Pielęg Chir Angiol. 2016; 2: Janiak M, Głowacka P, Kopeć A, Staśkiewicz A. Czynniki determinujące zgłaszalność na badania kolonoskopowe w Programie Badań Przesiewowych raka jelita grubego w Polsce. Gastroenterol Klin. 2016; 8(4): The manuscript accepted for editing: The manuscript accepted for publication: Funding Sources: This study was not supported. Confl ict of interest: The authors have no confl ict of interest to declare. Address for correspondence: Arleta Teresa Gromada Erazma Ciołka Warszawa phone: (0-22) arletagromada07@gmail.com Social Nursing Department, Medical University of Warsaw, Poland 378 POLISH NURSING NR 4 (70) 2018

57 Copyright Poznan University of Medical Sciences THE PROBLEM OF SEXUALLY ABUSED CHILDREN INCLUDING DISABLED CHILDREN ASPECTS OF MEDICAL AND NURSING CARE PROBLEM DZIECI WYKORZYSTYWANYCH SEKSUALNIE Z UWZGLĘDNIENIEM DZIECI NIEPEŁNOSPRAWNYCH ASPEKTY OPIEKI LEKARSKIEJ I PIELĘGNIARSKIEJ Grażyna Jarząbek-Bielecka 1, Dariusz Radomski 2, Małgorzata Mizgier 3, Małgorzata Grys 4, Ewa Jakubek 5 1 Division of Developmental Gynecology and Sexology, Department of Perinatology and Gynecology, Poznan University of Medical Sciences 2 Rad-Dar-Med, Poland 3 Poznan University of Physical Education, Department of Morphological and Health Sciences, Dietetic Division, Faculty of Physical Culture in Gorzów Wlkp. 4 Warsaw University of Technology, Division of Nuclear and Medical Electronics 5 Department of Law, Organization and Management in Healthcare, Poznan University of Medical Sciences DOI: ABSTRACT The problem of sexually abused children, including children with disabilities, is an important issue in both gynecology and sexology of developmental age. Medical assistance to victims of sexual violence, especially children including children with disabilities, comprises not only the correct medical care of injuries but also all other activities that accompany the performance of treatment to reduce the psychological trauma caused by sexual abuse. This paper presents symptoms of sexual violence against children, its consequences as well as rules of a medical examination of a disabled child a victim of sexual violence. KEYWORDS: sexually abused children, disabled children. STRESZCZENIE Problem dzieci wykorzystywanych seksualnie, w tym dzieci niepełnosprawnych, jest ważną kwestią zarówno w ginekologii, jak i w seksuologii wieku rozwojowego. Pomoc medyczna ofi arom przemocy seksualnej, w szczególności dzieciom w tym dzieciom niepełnosprawnym, obejmuje nie tylko właściwą opiekę medyczną nad urazami, ale także wszystkie inne czynności towarzyszące wykonywaniu leczenia w celu ograniczenia urazów psychicznych spowodowanych wykorzystywaniem seksualnym. W artykule przedstawiono objawy przemocy seksualnej wobec dzieci, jej konsekwencje oraz zasady badania lekarskiego niepełnosprawnego dziecka ofi ary przemocy seksualnej. SŁOWA KLUCZOWE: dzieci wykorzystywane seksualnie, dzieci niepełnosprawne. Taking care of a child is the fi rst and fundamental test of human to human relation. Pope, John Paul II Introduction Both in gynecology and sexology of the developmental age in terms of the problem of sexual offenses against children, concern is expressed in a particular and specifi c manner, and the problem is even more diffi cult if victims of sexual violence are children with disabilities. Care for children, including children with disabilities who are victims of sexual violence, requires a specialized, specifi c, fully empathic and professional approach. According to Professor Imieliński, one should leave as much freedom as possible in expressing and satisfying one s needs, if it does not negatively affect the development of another human being or society [1]. The pedophile actions are harmful in this aspect of expressing and satisfying one s sexual needs [2 7]. Often the victims of sexual offenders are people with disabilities. For pedophiles, they are particularly easydefense victims [3, 7 8]. Authors of many reports on sexual violence against children emphasize the fact that the majority of such cases are not due to various complex issues revealed by both children and their caregivers. This applies especially to children with disabilities, both somatically and intellectually. In the opinion of the perpetrators, their deeds will not come to light. It is important in medical practice to know not only somatic POLISH NURSING 4 (70) 2018 REVIEW PAPER 379

58 symptoms, but also changes in the child s behavior that may indicate sexual harassment [2 6]. The first diagnostic step is a professional interview. In the case of intellectually disabled children, the interview with the child is unfortunately very diffi cult or even impossible. However, you should always make such an attempt. Most often, the source of information about these acts of sexual abuse are the victims themselves; however, in the case of children with disabilities, it is not easy to read the information properly. Children in general rarely speak directly about the fact that someone uses them sexually. Symptoms depend on the duration of abuse, relationships with the perpetrator, type of sexual activity, as well as factors related to the development of the child, in the case of children with disabilities with the type of disability. They can be divided into three groups: symptoms concerning the child s behavior, his emotions and the sexual sphere. There are many reasons why children hide harassment. They are often intimidated, forced to be silent by bribery or blackmail, they are afraid of rejection on the part of their parents, they also have a sense of their separateness, feel inferior, often are unaware that sexual actions taken by the perpetrator are unacceptable and outlawed the problem is even more complicated for disabled children. A separate problem is connected with the symptoms that may indicate the sexual abuse of a child. If they occur in the form of physical injuries, then most likely they will be able to be diagnosed only by medical services. They are often noticed during nursing care of a disabled child. Acute somatic symptoms requiring rapid medical intervention are e.g. external and internal genital injuries vulvae area, perineum: midline crotch fracture, which may extend from the vaginal mucosa to the rectal mucosa (vulvae vestibule and rectum as one traumatic cavity) [4-7]. The classification of the symptoms of sexual violence against children I. Acute (immediate medical intervention required): 1. Injuries of external and internal genital organs: vulvae area, perineum: midline crotch fracture, which may extend from the vaginal mucosa to the rectal mucosa (vulvae vestibule and rectum as one post-traumatic cavity); hematoma within the hymen (made with the finger are smaller); damage to the anal area: bruising, anal fissures reaching the surrounding skin. 2. Damage to other parts of the body: the lips and oral cavity (bruises and bloody petechiae on the palate), lower and upper limbs. 3. Bite wounds. 4. Genital ulcers and wounds caused by sexually transmitted diseases (STDs). Acute somatic symptoms are usually infected wounds with uneven edges, massed and bruised. The important thing is that if the child is afraid to say in what circumstances the injuries have occurred and the person reporting with the child wants to conceal the truth (e.g. the mother knows the perpetrator and wants to protect him), the circumstances of the injuries given by the mother or child are incoherent or unlikely:... fell on a frame from a bicycle, a clotheshorse, a table edge, a tree branch, etc.... II. Chronic: 1. Leading are psycho-emotional disorders. 2. Calm and confi dent behavior of the child during the gynecological examination (this attitude should arouse suspicions of the gynecologist, because the non-abused child is usually afraid of the examination). 3. Loss of hymen (location of changes can be described in terms of reference to clock hands on the dial): lack of hymen below the hypothetical horizontal line between 3 o clock and 6 o clock, loss or healed crack, most often at Permanent dilation of the anus to diameter > 1.5 cm. In the general and gynecological examination in 50 90% of patients we do not find any changes, which results from a different way of sexual abuse of a child, e.g. sexual intercourse, oral relations. Even after 3 months after vaginal intercourse there may not remain visible traces. III. Certain, direct: 1. Pregnancy. 2. Sexually transmitted disease (STD). 3. Semen in the vagina. 4. Someone else s hair, blood, saliva, epidermal cells (in the vagina, in the oral cavity, underneath the nails of the victim) confirmed by molecular DNA analysis. IV. Unjustified, doubtful, confusing inexperienced doctor A register of possible behaviors of the child associated with sexual violence has been constructed (also in the case of disabled victims of sexual violence in childhood changes in their behavior are observed). They are: 1. Sleep disorders, nightmares and fears. 380 POLISH NURSING NR 4 (70) 2018

59 Incomprehensible appearance of somatic complaints, such as abdominal pain, headache, vomiting, nausea. Anxiety, fear, phobias. Isolation, closing in on oneself. Regressive behavior, such as crying, persistent adherence to parents. Hyperactivity, masturbation. Learning problems, conflicts at school, unwillingness to do homework. Depression, melancholy, sadness, suicide attempts. Fears suddenly revealed to the parent of a given sex. Sudden and unexpected interest in sex, own and others body, sexual life of parents and other people. Medical examination of a child with disability In the medical examination of a child with disability a victim of sexual violence, a nurse specifi cally trained for such cases should participate. Foundations and principles of a physical examination: 1. Examination of the general condition of the child in terms of other currently occurring diseases, taking into account the type of disability: whole body skin screening, palpation of the head, lung and heart auscultation, etc. 2. During the examination, an attempt should be made to establish contact as much as the child s incompetence allows one should try to minimize the fear associated with the examination. 3. Symptoms related to sexual violence should first be sought in other parts of the body than the genitals. 4. Genital examination is performed at the end. Regardless of the type and degree of disability, an attempt should be made to explain the purpose of the examination to the child, put on the gynecological chair or on the couch depending on the type of disability (a trained nurse assisting in the examination helps in proper placement of the child) [2, 4 7]. Among girls with spastic paralysis, the big problem is placing the lower limbs on the footrests or loosening the perineal muscles enabling the examination. The solution to these limitations is to carry out a test on a chair or a trolley in positions known in obstetrics and gynecology. The recommended position is the diamond shaped position, which does not require opening the feet, or the M-shape position. In extreme situations with increased spasticity, a knee-chest position should be used. Unfortunately, this position prevents full evaluation of the vaginal portion of the cervix in the sight glass. An examination of a disabled girl may require much more time, especially a disabled girl who is a victim of sexual violence. Both in patients with cerebral palsy and in some patients with nerve root injury, the relaxation time are considerably extended. In the absence of a twohanded test, the only method remains the ultrasound examination of the abdominal wall. Some authors also consider the possibility of examining these patients under anesthesia. Others suggest using relaxation techniques in the examination of girls with increased spastic tension, but there is no evidence for the effectiveness of this technique. Recommended positions of the gynecological examination of girls with physical disabilities are: knee-chest position the patient lies on the side of the table; legs flexed toward the abdomen/chest, the top leg is raised by the midwife; the inner leg is pushed to the back. This position allows a limited palpation examination; in particular the posterior wall and posterior vaginal vault are available. Unfortunately, this position prevents full and thorough expertise of the vaginal portion of the cervix in the sight glass. It is highly recommended in extreme situations with increased spasticity. diamond-shaped position the patient lies on her back with her knees bent so that both legs are spread flat and her heels meet at the foot of the table; legs bent form the shape of a rhombus. It is the recommended position for patients with limited mobility in the hip joint. M-shaped position the patient lies on her back, knees bent and apart, feet resting on the exam table close to her buttocks. After the legs are positioned letter M is shaped which resembles the classic position of the gynecological examination. Recommended for patients with moderate leg paresis. V-shaped position the patient lies on her back with her straightened legs spread out wide to either side of the table. It is the recommended position when examining on the wheelchair. The mother of the disabled child should participate in the examination; she is asked to stand close to child s head and hold her hand. Often, however, children with disabilities remain without their parents or legal guardians [2, 3, 8]. An important stage of a gynecological examination in which a trained nurse is necessary is to watch the skin: abdomen, medial compartment of thighs, buttocks, anus, crotch, labia majora, and mucous mem- The problem of sexually abused children including disabled children aspects of medical and nursing care 381

60 brane: rectal, clitoral, labia minora, hymen and vaginal walls. The examination should be carried out gently using heated (!) vaginal speculum, bi-valve and pediatric ones (No. 1, No. 2) tools are prepared and given by a trained nurse. The vagina can be seen in the colposcope, using a magnifying glass, an immunofluorescent lamp (examination for the presence of semen). It is important to wipe the mucous membranes and skin with a 1% solution of toluidine blue to detect microinjury (an invisible symptom after 48 hours). A trained nurse assists in smear tests (carefully, without touching the hymen s ring) and other possible places of contact with the semen. During this procedure, you can give the child to hold cotton brushes used to collect the samples it reduces his anxiety, improves mood. In the course of the examination, it is worth taking pictures that should be attached to the medical documentation. In fresh extensive lesions and wounds, the examination according to the principles of 1 5 may be impossible, and then the examination is carried out under general anesthesia in the operating room, using specialized equipment (vaginoscope, cystoscope or ophthalmoscope). In clinics of the child and teen gynecology as well at the hospital emergency room a kit for the examination of rape victims should be available. Consequences of sexual violence against children Obvious consequences of sexual violence against children are, as mentioned, bodily injuries, such as: urinarygenital tract infections, injuries of external sexual organs such as redness, painfulness, abdominal pain and many more. More severe, however, are the psychological effects than physical injuries this problem is particularly complicated among children with disabilities who are victims of sexual offenses. Profound, adverse changes in the child s psyche arise because of the disability itself, and this is due to the special type of trauma that is sexual harassment. Another aspect of this case is the fact that the child is usually hurt by the person known to him, sometimes close to whom the child is dependent and whom he loves. Among girls and boys sexually abused, there is a regression to the earlier stage of development, inhibition, anxiety, phobias, and sense of guilt, shame, helplessness, harm and deepening the feeling of otherness, which often results from the fact of disability. Children can react with fear to some places, have memory gaps. Their reactions are often inadequate to the strength of the stimulus. There may be aggression, crying, fits of rage, hyperactivity, and concentration and memory disorders. Sometimes these children wet, and not only at night, they self-mutilate and make suicide attempts. They also have nightmares or diffi culties in falling asleep, they complain about various types of pain and general fatigue [2, 4 7]. Depending on the degree and type of disability of a child who is a victim of sexual violence, one can observe inadequate to child s age sexualization of character play, the use of vocabulary of the sexual context, touching genitals and other people or unwillingness to undress or hypersensitivity to touch. The most frequently recognized sexual violence with physical contact includes, i.e.: touching, kissing or caressing the child s intimate places, rubbing against a child, masturbating in his presence, penetration of the child s genital organs (also with the help of a finger or objects), forcing a child to do it in the presence of the perpetrator and rapes. Things are less often diagnosed when a parent is constantly sleeping with a child (who is no longer an infant) in one bed (often naked) or bathing a child in order to get his own sexual pleasure. There are mothers who for fun or nursing touch the intimate places of their sons and fathers, uncles, grandparents or grandmothers, who, laughing, touch the breasts or buttocks of adolescent girls. A child sexually abused not necessarily has to be touched. Sexual violence without physical contact refers, among others, to exposing yourself in the presence of a child, walking naked at home, peeping a child in a room while changing clothes or in a bathroom while bathing, forcing him to watch sexual intercourses, showing newspapers and pornographic films or allowing them to watch them. On the other hand, emotional sexual violence includes for example: vulgar calling of the child, excessive attention to the sexual aspects of his body, telling him about own sexual contacts with other adults, arranging meetings where people talk about sex in the presence of children. All these behaviors are unlawful, unsuitable for the child and must be banished immediately. Sexual violence cannot be observed directly unless someone (i.e. a nurse or doctor) notices that there has been mechanical damage to the reproductive organs; unnatural redness of the vagina or anus; there are bleedings and the discharge from the vagina or damage to the anal sphincter muscles, causing involuntary fecal contamination, the child may have frequent and long constipation without a clear medical reason. Disconcerting may be very frequent urination caused by mental tension and irritation of the urethra and constantly re- 382 POLISH NURSING NR 4 (70) 2018

61 peated urinary tract infections. In addition, a child may have a genital infection or a sexually transmitted disease, and a girl under 15 may be pregnant [2, 4 7, 9]. Children affected by sexual violence can be cruel to animals, steal and tell lies, take drugs, abuse alcohol, more often than other children flee from school. For girls, eating disorders are typical. Young people are suddenly disturbingly overweight or overly tying, becoming addicted to sweets. This serves to reduce your physical attractiveness, although for the perpetrator the appearance of the child is usually irrelevant. The most common eating disorders include anorexia nervosa and bulimia nervosa (usually called simply anorexia and bulimia ). This is a very important problem in the aspect of gynecology of the developmental age, which should also be taken into account in the case of children used sexually [10]. Summary To summarize, sexual violence imposes a mark on the child, even if it does not seem to be so, because no obvious external symptoms are observed (in children with disabilities this is diffi cult). It should be emphasized that among children who are victims of sexual abuse are (and this is a group of special risk) children with disabilities. Sexual violence is the most serious form of child abuse. Medical assistance to victims of sexual violence, especially children including children with disabilities, comprises not only the correct medical care of injuries but also all other activities that accompany the performance of treatments to reduce the mental trauma caused by sexual abuse [2, 5 9]. References 1. Imieliński K. Erotyzm, Warszawa Marzec-Holka K. Przemoc seksualna wobec dziecka: studium pedagogiczno-kryminologiczne, Wydawnictwo Uczelniane WSP, Bydgoszcz 1997: Jarząbek-Bielecka G, Radomski D, Bielecki M. O opiece ginekologicznej i seksuologicznej nad pacjentką niepełnosprawną (z uwzględnieniem poradnictwa aptekarskiego). W: Nauka o płci. Zagadnienia wybrane. Pod red. Grażyny Jarząbek-Bieleckiej. Poznań, Łabęcka M, Jarząbek-Bielecka G, Lorkiewicz-Muszyńska D. Przestępstwa seksualne wybrane przypadki. Sexual offences selected cases. Ginek. Pol. 2013; 84, 4: Sowińska-Przepiera E, Andrysiak-Mamos E, Jarząbek-Bielecka G, Walkowiak A, Syrenicz A. Wykorzystywanie seksualne dziewcząt [-] aspekty medyczne, prawne i etyczne. Sexual abuse of girls [-] aspects of medical, legal and ethical. Klin. Pediat. 2014: Vol. 22, [zesz. spec.] Algorytmy w pediatrii: Sowińska-Przepiera E, Jarząbek-Bielecka G, Andrysiak- Mamos E, Syrenicz A, Friebe Z, Kędzia W, Pawlaczyk M. Wybrane aspekty prawne w ginekologii wieku rozwojowego. Legal aspects in pediatric and adolescent gynecology, Ginek. Pol. 2013; 84, 2: Jarząbek-Bielecka G. Seksuologia a etyka seksualna i problem przemocy seksualnej wobec dzieci, Wydawnictwo UMP. 8. Radomski D, Jarząbek-Bielecka G, Sowińska-Przepiera E, Milewczyk P. Problem opieki ginekologicznej nad dziewczętami i kobietami niepełnosprawnymi. Ginek. Prakt. 2010; 18, 2: Grys E, Bieś Z, Jarząbek G, Grys M, Sowińska E, Paczkowska A. Medyczny, psychologiczno-pedagogiczny aspekt opieki nad młodzieżą w Pracowni Ginekologii Wieku Rozwojowego i Seksuologii, Pol. Prz. Nauk Zdr. 2007; 3 (12): Jarząbek-Bielecka G, Mizgier M. Zaburzenia odżywiania jako problem ginekologii wieku rozwojowego. Nowiny Lekarskie 2009; 78: 3 4, The manuscript accepted for editing: The manuscript accepted for publication: Funding Sources: This study was not supported. Confl ict of interest: The authors have no confl ict of interest to declare. Address for correspondence: Ewa Jakubek Smoluchowskiego Poznan phone: ejakubek@ump.edu.pl Department of Law, Organization and Management in Healthcare, Poznan University of Medical Sciences The problem of sexually abused children including disabled children aspects of medical and nursing care 383

62 Copyright Poznan University of Medical Sciences Recenzenci Pielęgniarstwa Polskiego w roku 2017 dr hab. Agnieszka Bień, Uniwersytet Medyczny w Lublinie (Polska) dr Aleksandra Gutysz-Wojnicka, Uniwersytet Warmińsko-Mazurski w Olsztynie (Polska) dr Tomasz Guzel, Warszawski Uniwersytet Medyczny (Polska) dr Renata Jabłońska, Collegium Medicum w Bydgoszczy, Uniwersytet Mikołaja Kopernika w Toruniu (Polska) dr Mariusz Jaworski, Warszawski Uniwersytet Medyczny (Polska) dr Bożena Kulesza-Brończyk, Uniwersytet Medyczny w Białymstoku (Polska) dr Anna Majda, Uniwersytet Jagielloński (Polska) dr Wioletta Mędrzycka-Dąbrowska, Gdański Uniwersytet Medyczny (Polska) dr Mariusz Panczyk, Warszawski Uniwersytet Medyczny (Polska) dr Małgorzata Posłuszna-Lamperska, Uniwersytet Medyczny im. Karola Marcinkowskiego w Poznaniu (Polska) dr Dorota Rębak, Uniwersytet Jana Kochanowskiego w Kielcach (Polska) dr Bogusław Stelcer, Uniwersytet Medyczny im. Karola Marcinkowskiego w Poznaniu (Polska) dr Magda Strugała, Uniwersytet Medyczny im. Karola Marcinkowskiego w Poznaniu (Polska) dr Barbara Tamowicz, Uniwersytet Medyczny im. Karola Marcinkowskiego w Poznaniu (Polska) dr Joanna Zdanowska, Uniwersytet Medyczny im. Karola Marcinkowskiego w Poznaniu (Polska) dr hab. Jakub Żurawski, Uniwersytet Medyczny im. Karola Marcinkowskiego w Poznaniu (Polska) 384 POLISH NURSING NR 4 (70) 2018 INFORMATION

63 Copyright Poznan University of Medical Sciences WSKAZÓWKI DLA AUTORÓW GUIDANCE FOR AUTHORS WSTĘP Informacje dla autorów Pielęgniarstwo Polskie jest kwartalnikiem. Zamieszcza recenzowane prace oryginalne, poglądowe i kazuistyczne oraz recenzje książek, sprawozdania ze zjazdów naukowych, notatki kronikarskie, wspomnienia pośmiertne itp. napisane w języku polskim oraz angielskim. Czasopismo ukazuje się w papierowej wersji pierwotnej oraz w wersji elektronicznej w systemie open- -access na stronie internetowej edu.pl/. Siedziba redakcji czasopisma mieści się w Katedrze Pielęgniarstwa Uniwersytetu Medycznego im. Karola Marcinkowskiego, ul. Mariana Smoluchowskiego 11, Poznań. Zgłoszenia prac Prace należy przesyłać drogą elektroniczną poprzez internetowy system redakcyjny przetwarzania prac Open Journal Systems (OJS), dostępny w zakładce zgłaszanie manuskryptów on-line. Pracę należy wprowadzić do systemu zgodnie z instrukcją, po uprzednim zalogowaniu się lub zarejestrowaniu w przypadku braku swojego konta w systemie. W procesie zgłaszania pracy w systemie OJS należy pamiętać o wprowadzeniu danych: imię i nazwisko wszystkich autorów z afiliacją (skorzystać z opcji dodać autora ), skan wypełnionego druku Oświadczenia autorów w pliku pomocniczym systemu edytorskiego. Wzór oświadczenia dostępny jest na: oswiadczenie.doc, adres autora, do którego będzie kierowana korespondencja. Adres należy wpisać wyłącznie w biogramie pod afiliacją wybranego autora. Należy podać: imię i nazwisko, pełny adres (ulica, kod, miejscowość), numer telefonu (służbowy), , afiliację autora. Przygotowanie manuskryptu Tekst powinien być napisany 12-punktową czcionką Times New Roman, z odstępem między wierszami 1,5 (półtora odstępu), 2,5 cm marginesem z każdej strony, bez sformatowania, tj. bez twardych spacji, znaków końca linii, przy użyciu tzw. miękkich enterów. Powinien być wyjustowany (wyrównany do lewego i prawego marginesu). Należy pisać zwykłą czcionką w kolorze jednolicie czarnym (dopuszcza się wytłuszczenie tytułów i podtytułów), bez wyróżnień dużymi literami, bez rozstrzelania, podkreśleń linią ciągłą itp. W liczbach miejsca dziesiętne należy oddzielać przecinkami (nie kropkami). Akapity należy rozpoczynać wcięciem przy użyciu odpowiedniego polecenia w edytorze tekstu (bez używania tzw. enterów). Przed zapisem z tekstu należy usunąć wszystkie zaznaczenia używane podczas redagowania tekstu w edytorze. Prace w języku angielskim powinny być napisane poprawną angielszczyzną. Plik należy zapisać w formacie: DOC lub DOCX. Kolejne strony należy ponumerować, zaczynając od strony tytułowej. Praca powinna zawierać, w kolejności: stronę tytułową, streszczenie w języku polskim i angielskim, słowa kluczowe w języku polskim i angielskim, manuskrypt wraz z tabelami, rycinami, fotografiami, piśmiennictwo wg stylu Vancouver, informację o źródłach finansowania i konflikcie interesów. Strona tytułowa Zawiera tytuł pracy w języku polskim i angielskim. W tytule nie należy zamieszczać skrótów. Prosimy o niepodawanie danych dotyczących nazwisk autorów i ich afiliacji ze względu na anonimowość recenzji. Strona druga Zawiera streszczenie w języku polskim i angielskim. Streszczenie w pracach oryginalnych powinno mieć charakter struk- INTRODUCTION Information for authors Pielęgniarstwo Polskie ( Polish Nursing ) is a quarterly. It prints reviewed original research, opinion articles and case studies, book reviews, conference reports, notes on events, obituaries, etc. in both Polish and English. Pielęgniarstwo Polskie ( Polish Nursing ) is published in the open-access on the following website: The editorial office is located in the Chair of Nursing, Poznan University of Medical Sciences, Smoluchowskiego 11, Poznan. Paper submission Papers should be submitted electronically via the editorial journal processing system Open Journal Systems (OJS), available in submission of manuscripts on-line. The paper should be entered into the system in accordance with the instructions, after logging in or registering if you are new to the system. When submitting papers in the OJS be sure to enter the following data: all authors first names and surnames with affiliation (use the option add the author ), the completed scanned form of Authors declarations in the auxiliary file of the editorial system. The model declaration is available on: oswiadczenie.doc, the corresponding author s address. The address should be entered only in the biographical note under the affiliation of the author in question. Please provide: name, full address (street, post code, town), office telephone number, address, author s affiliation. Manuscript preparation The text should be written with 12 spot font Times New Roman, with the space between the lines 1.5 (one and a half space), 2.5 cm margin from every side, without editing, i.e. without hard spaces, end of the line signs (so-called soft enters). It should be justified (balanced to the left and right-hand margins). One should write with an ordinary font in black exclusively (greased titles and subtitles are possible), without upper case distinctions, spacing out or underlining with the solid line, etc. In numbers, decimals should be separated by commas (not dots). Paragraphs should begin indented using the appropriate commands in a text editor (without using the so-called breaks between). Before saving, one must remove all selections used when editing the text. Papers in English should be written in the correct English language. The file should be saved in the format: DOC or DOCX. Pages should be numbered, starting with the title page. The paper should include, in order: title page, abstract in Polish and English, key words in Polish and English, manuscript with tables, figures and photographs, literature prepared in accordance with the Vancouver style, information on sources of funding and conflict of interest. Title page It includes the paper title in Polish and in English. The title should not contain abbreviations. Please, do not include authors names and affiliations due to review anonymity. Second page: It contains abstracts in Polish and in English. The abstract of original papers should be structural it should contain: Intro- POLISH NURSING NR 4 (70) 2018 INFORMATION 385

64 Copyright Poznan University of Medical Sciences turalny zawierać: Wstęp, Cel, Materiał i metody, Wyniki, Wnioski; w przypadku prac kazuistycznych Wprowadzenie, Cel, Opis przypadku, Wnioski; w przypadku prac poglądowych Wstęp, Podsumowanie kolejnych rozdziałów, Podsumowanie/Wnioski. Streszczenie (w języku polskim oraz angielskim) powinno zawierać nie więcej niż 250 słów. Należy unikać skrótów, a w przypadku ich użycia podać wyjaśnienie przy pierwszym zastosowaniu. Pod streszczeniem należy umieścić słowa kluczowe nie więcej niż pięć w języku polskim i angielskim, spośród wymienionych w Medical Subject Headings (MeSH). Strona trzecia i kolejne Powinny zawierać zasadniczy tekst pracy. PRACA ORYGINALNA Praca w tej kategorii przedstawia wyniki oryginalnych badań przeprowadzonych w dziedzinach zgodnych z obszarem zainteresowań czasopisma (zob. Wstęp). Konstrukcja tekstu powinna być następująca: Wprowadzenie powinno zawierać syntetycznie ujętą podstawę teoretyczną i empiryczną badania wraz z jego uzasadnieniem, bez szczegółowego, obszernego przeglądu literatury i wcześniejszych badań. Cel pracy powinien być jasno określony i nawiązywać do informacji podanych we Wprowadzeniu. Materiał opis powinien być na tyle szczegółowy, aby możliwa była replikacja badania. Metody opis powinien być na tyle szczegółowy, aby możliwa była replikacja badania. W przypadku stosowania wcześniej opublikowanych metod i narzędzi badawczych należy podać stosowne przypisy bibliograficzne. Wyniki powinny być przedstawione w sposób jasny i zwięzły, bez szczegółowego powtarzania informacji zawartych w tabelach i rycinach. Dyskusja powinna podkreślać znacznie wyników badań własnych w kontekście literatury przedmiotu. Nie powinna powtarzać wyników ani zastępować przeglądu piśmiennictwa. Wnioski powinny mieć uzasadnienie w przeprowadzonym badaniu. Tekst pracy nie powinien przekraczać 6 tys. słów, tj. ok stron (łącznie z tabelami, rycinami i Piśmiennictwem). Piśmiennictwo nie powinno przekraczać 25 pozycji. Należy podać informację o zgodzie właściwej komisji bioetycznej na przeprowadzenie badania (w części Materiał lub Metody). PRACA POGLĄDOWA Prace w tej kategorii dotyczą przeglądu wiedzy na temat ważnych zagadnień, istotnych odkryć w zakresie pielęgniarstwa i dziedzinach pokrewnych. Układ publikacji poglądowej różni się od publikacji oryginalnej brakiem opisu przeprowadzonych badań, a zamiast dyskusji wyników zawiera kolejne rozdziały stanowiące główną część pracy (np. zestawione z sobą wnioski z innych publikacji). Zalecany jest podział tekstu na rozdziały opatrzone zwięzłymi tytułami i/lub śródtytułami. Podsumowanie/Wnioski zawierają własne przemyślenia wynikające z przeprowadzonego przeglądu piśmiennictwa opisanego w poszczególnych rozdziałach pracy. Objętość pracy nie może przekraczać 6 tys. słów, tj. ok stron (łącznie z Piśmiennictwem). Piśmiennictwo nie powinno przekraczać 40 pozycji. PRACA KAZUISTYCZNA Praca kazuistyczna opisuje jeden lub więcej interesujących, rzadkich przypadków. Praca powinna mieć następujący układ: Wprowadzenie, Opis przypadku, Dyskusja. Objętość nie może przekraczać 2,5 tys. słów, tj. ok. 3 4 stron (łącznie z Piśmiennictwem). duction, Aim, Material and methods, Results and conclusions; in case studies Introduction, Aim, Case, Conclusions; in review papers Introduction, Summary of each chapter, Summary/Conclusions. The abstract (in Polish and English) should contain no more than 250 words. Abbreviations should be avoided, and when used, the explanation of the first application should be given. Under the abstract key words should be included not more than 5 in Polish and English, from among those listed in the Medical Subject Headings (MeSH). Third and next pages They should contain the main text of the paper. ORIGINAL PAPER The original paper presents results of original investigations conducted in the field of nursery and medicine in general (see Introduction). The paper should be divided into: Introduction it should contain a synthetically recognized theoretical and empirical framework of the research along with its justification, without a detailed, comprehensive literature review and previous studies. Aim it should be clearly defined and should refer to the information included in the Introduction Material the description should be sufficiently detailed to allow for the study replication Methods the description should be sufficiently detailed to allow for the study replication. When using previously published methods and research tools, provide the appropriate bibliographical references. Results they should be presented in a clear and concise way, without a detailed repetition of the information contained in tables and figures. Discussion it should emphasize the importance of one s own research results in the context of literature. It should not repeat results or replace the literature review. Conclusions they should be justified in the research carried out. The text should not exceed 6000 words, i.e. about pages (including tables, figures and References). References should not exceed 25 items. Please provide information on the approval of conducting the research by the relevant bioethics committee (in Material or Methods). OPINION ARTICLE Opinion articles concern fundamental findings in the field of nursery and medicine in general. The opinion article structure is different from the original paper in the lack of the conducted study description and, instead of Discussion, it contains subsequent chapters constituting the main part of the paper (e.g. summarized conclusions from other publications). It is recommended to divide the text into chapters with concise titles and/ or subtitles. Summary/Conclusions contain authors own reflections resulting from the literature review, as described in separate chapters of the paper. The text should not exceed 6000 words, i.e. about pages (including References). CASE STUDY The case study presents one or more interesting rare cases or clinical conditions. The paper should be divided into: Introduction, Case description and Discussion. The text should not exceed 2500 words, i.e. about 3 4 pages (including References). 386 POLISH NURSING NR 4 (70) 2018 INFORMATION

65 Copyright Poznan University of Medical Sciences PODSUMOWANIA ZJAZDÓW I INNE TEKSTY INFORMACYJNE (por. Wstęp) Artykuły w tej kategorii nie powinny przekraczać 1 1,5 tys. słów (2 strony). PIŚMIENNICTWO Piśmiennictwo powinno być napisane na oddzielnej stronie, wg standardu Vancouver. Należy podawać tylko pozycje związane z tematem pracy i uwzględnione w tekście manuskryptu. Cytowania powinny być numerowane w kolejności ich występowania w tekście i powinny być oznaczane cyframi arabskimi w nawiasach kwadratowych. W spisie piśmiennictwa każda kolejna pozycja powinna być pisana od nowego wiersza i poprzedzona numerem. Należy przestrzegać jednolitej interpunkcji wg wzorów: W przypadku źródeł z czasopisma należy podać: nazwiska autorów i pierwsze litery imion, następnie: tytuł artykułu, tytuł czasopisma z zastosowaniem obowiązujących skrótów wg bazy danych MedLine (zawsze zakończone kropką), rok publikacji, tom, numer strony pierwszej i ostatniej. Nie należy podawać źródeł: w druku, w przygotowaniu, informacja ustna. Przykład: 1. Kowalski J, Nowak J. Nozologiczne aspekty bólów głowy. J Med. 2007; 1: W przypadku cytatu z książki należy podać: nazwiska autorów i pierwsze litery imion, następnie: tytuł książki, siedzibę i nazwę wydawnictwa, rok wydania, numer strony pierwszej i ostatniej. Przykład: 2. Pawlak P. Życie i umieranie. Warszawa: PWN; W przypadku cytowania rozdziału pochodzącego z książki należy podać: nazwisko/nazwiska i pierwsze litery imion autora/ autorów tegoż rozdziału, tytuł rozdziału cytowanej książki, nazwisko i imię autora (redaktora) książki, tytuł książki, siedzibę i nazwę wydawnictwa, rok wydania, numer pierwszej i ostatniej strony cytowanego rozdziału. Przykład: 3. Pawlak P. Życie i umieranie. W: Malinowski A (red.). Gerontologia. Warszawa: PWN; CONFERENCE REPORTS AND OTHER INFORMATION TEXTS (compare Introduction) The text should not exceed words (2 pages). REFERENCES Literature should be presented on a separate sheet of paper using the Vancouver style. Only references related to the topic of the paper should be included in the text of the manuscript. Quotations should be numbered according to their appearance in the text and marked using Arabic numerals in square brackets. Each new item in the list of references should be written in a new line, preceded by a number. Homogeneous punctuation should be respected as follows: The sequence for a journal article should be the following: authors names and first names, paper title, journal title abbreviated as in the MedLine database (always ended up with a dot), year of publication, volume number, first and last page numbers. One should not include references: in print, to appear soon, oral information. Example: 1. Kowalski J, Nowak J. Nozologiczne aspekty bólów głowy. J Med. 2007; 1: The sequence for the book should be as follows: authors names and first letters of their first names, book title, place and edition of publication, year of publication, first and last page numbers. Example: 2. Pawlak P. Życie i umieranie. Warszawa: PWN; The sequence for the book chapters should be as follows: chapter authors names and first letters of their first names, chapter title, book title, book authors, place and edition of publication, year of publication, chapter first and last page numbers. Example: 3. Pawlak P. Życie i umieranie. W: Malinowski A (red.). Gerontologia. Warszawa: PWN; W przypadku cytowania materiału elektronicznego (Internetu) należy podać: nazwiska autorów i pierwsze litery imion, następnie: tytuł artykułu, pełny adres strony internetowej oraz datę dostępu (datę wejścia). TABELE Tabele należy wykonać w programie Word dla Windows. Powinny być w formie edytowalnej, z ograniczeniem linii wertykalnych. Tabele powinny być oznaczone numerami arabskimi, z użyciem pełnego wyrazu Tabela, a nie skrótu tab. (np. Tabela 5). Tytuły w języku polskim i angielskim powinny znajdować się nad tabelami. Tekst w tabeli powinien być napisany czcionką Arial Narrow CE wielkości 10 pkt. Szerokość tabeli nie powinna przekraczać 8 cm lub 16 cm. Wnętrze tabeli powinno zawierać również wersję angielską. Liczba tabel powinna być ograniczona do niezbędnego minimum. RYCINY Wykresy należy wykonać w programie Word dla Windows lub Excel. Ilustracje należy zapisać w formacie TIF lub JPG. Ryciny należy podpisywać w języku polskim i angielskim z użyciem numeracji arabskiej, bez używania skrótu ryc. (czyli np. Rycina 5). Tytuły w języku polskim i angielskim powinny być napisane w programie Word, edytowalne i powinny znajdować się pod rycinami. Liczba rycin powinna być ograniczona do niezbędnego minimum. The sequence for the Internet should be as follows: authors names and first letters of their first names, paper title, full address of the website, access date. TABLES Tables should be prepared in Word for Windows. They should be in the editable form, limiting vertical lines. All tables should be numbered using Arabic numerals and a full word TABLE, not an abbreviation tab. (e.g. Table 5). The titles in both Polish and English should be placed above tables. The text in the table should be written in 10-point Arial Narrow CE font. The width of the table should not exceed 8 cm or 16 cm. The interior of the table should also include the English version. The number of tables should be limited to the necessary minimum. FIGURES Charts should be prepared in Word for Windows or Excel. Illustrations must be saved in JPG or TIF format. Figures should be provided with Polish and English captions and numbered using Arabic numerals, with no abbreviation fig. (e.g. Figure 5). Titles in Polish and English should be written in Word, they should be editable and should be placed under figures. The number of figures should be limited to the necessary minimum. POLISH NURSING NR 4 (70) 2018 INFORMATION 387

66 Copyright Poznan University of Medical Sciences OŚWIADCZENIE AUTORÓW Do każdej pracy należy dołączyć oświadczenie autorów, że praca nie była drukowana wcześniej w innym czasopiśmie. Aby przeciwdziałać przypadkom ghostwriting oraz ghost authorship, redakcja prosi autorów nadsyłanych prac o podanie informacji, jaki jest ich wkład w przygotowanie pracy. Informacja powinna mieć charakter jakościowy, tzn. autorzy zobowiązani są podać, czy ich wkład w powstanie publikacji polegał na opracowaniu koncepcji, założeń, metod, protokołu itp. Autorzy są także proszeni o podanie źródeł finansowania badań, których wyniki są prezentowane w nadsyłanej pracy. Załączone do pracy oświadczenie powinno być podpisane przez wszystkich autorów zgłaszanej pracy. SKRÓTY Skróty należy objaśniać przy pierwszym wystąpieniu, umieszczając je w nawiasie po pełnym tekście. Należy sprawdzić poprawność użytych skrótów. W tytule i streszczeniu zaleca się unikania skrótów. W tabelach i rycinach użyte skróty powinny być wyjaśnione w podpisach znajdujących się poniżej. PROCEDURA RECENZOWANIA Wszystkie artykuły podlegają wstępnej ocenie Redaktora Naczelnego lub jednego z członków Rady Naukowej, którzy mogą odrzucić pracę lub przesłać ją do recenzji zewnętrznej. Podwójnie anonimowy system recenzowania przez przynajmniej dwóch ekspertów w danej dziedzinie jest stosowany dla artykułów zaakceptowanych do dalszej oceny. Po otrzymaniu recenzji Redaktor Naczelny podejmuje decyzję o akceptacji artykułu do druku, akceptacji po drobnej poprawie, akceptacji po zasadniczej poprawie lub odrzuceniu. Autorzy otrzymują uwagi do manuskryptu niezależnie od decyzji. W przypadku akceptacji pracy wymagającej poprawy autorzy zobowiązują się ustosunkować się do recenzji w ciągu 30 dni. Redakcja zastrzega sobie prawo poprawienia usterek dotyczących stylistyki, mianownictwa i skrótów oraz poprawek wersji w języku angielskim bez uzgodnienia z autorem. PRAWA AUTORSKIE W przypadku akceptacji artykułów do druku wydawca nabywa do nich prawa autorskie, a wszelkie reprodukcje wersji elektronicznej lub papierowej nie mogą być dokonywane bez zgody wydawcy. AUTHORS DECLARATIONS Each manuscript should be accompanied by authors declarations that the paper has never before been published in any other journal. To counteract the occurrence of ghostwriting or ghost authorship phenomena the Editorial Board asks all listed authors of submitted papers to provide information on their contribution to manuscript preparation. The information has to be qualitative in character, i.e. the authors should state whether their work included preparation of the conceptual framework, assumptions, methods, protocol, etc. Authors are also asked to state sources of funding for research, the results of which are presented in the submitted paper. The declaration, attached to the manuscript, should be signed by all authors of a submitted paper. ABBREVIATIONS Abbreviations must be defined in full along with their first appearance in the text. They should be placed in brackets after a full text. Their correctness should be checked. Avoiding abbreviations in titles and abstracts is recommended. Abbreviations used in tables and figures should be defined in captions below. REVIEWING PROCEDURE All submitted papers are initially evaluated by the Chief Editor or a member of the Academic Council. The manuscripts may be turned down or reviewed further by two reviewers who do not know authors names or the name of authors institutions. On receiving the reviews, the Chief Editor decides whether the manuscript should be published, published after slight corrections, published after essential corrections or rejected. Authors receive remarks on the paper regardless of the decision made. If the manuscript is to be published after corrections, authors are required to express their opinion on reviews within 30 days. The Editor reserves the right to make any adjustments of style, terminology and abbreviations as well as corrections of the English version without asking for the author s consent. COPYRIGHTS In case manuscripts are to be published, the Editor acquires the copyrights and no electronic or hard copy can be made without the Editor s consent. 388 POLISH NURSING NR 4 (70) 2018 INFORMATION