Self-care deficit versus the potential to improve self-care: explanation of the nurse's clinical judgments

ARTIGO DE INVESTIGAÇÃO RIIS | Vol.4(2), 7-18 7 RIIS Re is a de In es igação & Ino ação em Saúde SELF-CARE DEFICIT VERSUS THE POTENTIAL TO IMPROVE SELF-CARE: EXPLANATION OF THE NURSE'S CLINICAL JUDGMENTS Comp omisso no au ocuidado e sus po encial pa a melho a o au ocuidado: Explanação do juízo clínico do en e mei o Comp omiso con el au ocuidado e sus po encial pa a mejo a el au ocuidado: explicación del juicio clínico de las en e mei as Ma isa Lou enço*, Paula Enca nação**, Te esa Ma ins***, Fá ima A aújo****, Paulo Machado***** ABSTRACT Backg ound: people who become unc ionally dependen due o se ious illness and/o he wo sening o a ch onic illness ha e di e en eco e y pa hs. The a ibu ion o he nu sing diagnosis o sel -ca e de ici e sus po en ial o imp o e sel -ca e equi es, on he pa o he nu se, a igo ous clinical judgmen , o which a se o diagnos ic ac i i ies is necessa y. Objec i es: he p esen s udy sough o iden i y he assump ions used by expe nu ses when o mula ing he clinical judgmen o sel -ca e de ici e sus he po en ial o imp o e sel -ca e Me hodology: quali a i e design. Da a we e gene a ed in wo ocus g oup mee ings ha included ele en nu ses expe ienced in ca ing o pe sons wi h unc ional dependence and sel -ca e de ic . P e iously p epa ed s uc u ed ques ions we e used o acili a e discussion. The ocus g oup mee ings we e eco ded in audio and ansc ibed. Induc i e con en analysis was used o iden i y eme ging hemes. The checklis Consolida ed C i e ia o Repo ing Quali a i e Resea ch (COREQ) was also used. Resul s: nu ses` decision-making depends: he ac o s o in luencing he po en ial o imp o e sel -ca e abili ies o a pe son wi h unc ional dependence, he domain o in luence o hese ac o s, and h ee undamen al aspec s o conside when e alua ing a pe son wi h unc ional dependence. Conclusions: he absence o eco e y po en ial can a ely be deduced. People wi hou cogni i e impai men o wi h mild cogni i e impai men p esen highes po en ial o eco e y. Keywo ds: nu sing diagnosis; sel -ca e; unc ional dependence; decision making RESUMO Enquad amen o: as pessoas em si uação de dependência uncional, de ido a doença g a e e ou ag a amen o de doença c ónica, êm pe cu sos di e en es no p ocesso de ecupe ação. A omada de decisão do en e mei o pa a melho a a au onomia da pessoa, es á sujei a aos dados de a aliação do seu po encial de ecupe ação. Obje i os: iden i ica os p essupos os u ilizados pelos en e mei os pa a enuncia o juízo clínico: au ocuidado comp ome ido e sus o po encial pa a melho a o au ocuidado. Me odologia: es udo quali a i o. Os dados o am ge ados em duas euniões de ocus g upo com onze en e mei os, com expe iência no cuida da pessoa com dependência uncional e comp omisso no au ocuidado. Fo am di ecionadas algumas pe gun as p e iamen e es u u adas pa a acili a a discussão. As e lexões o am g a adas em áudio e ansc i as. Análise de con eúdo indu i a oi usada pa a iden i ica os emas eme gen es. U ilizada a lis a de e i icação Consolida ed C i e ia o Repo ing Quali a i e Resea ch (COREQ). Resul ados: a omada de decisão dos en e mei os depende: dos a o es que in luenciam o po encial pa a melho a as capacidades pa a o au ocuidado de uma pessoa com dependência uncional, do domínio de in luência desses a o es e dos p essupos os u ilizados pa a a alia as capacidades da pessoa com dependência uncional. Conclusão: a ausência de po encial de ecupe ação a amen e pode se deduzida. Pessoas sem comp ome imen o cogni i o ou com comp ome imen o cogni i o le e, ap esen am maio po encial de ecupe ação. Pala as-Cha e: diagnós ico de en e magem; au ocuidado; dependência uncional; omada de decisão RESUMEN Ma co con ex ual: las pe sonas que se uel en uncionalmen e dependien es debido a una en e medad g a e o al empeo amien o de una en e medad c ónica ienen di e en es ías de ecupe ación. La oma de decisiones del en e me o pa a mejo a la au onomía del pacien e, es á suje a a la e aluación de da os de su po encial de ecupe ación. Obje i os: iden i ica los supues os u ilizados po las en e me as pa a enuncia el juicio clínico: au ocuidado comp ome ido e sus po encial pa a mejo a el au ocuidado. Me odología: diseño cuali a i o. Los da os se gene a on en dos euniones de g upos ocales que incluye on a once en e me as con expe iencia en el cuidado de pe sonas con dependencia uncional, comp omiso con el au ocuidado. Se u iliza on p egun as es uc u adas p e iamen e p epa adas pa a acili a la discusión. Las euniones de los g upos ocales se g aba on en audio y se ansc ibie on. Se u ilizó el análisis de con enido induc i o pa a iden i ica emas eme gen es. También se u ilizó la lis a de e i icación Consolida ed C i e ia o Repo ing Quali a i e Resea ch (COREQ). Resul ados: la oma de decisiones de las en e me as depende: los ac o es que in luyen en el po encial pa a mejo a las habilidades de au ocuidado de una pe sona con dependencia uncional, el dominio de in luencia de es os ac o es y los supues os que se hacen al e alua las capacidades de una pe sona con dependencia uncional. Conclusión: a a ez se puede deduci la ausencia de po encial de ecupe ación. Las pe sonas sin de e io o cogni i o o con de e io o cogni i o le e p esen an el mayo po encial de ecupe ación. Palab as Cla e: diagnós ico de en e me ía; au ocuidado; dependencia uncional; oma de decisiones *PhD, associa e p o esso and esea che a Po o Nu sing College and esea che a CINTESIS - h ps://o cid.o g/0000-0001-5953- 788X - Au ho 's con ibu ion: Concep ion and s udy design, Da a Collec ion, Da a analysis and in e p e a ion, D a ing he manusc ip , C i ical e ision o he in ellec ual con en **PhD, associa e p o esso a School o Nu sing, Uni e si y o Minho, and esea che a Coimb a Nu sing College - h ps://o cid.o g/0000-0002- 7458-8105 - Au ho 's con ibu ion: Concep ion and s udy design, Da a analysis and in e p e a ion, C i ical e ision o he in ellec ual con en *** PhD, coo dina ing p o esso , a Po o Nu sing College and esea che a CINTESIS - h ps://o cid.o g/0000-0003-3395-7653 - Au ho 's con ibu ion: Concep ion and s udy design, Da a Collec ion, Da a analysis and in e p e a ion, D a ing he manusc ip , C i ical e ision o he in ellec ual con en **** PhD, associa e p o esso , a Po o Nu sing College and esea che a CINTESIS - h ps://o cid.o g/0000-0002-3059-7480 - Au ho 's con ibu ion: Concep ion and s udy design, Da a Collec ion, C i ical e ision o he in ellec ual con en ***** PhD, coo dina ing p o esso , a Po o Nu sing College and esea che a CINTESIS - h ps://o cid.o g/0000-0002-3187-6860 - Au ho 's con ibu ion: Concep ion and s udy design, Da a Collec ion Como e e encia : Lou enço, M., Enca nação, P., Ma ins, T., A aújo, F., & Machado, P. (2021). Sel -ca e de ici e sus he po en ial o imp o e sel -ca e: explana ion o he nu se's clinical judgmen s. Re is a de In es igação & Ino ação em Saúde, 4(2) 7-18 Recebido pa a publicação: 01/07/2021 Acei e pa a publicação: 23/11/2021 Sel -ca e de ici e sus he po en ial o imp o e sel -ca e: explana ion o he nu se's clinical judgmen s 8 RIIS Re is a de In es igação & Ino ação em Saúde INTRODUCTION Loss o unc ional capaci y (physical and psychological) may be associa ed wi h he de e io a ion o a ch onic disease condi ion, which may condi ion he pe son o unc ional dependence and sel -ca e de ici , ha is, o he need o someone o help in sel -ca e ac i i ies. Sel -ca e is conside ed he aking ca e o wha is needed o main ain onesel , keep onesel going and handle basic indi idual and in ima e necessi ies and ac i i ies in daily li e (In e na ional Council o Nu ses [ICN], 2019). Ac i i ies o daily li ing include ea ing, ba hing, d essing and und essing, using he oile , ge ing eady, ge ing ou o bed, mo ing be ween bed and chai and u ning in bed (ICN, 2019). O em is an impo an e e ence o he de elopmen o he concep o sel -ca e, ha ing de ined i as a p ac ice o ac i i ies ha indi iduals ini ia e and ca y ou o main ain li e, heal h, and well-being (O em, 1991). He heo y gi es special emphasis on heal h de ia ions, which is when a pe son is no able o p omo e he necessa y sel -ca e ac i i ies and equi es he help o ano he pe son. Many nu sing he apies aim o e e se unc ional dependence and sel -ca e de ici as soon as possible. Assessing he sel -ca e ac i i ies ha he pe son is able o no o pe o m, acili a ing he de elopmen o knowledge and new sel -ca e skills, such as he assessmen and e o mula ion o housing condi ions, emo ing ba ie s o mobili y, o pu ing hand ailings in he ba h oom, a e o g ea use when he dependen pe son has he po en ial o imp o e (Lou enço, 2015). Fo people wi h unc ional dependence and a high le el o commi men in sel - ca e, nu sing in e en ions aim o eplace he pe son when pe o ming sel -ca e ac i i ies. In o he wo ds, he nu ses' ac ions a e p edominan ly o he ype o execu e; o example, posi ion, ba he, d ess, eed (ICN, 2019). The p esen s udy sough o iden i y he assump ions used by expe nu ses when o mula ing he clinical judgmen o sel -ca e de ici e sus he po en ial o imp o e sel -ca e BACKGROUND P omo e sel -ca e is he i s le el o heal hca e p o ided, and i s scope includes heal h p omo ion, disease p e en ion, ehabili a ion, and pallia i e ca e (WHO, 2019). Sel -ca e ac i i ies in a pe son wi h se e al ch onic condi ions, in an ad anced s age o he disease, and e idencing cogni i e al e a ions a e a cu en challenge (Jaa sma e al., 2017). Addi ionally, he in luence o amily, iends, and heal h p o essionals in de eloping sel -ca e abili ies needs o be u he in es iga ed (Riegel e al., 2017). Riegel e al. (2012), in he Middle-Range heo y on sel -ca e in he con ex o ch onic illness, based on clinical p ac ice, de ine sel -ca e as a p ocess o heal h main enance and disease managemen a he . This p ocess equi es a pe son o be in ol ed and ac i ely engaged in hei own heal h-illness ansi ion. The e o e, sel -ca e is unde s ood as a polysemic concep and a dynamic p ocess ha depends on a pe son's will powe . Is in luenced by indi idual needs, capaci ies, p e iously iden i ied disabili ies, and a pe cep ion o hei new heal h condi ion. Hence, some sel -ca e ac i i ies di e acco ding o he pe son (Riegel e al., 2012). Sel -ca e de ici e sus he po en ial o imp o e sel -ca e: explana ion o he nu se's clinical judgmen s 9 RIIS Re is a de In es igação & Ino ação em Saúde A e he acu e phase o an illness, he onse o he unc ional dependence and he sel -ca e de ici a e conside ed p io i ies, meaning ha a pe son mus ini ia e hei eco e y p ocess. Se e al ac o s can limi he abili y o a pe son wi h unc ional dependence o eco e sel -ca e beha io s and ac ions a indi idual and social le els. As well age, heal h s a us, decision-making abili y, physical abili y o pe o m sel -ca e ac ions, cogni i e and emo ional abili y (Jaa sma e al., 2017), expe ience, mo i a ion, belie s, cul u al alues, habi s, unc ional and cogni i e abili ies, suppo sys em, access o ca e and sel -e icacy (Lou enço, 2015; Riegel e al., 2012, Vellone e al., 2016). The cu en inc easing need o heal hca e esponses associa ed wi h unc ional dependence and sel -ca e de ici is a signi ican challenge o heal h se ices and, in pa icula , o nu ses. The changes in a pe son's abili y o pe o m sel -ca e ac i i ies can be ansla ed in o wo nu sing diagnos ic labels sus ained on di e en decision-making bases. Fo he diagnos ic label-impai ed sel -ca e a nu se p esc ibes nu sing in e en ions ha eplace he pe son in sel - ca e ac ions. Fo he diagnos ic label-po en ial o imp o e sel -ca e abili ies a nu se can p esc ibe in e en ions ha include assis ance, in o ma ion, and aining o imp o e o egain he pe o mance o sel -ca e ac i i ies and p omo e au onomy. The designa ion o po en ial e e s o inhe en e capaci y o coming in o being (ISO 18104, 2014, p.4) ha is, he pe son's abili y and he oppo uni y o de elop new sel -ca e abili ies and, hus, become mo e au onomous. Quei ós e al., (2021) s a es ha he e a e wo pe spec i es o diagnos ic easoning, gi en he uni e sal sel -ca e equi emen s: i) sel -ca e de ici o ii) he indi idual's oppo uni y o de elop skills and/o knowledge o deal wi h he sel -ca e de ici . Highligh ing he indi idual need o acqui e knowledge and mas e skills o managing a new challenging condi ion (Quei ós e al., 2021, p.6). In he long- e m, hese in e en ions will p oduce di e en ou comes wi h ega ds o a pe son's heal h condi ion. Howe e , he ques ion emains, which pa ien s ha e eco e y po en ial? Imp o ing he abili y o a pe son wi h unc ional dependence o pe o m sel -ca e ac i i ies implies sys ema izing a p o essional app oach in o de o egula ly and speci ically assess he di e en impai men s. Such as physical, psychological, and o he cons ain s/limi a ions, ela ed o he momen and con ex expe ienced by he pe son (Lou enço, 2015). The ac o s ha posi i ely and nega i ely in luence he sel -ca e beha io s o a pe son wi h unc ional dependence a e well known (Schulman-G een e al., 2016). Howe e , his e idence has had li le ans e abili y o clinical nu sing p ac ice (Lou enço, 2015). Despi e he exis ence o se e al s udies ocused on iden i ying ac o s ha in luence sel -ca e beha io s o a pe son wi h unc ional dependence (Jaa sma e al., 2017; Vellone e al., 2016), in he con ex o clinical p ac ice, no assessmen ins umen exis s o help nu ses iden i y he di e en ia ing indica o s o he diagnoses, sel -ca e de ici o po en ial o imp o e sel -ca e abili ies. METHODS Design This is an explo a o y s udy, using a quali a i e me hod comp ising in e iews wi h a ocus g oup. Sel -ca e de ici e sus he po en ial o imp o e sel -ca e: explana ion o he nu se's clinical judgmen s 10 RIIS Re is a de In es igação & Ino ação em Saúde The Consolida ed C i e ia o Quali a i e Resea ch Repo s (COREQ) checklis was used (Supplemen a y File 1). The s udy included wo mee ings held in 2019 wi h ele en nu ses expe ienced in he ca e o pe sons wi h unc ional dependence and sel -ca e de ic . The mee ings las ed abou wo hou s and 30 minu es (K uege & Casey, 2014). Pa icipan s Pa icipan s we e selec ed by an in en ional sampling me hod o ob ain de ailed desc ip ions o he wo k expe ience ele an o he s udy (K uege & Casey, 2014). The selec ion c i e ia we e: a) o be a nu se wi h ad anced aining in ehabili a ion nu sing, ecognized by he Na ional O de o Nu ses; b) ha e a leas h ee yea s expe ience in ca ing o people wi h unc ional dependency and commi men o sel - ca e; and c) sign he in o med consen o m, olun a ily ag eeing o pa icipa e in he s udy and au ho ize he dissemina ion o he esul s ob ained in he scien i ic ield. Two weeks be o e he ocus g oup, pa icipan s we e con ac ed by email, and he in o med consen o m was sen , cla i ying he objec i es o he s udy, pa icipa ion c i e ia, s udy me hods, and he es ima ed du a ion. Th ee days be o e he ocus g oup was held, pa icipan s we e con ac ed by elephone o con i m he mee ings. The place whe e he mee ings we e held was accessible o all pa icipan s. Pa icipan s we e mos ly women (82%), aged 36 yea s o olde , wi h ad anced aining in ehabili a ion nu sing, and wi h 15 yea s o mo e o p o essional expe ience. Pa icipan s wo ked in long- e m ca e uni s o unc ional ehabili a ion and aining in sel - ca e ac i i ies. Da a collec ion The in e ac ion among he g oup p oduced impo an in o ma ion ele an o he concep s s udied, and pa icipan s we e encou aged o discuss and commen on hough s and expe iences on he opics unde discussion. P e iously p epa ed ques ions we e used in a semi-s uc u ed manne o acili a e discussions. Ques ions we e p epa ed h ough collabo a ion and inpu o all he au ho s o he documen ( able 1). Table 1 Ques ions used in ocus g oup 1-Fo a pe son who su e ed a c i ical episode and became unc ionally dependen , wha ac o s do you ecognize ha could ha e in luenced his/he abili ies o imp o e sel -ca e? 2-Wha is he domain o in luence o he men ioned ac o s on a pe son's abili y? 3-Iden i y h ee undamen al aspec s o conside when e alua ing a pe son wi h unc ional dependence? The ques ions ga e ise o aluable discussions and e lec ions among he pa icipan s. Pa icipan s we e also allowed o aise ques ions du ing he ocus g oup in e iews. The sessions we e mode a ed by he i s au ho o he pape , who p esen ed he opics o discussion, kep an ac i e ole in conduc ing and main aining he discou se, ensu ing ha each pa icipan had he oppo uni y o expose his o he opinions. Pos -i s and a whi eboa d we e used o collec opinions abou he i s ques ion p esen ed by he mode a o . The pa icipan s eco ded on pos -i s ac o s ha , in hei Sel -ca e de ici e sus he po en ial o imp o e sel -ca e: explana ion o he nu se's clinical judgmen s 11 RIIS Re is a de In es igação & Ino ação em Saúde opinion, in luence he eco e y po en ial o a pe son wi h unc ional dependence and sel -ca e de ici . Subsequen ly, hese concep s we e g ouped hie a chically in o unc ional domains. The o he au ho s o he pape assis ed in his ask. The mode a o also p esen ed he o he ques ions. The pa icipan s discussed hei opinions, which we e audio- eco ded. A e da a collec ion, he in e iews we e ansc ibed, and he in o ma ion ob ained was submi ed o con en analysis, ollowing he S auss & Co bin (2014) guidelines. The mode a o pe o med he ansc ip ion because she had inside in o ma ion abou acial exp essions, ges u es, and one o oice in which he speeches we e deli e ed. I ems ha ecei ed a o able ag eemen om a leas six (55%) o he ele en ocus g oup pa icipan s we e added o he esul s. The con en analysis esul s we e colla ed in a epo ha was e u ned o he pa icipan s a he second ocus g oup mee ing. The second ocus g oup mee ing s a ed wi h he pa icipan s eading he epo o 40 minu es. This was ollowed by a discussion o opinions abou he alida ion o he in o ma ion. This ocus g oup mee ing was also audio- eco ded. All sugges ions o change we e ai h ully ca ied ou in he inal epo by he mode a o . All igh s ela ed o da a p o ec ion we e espec ed in he s udy. Da a analysis The da a ga he ed om he pa icipan s' discussion we e a he cen e o he coding wo k om an induc i e pe spec i e. The knowledge eme ged p og essi ely and was ma ked by he clinical expe ise o he p o essionals. The coding p ocess was he i s phase o he analysis, whe e he subs an i e codes, p ope ies, and dimensions we e iden i ied. This phase was ollowed by axial coding. The p e iously g ouped da a we e eg ouped in o concep s o iden i y he ca ego ies p esen . The selec i e coding, which was he las phase o he analy ical p ocess, included he e inemen o he ca ego ies and subca ego ies p e iously iden i ied. These we e compa ed and analyzed con inuously, in eg a ing some da a, and a cen al ca ego y eme ged (S auss & Co bin, 2014). RESULTS Wi hin he g oup o ele en expe ehabili a ion nu ses, nine we e women. The a e age age was 42.27 yea s. Mo e han hal he expe s (six) had o e i een yea s o wo k expe ience, h ee had en yea s, one nu se had wel e yea s, and ano he nu se had six yea s. All expe s wo ked on unc ional ehabili a ion uni s in ei he inpa ien o communi y con ex s and we e ecognized by hei pee s as ha ing an ou s anding nu sing esume. diagnos ic labels ha we e indica i e o he need o ca e o a pe son wi h unc ional dependence included sel -ca e de ici o po en ial o imp o e sel - -making was dependen on 1) ac o s in luencing he po en ial o imp o e sel -ca e abili ies o a pe son wi h unc ional dependence, 2) he domain o in luence o hese ac o s, and 3) h ee undamen al aspec s o conside when e alua ing a pe son wi h unc ional dependence The ac o s ha in luence a pe son wi h unc ional dependence o imp o e sel -ca e abili ies a e (a) unc ional capaci y ha includes cogni i e and physical issues, (b) emo ional ac o s, and (c) suppo Sel -ca e de ici e sus he po en ial o imp o e sel -ca e: explana ion o he nu se's clinical judgmen s 12 RIIS Re is a de In es igação & Ino ação em Saúde sys em, which includes amily membe s, heal h p o essionals, ime, and en i onmen ( able 2). Table 2 Fac o s ha in luence he po en ial o imp o e sel -ca e abili ies o a pe son wi h unc ional dependence Ca ego y Subca ego y Indica o Func ional capaci y Cogni i e Consciousness O ien a ion: Time, space and sel -pe son Senso y pe cep ion Memo y, hough , easoning A ailabili y Knowledge (heal h li e acy) Physical Balance Muscle s eng h Join mo emen Mo o coo dina ion Emo ional ac o s Belie s Sel -e icacy Expec a ions Voli ion: Willpowe , mo i a ion, sel -con ol Adap a ion, accep ance o he heal h condi ion Hope In ol emen P e ious expe iences Suppo Sys em Family Family in ol emen Knowledge A i ude Expec a ions Heal h p o essionals Ca e philosophy (biomedical model) A i ude En i onmen Communi y (Access o nu ses wi h ad anced p ac ice in ehabili a ion) Household a chi ec u al ba ie s Lack o ma e ial esou ces (assis i e de ice) Time Reco e y ime The p esence o se e e cogni i e impai men (caused by memo y, hough , o easoning al e a ions) is a -making p ocesses, leading hem o op o he diagnos ic label sel -ca e de ici . Unal e ed unc ional capaci y, posi i e emo ions, mo i a ion, and ini ia i e, posi i ely in luence he eco e y p ocess o a dependen pe son's sel -ca e abili ies. These indica o s sugges ha a nu se should op o he diagnos ic label po en ial o imp o e sel -ca e abili ies. Low willpowe , pe cep ion o low sel - e icacy, and he absence o li e goals we e conside ed ac o s ha nega i ely in luence a pe son's eco e y p ocess. These indica o s e lec he educed po en ial o he eco e y o sel -ca e abili ies and a e likely o lead o de ici in sel -ca e, leading o nu ses deciding on in e en ions ha o en eplace he pe son in sel -ca e ac ions ( able 3). Sel -ca e de ici e sus he po en ial o imp o e sel -ca e: explana ion o he nu se's clinical judgmen s 13 RIIS Re is a de In es igação & Ino ação em Saúde Table 3 Domains o in luence o iden i ied ac o s on po en ial o imp o e sel -ca e abili ies Ca ego y Indica o De e minan ac o Cogni ion: memo y, hough , and easoning Fac o s o posi i e in luence Func ional capaci y, posi i e emo ions, mo i a ion, and ini ia i e Fac o s o nega i e in luence Low willpowe , pe cep ion o low sel -e icacy, absence o li e goals Expe nu ses conside ha he assessmen o he abili y o a pe son wi h unc ional dependence mus ake in o accoun h ee o he ollowing aspec s (a) he iming o he assessmen , wi h he esul s guiding he le el o assis ance in heal h ca e; (b) he indica o s o assessmen , which in o m he igo o nu ses' decision-making and moni o he e ec i eness o a pe son's esponse du ing he au onomy eco e y p ocess; and (c) sys ema ic in he e alua ion, which acili a es he eadjus men o nu sing in e en ions and espec i e expec ed ou comes. DISCUSSION The p esen s udy sough o iden i y he assump ions used by expe nu ses when o mula ing he clinical judgmen o sel -ca e de ici e sus he po en ial o imp o e sel -ca e. E alua ing whe he o no a pe son has he po en ial o imp o e sel -ca e abili y in ol es speci ic c i e ia. A p ese ed cogni i e unc ion is essen ial o ecei e, decode, and e ain in o ma ion (Bidwell, 2015). Du e al. (2007) demons a ed ha impai ed unc ional and cogni i e capabili ies nega i ely a ec a pe son's abili y and in e es o be in ol ed in sel -ca e ac i i ies, which may make he assessmen pa icula ly challenging. Func ional capaci y e lec s he di icul ies ha a pe son may expe ience when pe o ming a ask o ac ion ha equi es a speci ic cogni i e s a us, which includes awa eness, o ien a ion, senso y pe cep ion, memo y, hough , easoning, and knowledge (in o ma ion acqui ed and/o pe cei ed). Acco ding o Jaa sma e al. (2017), a pe son needs o ha e speci ic unc ional and cogni i e skills o become in ol ed in sel -ca e, including making choices, iden i ying ca e needs, and knowing how o con ac a heal hca e p o essional when necessa y. Hence, a pe son needs o ha e a ce ain deg ee o in ol emen in hei ca e p ocess and commi o hei heal h and well-being. Func ional capaci y also includes physical s a us, a ca ego y iden i ied in ou s udy. Thus, muscle s eng h, mo o coo dina ion, balance, and join a e body p ocesses ha , a e being e alua ed, a e used o de e mine whe he o no a (N1). Howe e , e di icul ies a pe son aces when pe o ming sel -ca e ac i i ies (washing he back, d essing om he wais down, o al hygiene) [...] despi e impai men [...]" (N9). Sel -ca e de ici e sus he po en ial o imp o e sel -ca e: explana ion o he nu se's clinical judgmen s 14 RIIS Re is a de In es igação & Ino ação em Saúde hese ypes o de ici s, expe iencing hem o a long ime due o ch onic disease si ua ions, o en adop s a egies o pe o m sel -ca e ac i i ies (N4). Emo ional ac o s we e a ca ego y ha eme ged om his s udy and included mul iple indica o s showing how a pe son goes h ough he ehabili a ion p ocess o unc ional capaci y. Mos o he expe nu ses epo ed ha unc ional capaci y condi ions he p ocess o sel -ca e eco e y o a dependen pe son. Mo eo e , hinde ing belie s, o changes in he pe cep ion o sel -e icacy and demo i a ion, can indica e I can, bu I do no wan o, because I am in a denial phase hand, ha ing expec a ions, mo i a ion, and being in ol ed is essen ial o he adap a ion o he cu en heal h condi ion and imp o emen in sel -ca e au onomy Being ocused on he eco e y o hei indi idual capaci ies helps a pe son in he eco e y p ocess. These opinions co obo a e he esul s o se e al s udies ha demons a e he in luence ha emo ional ac o s ha e on a pe son's in ol emen du ing he p ocess o egaining sel -ca e abili ies (Chang e al., 2017; Sil a, 2019). Hope is also a ype o emo ion ha , once p esen , allows a pe son o deal wi h a s ess ul si ua ion mo e e ec i ely (Pin o e al., 2012). I assumes a he apeu ic ole, s onge han op imism, and is a ele an coping s a egy wi h in luence o e a pe son's well-being. O he in luencing ac o s epo ed by he pa icipan s we e p e ious expe iences. P e ious expe iences a e used as e ec i e pa e n iden i ie s ha p o ide ele an clues, sugges expec ed ou comes associa ed wi h speci ic esponses, and poin o easonable objec i es and ac ions in ce ain si ua ions (Jaa sma e al., 2017). Howe e , hey may also be po en inhibi o s o he de elopmen o he abili y o imp o e sel -ca e, as desc ibed by one expe ienced nu se, I am dealing wi h a pe son who, due o a p e ious nega i e expe ience, does no cu en ly wan o be ained on how o ans e om bed o chai , because he ell du ing hei p e ious hospi aliza ion (N11). The challenge o nu ses is o iden i y whe he p e ious expe iences acili a e o he momen s o assessmen and he de elop he abili y o pe o m sel -ca e. These p o essionals ha e a ield o ac ion ha allows hem o unde s and he expe iences and adap hem o imp o e indi idual pe o mance abili ies (N5). Wi hin his domain o emo ional ac o s, mo al p inciples and belie s ha e also eme ged, a ibu ing mo e meaning o li e, o ganizing, and men ally building a balance o eali y (Lou enço, 2015). The suppo sys em ca ego y was s uc u ed in o ou subca ego ies: amily, heal h p o essionals, en i onmen , and ime ac o s. Family is conside ed ca dinal suppo o a dependen pe son (Chen e al., 2017). Family suppo inc eases pa icipan s' in ol emen and con idence in he p ocess o egaining au onomy and p o es o be a acili a ing esou ce o de elop app op ia e sel -ca e abili ies and beha io s (Lou enço, 2015; Riegel e al., 2017). Ca ing o a amily membe wi h unc ional dependence is a linge ing, pain ul eali y wi hin he amily con ex (Chen e al., 2017 he lack o amily esou ces a ec s he unde u iliza ion o heal h se ices due o he p olonged delay o a pa ien 's discha ge [...] he ype o amily ca ing o he dependen pe son has a s ong (N8). Wi hin hei ca egi e ole, amily Sel -ca e de ici e sus he po en ial o imp o e sel -ca e: explana ion o he nu se's clinical judgmen s 15 RIIS Re is a de In es igação & Ino ação em Saúde membe s mus ge ac i ely in ol ed, be empa he ic, and a ailable o imp o e hei knowledge. Some imes we a e aced wi h amily ca egi e s who do no wan he dependen pe son o be au onomous [...] o en eplacing hem in hei ac i i ies, like d essing, ba hing, ea ing and e en choosing hei clo hes. These amily membe s conside ha he bes way o show a ec ion is o hem o eplace hei amily membe in his/he daily li e ac i i ies (N8). Acco ding o expe nu ses, he philosophy o ca e and heal hca e p o essionals' a i ude can in luence a pe son wi h unc ional dependence o de elop sel - ca e abili ies. When guided by a biomedical model, nu ses conside ha he main enance o body p ocesses, managemen o signs and symp oms, and he apeu ic p esc ip ions a e p io i y a eas. Wha we wan is o he pe son o keep he body p ocesses unc ioning and no de elop p essu e ulce s, o example , a pe son-cen e ed ca e -making. The psychological and emo ional aspec s mus be included and should be conside ed signi ican a eas in he eco e y p ocess o a pe son wi h unc ional dependence (Dineen-G i in e al., 2019; Lou enço, 2015). This is con i med by one nu se (N8) pa icipa ing in ou s udy in addi ion o he domain o body p ocesses, o he equally impo an ac o s such as emo ional aspec s, need o be conside ed when o mula ing a diagnos ic judgmen o a pe son wi h he po en ial o imp o e sel -ca e Acco ding o he nu ses in ou s udy, i is essen ial o adop a mo i a ing a i ude when ca ing o a pe son wi h unc ional dependence, p omo ing sel -e icacy and empowe men o egain au onomy. Nu ses mus be a ailable, a en i e, and cu ious o explo e he pe son's pe spec i es, in e es s, and needs. The s udy expe s conside ed language and a i ude ex emely impo an : "The language we use wi h [people wi h unc ional dependence] canno be p essing, igo ous o ocused exclusi ely on obliga ions o e en on guil The nu se wi h ad anced aining is mo e con iden in he he apeu ic ela ionship hey es ablish wi h a (N1). "I is impo an ha each o us choose a i udes ha help a pe son imp o e hei sel -e icacy [...]" (N11). The en i onmen also in luences he abili y o a pe son wi h unc ional dependence o imp o e sel - ca e. A chi ec u al ba ie s ha in e e e wi h accessibili y a home can nega i ely ehabili a ion p ocess, hinde ing he eco e y o au onomy (Lee e al., 2018). The lack o ma e ial esou ces such as assis i e de ices was ound o hinde he p ocess o a heal hy ansi ion o imp o e au onomy in sel -ca e (Roelands e al., 2002). Residency a eas co e ed by egula nu se home isi s inc eased he pe cep ion o pa ien s and amily ca egi e ega ding he home-ca e o mal suppo o heal h p o essionals Sha ing expe iences wi hin pee g oups, he pa ien 's con ac wi h people who ha e li ed simila si ua ions and he esul s achie ed, we e ound o inc ease in ol emen in he p ocess o acqui ing skills because people el ha i was possible o o e come he si ua ion (Lou enço, 2015). Nu ses pa icipa ing in his s udy also conside ed ha eco e y ime was associa ed wi h he oppo uni y o eco e y a ying acco ding o each pe son. We some imes a e in such a hu y ha we do no gi e people wi h unc ional dependence a chance o ca y The wo sening o he disease and he unc ional capaci y