PHASE 1: Integrative Literature Review (IRL)

The following question was formulated for the IRL: What are the basic nursing care recommended in the literature for the post-ATC client?

The inclusion criteria were: articles on the subject, published in english, portuguese or spanish; In the format of articles and available in full. The exclusion criterion was: studies conducted with clients under 18 years of age. The search was carried out in May 2017. The bases were used as data source: Medical Literature Analysis and Retrieval System Online (MEDLINE), Sciverse Scopus and Cumulative Index to Nursing and Allied Health Literature (CINAHL). When researching the descriptor "angioplasty" and "nursing care", 73 articles were found in MEDLINE, 22 articles in Cinahl and 51 articles in Scopus, totaling 146 articles. It is noteworthy that "and" was used among the descriptors as a boolean operator, and that was established as a temporal clipping the last twelve years, that is, articles published between 2005 and 2017, justified period due to the advancement in public policies of cardiovascular health between the years 2004 and 2005.

The titles and abstracts were read. Of the 146 articles found, 133 were excluded because they were not related to the theme and/or repetition in the bases, totaling 13 articles, five from MEDLINE, five from CINAHL and three from SCOPUS. Thus, the productions that met the previously established criteria were selected and read in full. From this sample, the described care was identified and they served as the basis for the elaboration of the Protocol, which initially counted with 25 items distributed in three blocks: Customer embracement in post-ATC, nursing interventions during Recovery and Rest and nursing care for discharge.

PHASE 2: Validation by Delphi Technique

After the elaboration of the protocol, validation was performed by specialist nurses using the Delphi technique. The technique is a systematic method of judgment of information, aimed at reaching the consensus of opinions on a given subject, of the knowledge of a group of experts, through assessments articulated in rounds of questionnaires, favored by anonymity, because there is no face-to-face encounter with the participants. For this, it is necessary an executor group, composed of researchers, and a respondent group formed by randomly selected participants. The number of participants may vary from seven to twelve^{6 7}.

The technique consists of six stages: the first one refers to the selection of participants and the second stage to the referral of the questionnaire. The third stage consisted of the analysis of the content of the answers, in which a qualitative and quantitative evaluation of the answers of the judges was made, and these data served as the basis for the fourth stage: elaboration of the second questionnaire. From the experts' responses, the protocol was altered, and a new questionnaire was elaborated. The document was forwarded again to the specialists and they were invited to perform a new trial. In the fifth stage there was the return of the responses of each round, a new analysis and modifications were made of the items that returned with suggestions in order to reach the consensus. The sixth stage refers to the elaboration of the final product and the return of the same to the participants with appreciation for participation⁷.

The selection of specialists had as inclusion criteria: nurses associated with the nursing Department of the Brazilian Society of Hemodynamics and Interventional Cardiology (DESBHCI), specialists and/or with experience in units post-angioplasty or hemodynamics for at least three years, and answer the e-mail regarding the invitation letter within seven days. The invitation was sent by DESBHCI to 105 nurse partners. Of these, 16 responded with acceptance and received the informed consent form (ICF). From this phase, the questionnaire/Protocol was forwarded, in which 12 nurses returned the signed ICF and received the other instruments. Of these, three were excluded, since they did not respond to the questionnaire within the established deadline, with nine participants remaining, a number considered satisfactor⁶.

For data collection were used: ICF, questionnaire to identify the profile of the specialists, and the instrument aimed at evaluating the protocol itself. Data were collected between may and november 2017, in which the six steps recommended by the Delphi technique were followed.

The questionnaire was formulated with evaluations for each item of the protocol described and using the Likert Scale, where the participant reports his/her opinion among the proposed points, and the same may agree or disagree with what is stated in the item. In this approach, respondents are asked to indicate to what extent they agree or disagree with the declaration⁸. For this study, the four-point Likert Scale was used, being: 1-Irrelevant, 2-Need a great review, 3-Need a small review and 4-Relevant. A field was added for the considerations, because for the scores of one to three, respondents were asked to justify their answers.

The analysis of the responses was performed according to the attributed score, and the Content Validity Index (CVI) was measured, which measures the proportion of specialists who are in agreement on certain aspects of the instrument. The score is calculated by means of the sum of concordance of the items that were marked by "3" or "4" by the specialists. Items that have been given a score of "1 " or "2" should be revised or deleted. Thus, for each item, the formula was used: Number of responses "3" or "4" divided by the total number of answers⁶. The acceptance of each aspect of the protocol should reach the rate of 0.9⁹. It was also established the accepTable concordance rate (CT) among the specialists. In the case of six or more participants, a rate of not less than 0.78⁹. is recommended.

The study was carried out through submission and approval by the Research Ethics Committee of Universidade Federal Fluminense - Faculty of Medicine under the opinion N º 2.090,479.

Socio-demographic Profile of the Specialists

Nine nurses participated in the study, all female, in the age range between 32 and 62 years. Of these, three are from the southeast region, three from the northeast, two from the south and one from the Federal district. All have some specialization courses in the various areas. In this group, five nurses have a master's degree, two have a doctorate and two have specialization. Regarding the time of experience in hemodynamics and post-angioplasty units, this time ranged between five and 25 years. The time of total experience as a nurse ranged from eight to thirty-nine years.

Analysis of experts' responses on protocol evaluation

The protocol is directed to the elective client, which maintains an average length of stay between 24 and 48 hours. It consists of three columns, and 25 lines in its first version (before validation), in each line the care is identified by a numeral and its justification/rationale. Each of the three blocks were changed according to the observations of the participants:

First Block - Customer Embracement in post-ATC - In the first step of questions and answers, four specialists suggested modifications regarding the recommendation of the elevation of the approached limb. On the physical examination, a modification was suggested regarding the observation of the puncture site (transparent dressing) by two specialists, and alteration of the essay. In the measurement of vital signs, it was suggested to add which signs should be measured and the periodicity, and on the location of the cuff to measure blood pressure, was suggested alteration in the essay. In the second phase, there was only suggestion to change the wording of two items and in the third phase, there were no suggestions for changes and this block was then finalized, having the agreement of all specialists.

Second Block - Nursing interventions during recovery and rest - In the first phase there was suggestion of alteration in items related to head elevation and grids, routine examinations, continuous monitoring of vital signs, bruising and bleeding and the compression of the dressing, the latter being the most criticized. The items on pain assessment, diet acceptance and early ambulation also received suggestions for alterations. In the second phase, the items referring to spirituality, electrocardiogram, regular assessment of vital signs, cardiac monitoring, use of compressive dressing-including length of stay, pain, bladder eliminations and bathing were discussed and altered. In the third phase, the item on electrocardiographic monitoring was punctuated as irrelevant by an expert. Considering the risk of cardiac alterations after the procedure, the item was maintained, and the observation on the alert for signs, such as chest pain and tachycardia, was included. Item 9 was dismembered, since it deals with two distinct situations, which occur at different times: The hematoma -e arlier, and the skin lesion later. This proposal was made by an expert and accepted. The frequency for urinary output recording was also altered and in the item about bathing, the expression "when necessary" was added, since bathing should not be a routine to be fulfilled with 3 hours of rest, but in the need of it, this minimum time must be respected. Thus, this block is finalized, based on the suggestions made and according to the agreement between the specialists.

Third block- Nursing care for high in the first phase - The vital signs item was considered repeated and suggested by two specialists who were excluded. This suggestion was not accepted, but the moment when vital signs should be measured was added: Before forwarding the client to the residence. It was also suggested to add the evaluation of serum levels of urea and creatinine for evaluation of renal function, review the length of stay of the dressing, review the time established for the restrictions with the approached limb (48 hours) and specify the weight (load) to that the customer is restricted to pick up. The suggestion was accepted and according to the recommendations of SOCERJ (Society of Cardiology of the State of Rio de Janeiro) it was recommended the rest period of two weeks and the maximum permissible load of ten kilos¹⁰. In the second phase of evaluation by the specialists, changes were made to the text. In addition, in item 23, five specialists criticized the limb resting time and the established load. Regarding these criticisms, the observation was not excluded, it was decided to describe that this is a recommendation given by specialists in the area. In the third phase, small changes in the wording of the items were also made and thus, this block was finalized, having the agreement of all specialists, since the acceptance rates were favorable and the changes made were contributions to valorization of the document. The final version of the protocol is illustrated in the Table below:

Table 1. Protocol items after changes. Niterói. Universidade Federal Fluminense, 2017 

Source: Own elaboration. Niterói, 2017.

Descriptive statistical analysis

The values of the three phases performed were organized and evaluated the concordance rates (CT) and content validity index (CVI) of each item of the protocol. Regarding the CVI, in the first phase, of the 25 items, two did not reach the recommended rate (0,9), already in the second phase, all items were accepted, remaining in this way in the third phase. Regarding CT, only six items of the protocol reached the recommended rate, in the first phase, while in the second phase, 17 items reached the recommended rate, when it comes to research with more than six specialists⁹. In the third phase, all items had a TC equal to or higher than 0,9, which shows how much the alterations in the actying contributed to the improvement of the Protocol. The Mean Content Validity Index (MCVI) in the first phase was 0.96 and in the second phase it rose to 0,99, reaching the score of 1.0 in the last phase. The Mean Concordance Rate (MCR) was 0,69 in the first phase, being elevated to 0.86 in the second phase and 0,94 in the third. This finding reveals that, for this research, three assessments were necessary to reach the recommended rate. The data are elucigiven in the following Tables :

Table 2. Data from the first round of questions and answers. Niterói. Universidade Federal Fluminense, 2017 

Caption - CVI: Content Validity Index - number of specialists with attribution of note 3 or 4 / total of specialists, CR-N: Concordance rate- number of specialists with a score of 4 /total specialists.

Table 3. Data from the second round of questions and answers. Niterói. Universidade Federal Fluminense, 2017 

Caption - CVI: Content Validity Index - number of specialists with attribution of note 3 or 4 / total of specialists, CR-N: Concordance rate- number of specialists with a score of 4 /total specialists.

Table 4. Data from the third round of questions and answers. Niterói. Universidade Federal Fluminense, 2017 

Caption - CVI: Content Validity Index - number of specialists with attribution of note 3 or 4 / total of specialists, CR-N: Concordance rate- number of specialists with a score of 4 /total specialists.