RESEARCH ARTICLES

Nursing professional wear in hemodynamics

Rita de Cássia Flôr^I; Francine Lima Gelbcke^II

^IPhD Professor in Nursing at the Federal Institute of Education, Science and Technology of Santa Catarina, Brazil. Pedagogical Advisor and Executive at the Department of Distance Education. Email: flor@ifsc.edu.br
^IIPhD Professor in Nursing Associated with the Department of Nursing Graduate Program at the Federal University of Santa Catarina and Coordinator of the Master's Professional Management in Nursing Care from the same University. Santa Catarina, Brazil. Email: fgelbcke@ccs.ufsc.br

ABSTRACT

Qualitative and quantitative study that used the work psychodynamic methodology. The method includes: demand and pre-research, research, research material, interpretation method and data validation. It aimed to analyze wear manifestations of nursing workers from exposure to ionizing radiation, at the hemodynamic service. The research material was extracted from observations, collective interviews and pre-research data. Altogether, 36 meetings were held between March and November 2009, totaling approximately 54 hours of observations. Data were analyzed through the use of simple statistics and developing analytical categories. Results showed that when stress is manifested by such exposure, the workers do not associate it with physical load of ionizing radiation. They employ defense strategies such as denial and relate those damages to the family inheritance, to the fact of being a woman and even by chance. It is concluded that workers trivialize demonstrations and get adapted to the situation, suggesting they are afraid to face reality, and the wear process might be veiled or hidden because it is an invisible physical load.

Keywords: Occupacional Health; workload; ionizing radiation; nursing staff.

INTRODUCTION

The ionizing radiation used in hemodynamic services in the diagnosis and treatment of pathologies are a type of radiation similar to light, but invisible and with enough energy to interact with the human body and cause damage/wear to the health of workers¹. This wear is classified in the literature as biological effects of ionizing radiation, here called wear, by understanding that this term fits better with the theoretical assumptions adopted in this study.

As the ionizing radiation is imperceptible to the five human senses, many times the workers exposed to this physical load and do not worry about it. They tend to ignore the existence of signs and symptoms, since these effects triggered by the action of ionizing radiation on human body is not clearly expressed, because are not immediate, and in some cases may take many years to manifest, or until they are repaired before, they are evidenced¹.

The radiology and diagnostic imaging (SRDI) services demand a wide variety of procedures involving the use of ionizing radiation, as well as the performance of nursing workers. An example of this is the hemodynamic service, the object of this study. In this context the worker, often lacking expertise in this area of knowledge, exposes them self to the physical load of ionizing radiation because in this service, the nursing workers perform actions involving such exposure, especially in patient care with trans interventional procedures, as is the case of cardiac catheterization and angioplasty, the observation object in this study. Nursing also performs procedures in the pre and post examinations, such as reception, preparation, orientation, recording of images, among others^2,3.

It reminds us that the technological advance with respect to the use of ionizing radiation has revolutionized health practices and consequently nursing work. However, it is perceived that the incorporation of these technologies did not bring the end of painful and dangerous work instead it widened inequalities and social injustice and caused forms of more complex and subtle qualitative suffering which are not always perceived by workers^3.4 , especially when it comes to exposure to ionizing radiation.

Considering the above, this research was designed with the following guiding question: What wear from exposure to ionizing radiation have been manifested in nursing workers in hemodynamic services? To answer this question, based on understanding and in the context of the working process of the Nursing praxis in hemodynamics, aiming at the promotion of the health of these workers, outlining as its objective: to analyze the manifestations of wear on Nursing workers arising from exposure to physical charges of ionizing radiation in hemodynamic service.

THEORETIC REFERENTIAL

For the theoretical base of the wear process from exposure to physical charges of ionizing radiation, we used the theoretical framework of Medicina Social Latinoamericana⁵. This approach assumes the Marxist framework, taking the work process as the central category to analyze the bio psychosocial nexuses that are reflected in the worker's health. In addition to this theoretical framework, it has also used the theoretical and methodological assumptions of the Work Psychodynamics of Dejours^4,6, as well as the framework of national and international regulatory agencies that have regarding the use of ionizing radiation^7-9.

The wear is manifested as the result of adaptive processes that affect the worker, causing "loss of effective capacity and/or biological and mental potential."^5:115 Wear is not necessarily, an irreversible process, in addition, being understood as loss of capacity, being expressed or not as pathology, from a medical perspective. Although the wear is manifested in individuals, it is only in the collective that earns dimension, because from the point of view of work psychodynamics, the psychopathological wear is generated by the conditions and work organization ^4-6.

The damage caused by exposure to physical charges of ionizing radiation, described in the literature as the biological effects of radiation are classified into deterministic and stochastic effects^1,8.

The deterministic effects are those whose gravity is directly proportional to the dose of ionizing radiation received by the tissue, for which there may be a threshold dose. These effects occur when the threshold dose of radiation is exceeded. The symptoms of this effect include: erythema, desquamation, cataract, leukopenia, atrophy of components and sterility ^8,10.

The stochastic effects are associated with genetic mutations in cells. It is considered that the interaction of a single photon can cause a serious damage to a DNA strand, resulting in the onset of a cancer, 5 to 10 years after the exposure. The ionizing radiation are mutagenic agents and can produce congenital malformations, reduce fertility and cause sterility, leukemia and premature death ^10,11. The International Commission on Radiological Protection (ICRP) starts from the assumption that any dose of exposure to ionizing radiation, as small as it might be, can trigger these effects⁸. Authors^10-12 indicate that the neoplasm is the most important effect of exposure to ionizing radiation, but there is a great variation in the disease onset time. Since the leukemia can manifest itself in periods of up to five years, and lung tumors, thyroid and liver, in periods of one or two decades post-exposure.

It is important to clarify that, even leukemia being associated with exposure to ionizing radiation, it is unlikely determine if this exposure can actually be the determining cause of the development of the disease in workers who exposes them self to this physical work load. It can be said that, due to his work, this professional presents greater probability of developing this type of cancer^12,13. Lastly, invisible and acting slowly, the ionizing radiation has harmful effects if the precautions are not strictly adhered to avoiding unnecessary exposure and inappropriate doses.

METHODOLOGY

We used the methodology of the psychodynamics of work, which, according to its epistemological nature, focuses on the qualitative aspects, in addition to also raising quantitative data. Such a method comprises: the demand and pre-research, research, research material, method of interpretation and data validation^4,6. The demand and the pre-research constitute the first stage of the research and follows some criteria established by Dejours in developing the method. These include responding: Who demanded the research? What is the demand? To whom was this demand directed?

Therefore in view of these criteria, the research was demanded by nursing staff of seven hemodynamic services in the State of Santa Catarina, Brazil, from questions about working conditions, including issues related to wear, such as: What kind of risk are we exposed to from working with ionizing radiation? What we must do to prevent exposures, among other questions. A meeting was held with professionals in these seven services, aiming at gathering this information. An opinion poll was applied; there are 36 workers, 20 technicians and 4 nursing assistants; 11 nurses and a worker who is not identified.

An opinion poll is held "through structured questionnaire, in which the choice of the informant is conditioned to give answers to questions posed by the investigator"^14:261.

The opinion poll was about the working time in activities involving exposure to ionizing radiation and the type of wear presented. Given the results of this survey it was directed to research itself is a hemodynamic service, based on the premises of a private philanthropic hospital accredited to provide assistance in the interventional cardiology area in Florianópolis, Santa Catarina, Brazil. In this service, took part in the survey: a nurse, five nursing technicians and a nursing assistant, totaling seven participants.

The research material is the result obtained from the discussion with the respondents, identified by an ad hoc collective of workers, the title given by Dejours in their method referring to the survey participants ⁶, from the observations, the group interviews and the data of the opinion poll applied in the pre-research.

In total 36 meetings were held in the period from March to November 2009, totaling approximately 54 hours of observations. The meetings took place in the morning and afternoon, usually at their scheduled times for the cardiac catheterization and angioplasty examinations, with a duration of one to two hours. On average four to five, workers attended each meeting.

The quantitative data were analyzed by means of simple statistics and qualitative data were grouped together, yielding analytical categories.

The data validation was performed in two steps. The first in the course of observations and the second in the inclusion of other hemodynamic workers, which did not participate in the field search. The data analysis considered the experience of the researchers who interpreted the research material in the light of theoretical corpus proposed for this study, being conducted by the statements from the subjective experiences of workers.

The study was submitted to the Ethics Committee in Research of the research institution by CAAE. 0020.0.145.145-08, receiving a favorable opinion for its publication according to Protocol No. 101/2008. The participants were given the Term of Free and Informed Consent and the subjects statements were identified as the ad hoc collective of workers, there is no view that does not individual interviews were conducted, but collective, given that no individual interviews were conducted, but collective, as provided by the methodology from work psychodynamics.

RESULTS AND DISCUSSION

The opinion poll applied in pre-research lists some pathologies and arrhythmic events related to the effects of exposure to ionizing radiation by authors who discuss this topic and comprised the theoretical corpus of this research. Therefore, the nine items listed yielded 65 responses, expressed in percentages.

Among the responses, sleepiness was mentioned by 14 (21.5%); the loss of hair and headache, 11 (17.0%); decline in physical resistance, 9 (13.8%), followed by dismay with 8 (12.2%). Anemia was reported 5 (7.7%), followed by hypothyroidism with 4 (6.2%); dermatoses with 2 (3.1 %) and cataract with only 1 (1.5%).

It should be noted that the effects of exposure to ionizing radiation are also reported in the literature as a response to the exhibition of users submitted to diagnostic examinations, or in interventional procedures¹¹. Having in view that the "high doses administered in interventional procedures, if not known and optimized, can increase the risk of stochastic effects and also cause deterministic effects in patients and in workers' ^{15, 1:523}. Among the effects, we highlight the radio dermatitis patients, cataract cases and serious damage in the hands of the workers who perform this type of procedure. These lesions do not appear immediately, because they are almost "exclusively related to late effects" and depend on the doses received^1:523.

However, the workers and users do not perceive these events immediately after the procedure. To ensure the lowest possible doses it is necessary to optimize the dose to the patient, because smaller doses cause less amount of scattered radiation, which also decreases the dose in occupationally exposed workers¹⁶.

To avoid the onset of cataract the workers involved in the procedures must use IPE lead glasses. Since the professional can receive up to 2 mSv in the lens in a single procedure, and depending on the number of tests performed, this dose may exceed the limits recommended by Decree no. 453/1998, which is 150 mSv/year, as well as in other guidelines that deal with radiological protection^9.10. Regarding this recommendation, it should be noted that this IPE was not used by the ad hoc collective of workers in any of the tests observed, as well as the service does not provide workers did not make a point of using it.

The International Commission on Radiation Protection published case reports on deterministic effects for users and workers, warning that occupational doses in interventional procedures guided by fluoroscopy are the highest when compared with other areas of radiology⁸. Other studies^10,15 also reported cases of cataract and radiodermitis in occupationally exposed workers, highlighting the doctor interventionist as being the professional who more frequently receives the radiation dose.

Resuming the manifestation of wear on this exposure, it was observed that, in interviews, which the ad hoc collective of workers were afraid to talk about these issues. When it came to the subject, the discussion was deflated, as if these problems were far from their reality, and when asked, the answers were shallow and usually full of excuses, such as in the following report:

I have hair loss, but it runs in the family. At home, almost everyone has this hair fall. I don't care about this anymore. (Ad hoc collective of workers).

In addition to this report, this manifestation was also visually detected, confirming that the workers do not recognize such signs as coming from such exposure. In this sense, this study suggests that the hair loss is one of the consequences associated with a high dose of radiation by using fluoroscopy in interventional procedures, which is the case of this work process¹.

Research conducted in a nuclear power plant revealed that workers acquire or even adapt to situations linked to radioactivity, and even aware of the problems that the radiation can bring, do not present major disturbances with these⁴, thus confirming that the employees know that the danger exists, but don't worry about it. The study also showed that the employees are well trained on radiation production and against its effects.

Another manifestation as evidenced by the following report has a relationship with the hematological effect:

Here the workers have presented low hematocrit, including myself, but I've always had. Always had anemia, but as I already mentioned, it runs in the family, because my sisters also have it. (Ad hoc collective of workers).

The main change concerning this interaction in the hematopoietic system is the decreased amount of blood cells. Thus, to evaluate the radiation effects on this system, it uses the normal growth and development as one of the references. The study points out that "between the years of 1920 and 1930 a professional (who worked with radiology] used to visit the hematology laboratory once a week to carry out a routine blood examination"^1:549, since this was the only way of monitoring method, because the individual dosimeter was not used for this purpose yet.

Today, the labor legislation and the guidelines for radiological protection provide that every worker exposed to ionizing radiation are to perform platelet count examinations every six months, as well as the monthly individual dosimetric control^9. However, in the opinion poll applied in pre-research with the seven hemodynamic services, it was found that most of these services have not yet attained such determinations.

In this respect, it is important to consider that exposure to ionizing radiation always causes damage to cells and therefore, there does not exist a radiation dose value that is considered safe¹⁶. Some of the somatic damages may be reversible, but genetic damages are cumulative and irreversible. For this reason, one should seek to reduce the maximum occupational radiological exposure.

Another manifestation reported with respect to fatigue.

I feel tired, but it is due to the day-to-day rushing around, because as you know I work here and in another hemodynamic service, just as my other colleague. I leave straight from here to another service, and it is much more tiring due to the vascular examinations and endoprostheses that are performed. These are much more time-consuming. Here the strong point are the cardiology exams, which I think are much calmer. (Ad hoc collective of workers).

In this report, the worker fatigue associated with work overload, due to having two employment relationships in hemodynamic services.

The study also identified this duplicity, reminding that the workers have more of an employment relationship in hemodynamics¹⁷. In this study, the workers when asked about the reasons for which they worked at more than one location, they replied that they do because the financial gains and have the time and the labor ease to do so.

This double workday is in fact services that use ionizing radiation in the labor process, because the workload prescribed in the legislation for those who work with ionizing radiation is 24 hours per week. However, the real workload practiced by many workers, as is the case with the previous report, is twice, due to the double bond, very common in this area. This duplicity may contribute to cause wear by exposure to ionizing radiation in these workers, because the dose of radiation received is directly proportional to the time of exposure, i.e., the greater is this time, the greater will be the dose received, increasing the chances of the manifestation of the effects. Even in this respect, it is worth remembering that these exposures are cumulative and may take 5 to 10 years, or more, for such effects to appear¹³.

Therefore, it is necessary to protect their health, since the occupational exposure can generate, the medium and long term, problems due to stochastic effects that belatedly manifest themselves¹⁷.

In this study, the wear were fairly discussed and it became clear that has been hidden by ignorance not only of the demonstrations, but also because it is invisible, presenting a load latency time relatively large to manifest themselves and also because in the investigated scenario this issue was not discussed openly. The time in which workers perform their activities already exposing themselves to ionizing important configured physical load on the one hand the possibility of developing diseases arising from such exposure, and on the other to configure psychic load in relation to the ignorance of such load may affect their health and their families.

It is worth pointing out that the lack of activities in-service education on the theme, in the field of study, reinforces attitudes resistant.

It is important to highlight the scarcity of publications, notably for nursing workers in this area of knowledge and the reduced number of trainings that address issues related to the work process involving this exposure and their wear the health of workers. This recommendation is also corroborated by a survey conducted in three radio diagnosis hospital centers^18,19. The authors recommended periodic technical trainings on procedures for radiological protection for all workers who work exposed to radiation, according to current legislation, by providing appropriate equipment for the activities developed in this work process. They still warn, about the importance of informing pregnant women on the risks arising from exposure to ionizing radiation.

CONCLUSION

Investigating the wear of workers resulting from exposure to ionizing radiation in hemodynamic service was not a simple task. Because in addition to dealing with the invisible load and taking time to express itself, the workers are reluctant to relate these consequences with the physical workload, and also because this type of wear may occur as a result of other variables, such as the nature of the human being.

Resuming the questions that led to this research, it can be concluded that there is wear due to exposure to ionizing radiation that have manifested in nursing workers from hemodynamic services, however they deny them. Such damage may be associated with anemia and alopecia, among other events, reported in theoretical contributions and evidenced in the statements of the ad hoc collective of workers. It can be said that, due to the work with exposure to ionizing radiation, these workers have greater vulnerability to this type of wear.

However, when the wear are revealed, workers do not associate the physical burden of ionizing radiation, making use of defensive strategies expressed by denial and relate them to family heritage, the fact of being a woman and even by chance. They trivialize such manifestations and adapt to the situation, as something usual, perhaps for fear of losing their jobs or jobs as there are workers employed in two places, both with radiation.

Such a defense strategy was evidenced in a dialectical relationship that was maintained during the whole research process itself of the method: it was noticed that the ad hoc collective of workers feared talking about these issues as if the problem was not happening with them, and when asked, the answers were evasive and usually loaded with excuses.

In relation to the apparent lack of continuing education programs and nursing training regarding the approach of subjects on ionizing radiation, this may explain why the concealment or even deny this type of wear.

Among the limitations of this study can be considered as the subjectivity expressed by workers and the look of only one researcher. Since the method was developed for application by a collective of researchers and workers, among others, however, the path traveled has its relevance, to enable greater understanding of the subject, its interfaces with other services and the strategies of defense of workers.

It should be noted that the adaptation of the methodology psychodynamics of work with his theoretical contributions allowed these discussions and the reflection of the collective of workers to change attitudes regarding their health and radiation safety. However, other dietary intakes need to be considered for that knowledge about the health of nursing workers and ionizing radiation in hemodynamics will deepen and consolidate into actions. It is necessary to value the experience as well as their personal experience in the fight against poor working conditions for health, for their transformation.

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