Modes of being among nursing personnel in an emergency unit
Elayne Arantes EliasI; Ivis Emília de Oliveira SouzaII; Thelma SpíndolaIII; Sonia Mara Faria Simões IV; Letícia Becker VieiraV
Nurse, Master in Nursing. Anna Nery School of Nursing of the Federal
University of Rio de Janeiro. Brazil. Email: firstname.lastname@example.org
II PhD Professor in nursing. Anna Nery School of Nursing of the Federal University of Rio de Janeiro. Brazil. Email: email@example.com
III PhD in nursing. Adjunct Professor, Department of Fundamentals of Nursing of the University of the State of Rio de Janeiro. Rio de Janeiro, Brazil. Email: firstname.lastname@example.org
IV PhD in Nursing. Retired Full Professor of Fundamentals of Nursing of the Fluminense Federal University. Rio de Janeiro, Brazil. Email: email@example.com
V PhD in Nursing. Adjunct Professor of the School of Nursing of the Federal University of Rio Grande do Sul, Brazil. Email: firstname.lastname@example.org
Objective: to unveil the meanings of nurses' modes of being in an emergency unit in Rio de Janeiro State, Brazil, in 2012 and 2013. Method: this qualitative, phenomenological study took an approach based theoretically and methodologically on Martin Heidegger. The study participants were 14 women members of the nursing team. Results: transcript analysis revealed that the women were companionable, friendly and affectionate in their relations with the other member of the team in care directed to the client and to the coworker/friend. Conclusion: it was unveiled that, in caring for others, they suppressed care for themselves, revealing a movement towards impersonality. It is important that beings-women-nursing personnel care for themselves in order to care completely for others and to feel fulfilled caring for their own health and well-being.
Keywords: Women; nursing; philosophy; women working.
Women currently occupy a larger space in the Brazilian economic scenario, and they are also considered the main heads of families. The growth of female headship is related to various phenomena such as increasing education of women and participation in the labor market and the increase in the number of marital separations, causing cultural changes regarding the role of women in the family. Some economic activities in the fields of education, health and social services reveal the presence of women in a ratio of 17% compared to 3.8% of men in these activities1.
In terms of health services, nursing professionals stand out in the care setting because they are closer to customers as they are the ones who perform the direct and continuous care. The being-professional in the nursing world lives its worldliness, and the family world-of-work where something is always shared with others2.
The largest portion of the health workforce is made up of nurses, and, given the uniqueness and history of the profession, this is represented mostly by females. This is a reflection of the generic human profile of women in the everyday multiple functions, such as: health workers, main family caregivers, mothers and housewives. The appreciation of the feminine attributes in the nursing profession guides the nurse's daily work to the present day, through the discreet, quiet, compassionate and selfless care revealing the material and symbolic division of the social world 3.
Nursing has been expanding every day its place in the health sector, both at the national context and in the international scenario. The nurse assumes an ever more decisive and proactive role in the identification of the population's health care needs, as well as in promoting and protecting the health of individuals in its different dimensions4.
By taking care to the human being in all its dimensions, as the essence and specificity of the profession, nursing has the possibility to transit the different fields of knowledge as well as the different social realities 5. Several scholars strive to give visibility to the professional role of the nurse, either as autonomous community social practice or as institutionalized care practice, considering the current health care model in Brazil5,6.
This professional has multiple areas to act, as well as potentials and specific possibilities to develop interactive and associative processes in the ambit of social and health policies. Assuming an increasingly distinguishable place, nursing has been asserting itself as a growing profession and inserted in the process of changes in the various fields of activity in health5.
One of the scenarios where nurse professionals act in the Brazilian reality is in the Emergency Care Units (ECUs) which are characterized as fixed pre-hospital care services linked to primary health care, with Mobile Emergency Service (SAMU), hospital units, diagnostic and therapeutic support units and other health care services through logical and effective flows, promoting references and counter-references. They are commited, also, with the implementation of the risk classification in the reception of users in the ECU 24h, according to recognized national and/or international standards7,8.
An analysis on the organization of the work processes in an emergency service and autonomy of nursing workers in providing care to the user revealed that the nursing work is crucial, permeating all spaces of the care service and interlinking the actions9. Thus, solving everyday problems is part of the nursing work, as well as ensuring infrastructure and maintenance of care, occupying thus an empty space in the technical division of health work10.
The organizational work dynamics in an emergency care unit generates a workload of movement and tension. Ths makes it necessary to periodically monitor the mental and physical health of these workers in order to develop strategies to reorganize the work process in order to diminish the sources stress11.
With such everyday nursing work revealed in the analyzed productions, it is necessary to understand the relationship of these professionals in their world of work. Given that women represent most of the workforce in nursing teams, the understanding in the present study is focused on the everyday care exercised by them.
The ways of being indicate the possibilities and ways that professionals use in the pursuit of come-to-be in the world. Studies using the framework of phenomenology open horizons of possibilities for professionals, giving meaning to their experiences and their daily lives and promoting a reflection on the reality and the way of being of others12.
The study contributes in the sense that it makes nursing professionals reflect on their practice of care and they how show they show themselves in the daily life, in addition to producing relevant information to possible changes in the workplace, providing quality care for others and for themselves.
Thus, the concerns emerging from the experience of these women: How do they show themselves in their daily lives? How is their professional experience in an ECU understood? As guiding question of the study, we chose: How is the daily life of women of the nursing team of an Emergency Care Unit? We aimed to reveal the meaning of the way-of-being of nursing professionals in an ECU.
Phenomenology as the theoretical framework refers only to the manner how it is shown and how it leaves and makes visible what it is shown in itself. In order to acquire the transparency of what is shown, it is necessary to shake the stiffness of a petrified tradition to get the originating experiences of being. For this, it is necessary to suppress prejudgments, assumptions and get involved in the movement of empathy to access the entity. The task of the ontology in phenomenology is to understand the being of entities. The essential structures of being are, therefore, sought in themselves and not in those occasional or loose in the air. The philosopher Martin Heidegger deals with existentialism, of whom of the presence, of the understanding of being, among others. When it comes to ways of being, they are comprised in a existential manner, because the being is one of possibilities, it opens up itself and shows how its own being goes13.
This framework makes it possible to look at the world in its existence, understanding its uniqueness through intersubjectivity between researcher and the subject of the research, seeking the meanings and the senses attributed by the subjects in their daily lives, with their baggage of knowledge and their historicity. The Heidegger's theoretical-philosophical-methodological reference comes close to nursing principles because researchers turn their gaze to the subjective conditions of human beings14.
Phenomenology has a descriptive nature and includes the concepts of presence, pre-understanding, worldview, of existential themes and the hermeneutic circle.Phenomenology is a philosophy and a research approach. It is extensively used in nursing with a research approach, and thereby the interpretive phenomenology has become popular15.
This is a qualitative research with phenomenological approach and theoretical-methodological framework based on the method of Martin Heidegger 13-16. Such an approach takes as its starting point the experiences of female nursing professionals in the care of themselve in their everyday life of an ECU. The research scenario was one ECU of the state of Rio de Janeiro - Brazil, in the city of Campos dos Goytacazes. The number of professionals is 104 nursing professionals, among them 59 women.
Study participants were 14 women who are part of the nursing staff in the professional categories: nurses and nursing techniques. They were whether from the civil class - temporarily contracted, or from the military class - civil servant of the Military Fire Department of the State of Rio de Janeiro. Inclusion criteria were: be a nursing professional; be female; be under civilian or military work, and be on duty. The number of interviewees was not determined in advance, as the field stage showed the sufficiency of meanings expressed in the interviews, which were enough to meet the objective of the research.
Data were produced from December 2012 to February 2013. Phenomenological interview was the manner used to access the deponents. Professionals were invited to participate in the research after or during work activities in the healthcare setting. The meeting with those who agreed to participate in the study was mediated by empathy and intersubjectivity. Ontologically, the understanding of the phenomenon refers to the being, an unknown "who" and, therefore, in this instance, empathy and intersubjectivity are present in the relationship between the subjects by reducing assumptions16.
An open interview guide containing items for the characterization of the deponents and the guiding question was used: How is it, for you as a women, member of the nursing staff, the day-to-day experience in the ECU? The interview under the phenomenological method was, this way, carried out.
The impetus for research emerges not out of the theory or the method itself, but out of the situations still not understood or even the things in themselves in the way they become evident in everyday life. The researcher has the intention to question and is directed to an entity in order to grasp its meaning16.
The statements were recorded, as consented by participants, and transcribed as the original speech. During the meeting of the interview, the silence and body language of women were noted, and these are indicated in brackets in the transcript of the interviews. The interviewees were identified by names of flowers to preserve their anonymity.
The analysis proposed by Martin Heidegger is composed by two methodical moments 13. This study presents the first moment: a comprehensive analysis. First, attentive listening and reading of the interviews was developed through suppression of the researchers' assumptions, in order to understand the meanings expressed by women without imposing categories predetermined by the theoretical knowledge/practice. This was followed by the exercise of highlighting (underline) the essential structures (meanings) expressed in the transcripts of the interviews. The analytical framework of the empirical material was later outlined, with the meanings of being a female nursing professional in an ECU and their respective testimonials.
Thus, two units of meaning (UM) were formed with the caput (statement) composed by the very expressions of the testimonials of women. Each UM is presented in the results with some excerpts of the testimonials, followed by the phenomenological discourse of understanding of the women themselves. Finally, the UMs express the meanings of the concept, of the lived, of the care directed to themselves, in the view of female nursing professionals in an ECU.
Approval of the research by the Research Ethics Committee of the Anna Nery School of Nursing/Universtiy Hospital São Francisco de Assis, was obtained (nº 108.464 and CAAE nº 05998512.9.0000.5238).
The study participants were six nursing technicians and eight nurses. The age of the interviewees ranged from 24 to 60 years. With regard to maternity, four have children. Regarding civil situation, nine reported having a stable relationship and five reported not having a partner. The time operating in nursing ranged from 2 to 16; only three participants have only one employment. It is worth noting that all respondents carry out their activities in this ECU for more than 1 year and 6 months.
The testimonials revealed that the professionals live and share with respect, companionship, enjoyment and friendship with all professionals in the environment (UM1):
[...] The day-to-day is this sharing with our fellow team members, we talk about matters of private life. (Tulip)
[...] to keep a respectful attitude toward patients, toward colleagues. (Daisy)
As a team member, I see no problem, people respect one another [...] (Begonia)
[...] I try to make everyone as if we were a united family [...] (Field flower)
We help [...] these are friendships that we treasure [...] is not only in ourselves, between walls, in our workplace [...] our team is a team and structured [...] (Dahlia)
Even in the face of difficulties, in providing urgent assistance during a journey of 24 hours, in a hard and constantly stressful environment, the team has a good relationship, they respect each other, they have fun and act as if they were a family. The friendship and fellowship go beyond the workplace. The team as a whole, nursing and medical professionals, have a good rapport, feel and mean that one can count on the other. The being-in-the-world is present in interpersonal relationships, where one is with the other, relating and living together. Women show themselves in the way of be-there-with when in their daily life in the working world, they share a warm relationship, almost familiar.
The relationship of care of the female nursing professional toward the being who is receiving the care, whether a customer or co-worker, revealed: tries to engage and Take more care of others than of herself (UM2):
[...] Sometimes you get to try to focus more on the patient care and end up leaving your side a little in second place [...] (Orchid)
[...] I absorb, often, problems that are not mine [...] (Tulip)
[...] You take care of others, but you forget a little [...] you end up taking care of others and forgetting about yourself [...] (Hydrangea)
[...] We want to take care of those who are close to us, more than of ourselves [...] I want to make the other person feel good, feel better [...] and sometimes we get forgotten [...] (Field flower)
The interviewees reveal that they dedicate themselves so intensely to other's care, whether a patient or a co-worker, that they may even leave themselves in second place. This care is presented either as health care itself, or as a holistic care involving interpersonal relationships. They show themselves ready to serve the other when caring, they are dedicated to others, make the other person feel good or even when they absorb the problems of another person. In this UM, it is possible also observe that women show the be-with the other.
The phenomenological analysis by Heidegger's method is developed in two moments: comprehensive analysis and interpretative analysis. The first moment allows a vague and median understanding, with the suppression of assumptions of the researchers, the attentive listening and reading of interviews, in order to understand the meanings. In turn, the second moment comprises the interpretation, hermeneutics, in the unveiling of meanings 17.
Understanding is when the existential being can be the presence, so that in itself, opening and showing how the self goes; it is further understand the structure of this existential. The phenomenological interpretation must offer primordial openability to the very presence, of disposition and, at the same time, interpreting itself. The interpretation follows this opening to conceptualize the phenomenal content that opens itself in a existential manner13.
Initially it can be understood that the professionals mean everydayness of themselves as a friendship beyond the professional lived in the ECU. They prove themselves present, companions, friends and loving in the relationship with the other, with the group, where each one has its essence.
Everydayness is a way of being of the presence, precisely as being presence moved in a different culture. In the mode of be-there-with customers and colleagues is also being-in the world. The subject is not and is never given without the world, being as the very liberating presence, he is also co-presence when meeting with others. Be-with is a determination of the very presence; be co-present characterizes the presence of others when, by the world of the presence, releases the possibility for a be-with 13.
They also reveal that in this relationship, care is directed to the customer and also to the very coworker/friend. Therefore, when they realize they are taking more care of the other, they may fail to look to themselves, towards their own care, thus revealing a movement towards impersonality, because the other happens to be more important to them than themselves.
In the search for the entity and not for the being and not worrying in the sense of having a commitment with the being is what Heidegger calls everydayness. When the be-there is absorbed by the world which is circumscribed along with his be-with others, the being is not himself, he is submissive to the choices of others, becoming impersonal. The human being is a being of transcendent possibilities, of be-there in the world. The being in the world is free to choose the path of the own existence, and may be inauthentic or authentic18.
Women showing themselves in impersonality awaken to absorption of themselves by the everyday world, by the care with others, from customers of the ECU to the own colleagues/friends who sometimes also require the care of these professionals, even if it is a non-care relationship itself.
The impersonal belongs to others and consolidates its power, has in itself ways of being; its existential character is when the be-with fuses with the living together. The impersonal takes the burden of each presence in its everydayness and meets the superficiality trend and, therefore, everyone is the other and no one is himself. Nevertheless, this way of being does not mean a deterioration of the factuality of the presence17.
The ways of being of nursing professionals were revealed by their being companions with colleagues in the workplace or outside this and also being caregivers of patients and colleagues, leaving their own care in second place. All this came from their daily experiences, from the process of caring and relating to each other in the ECU.
This finding corroborates a study that highlights the practice of care by the nursing professional as the primary objective of taking care of the other, directing the caring attitude to the being that is under his care. The care of each other, by the exchanges that this provides, brings feelings of pleasure and satisfaction to the caregiver. That is, caring for another is also taking care of yourself19.
Self-care is important and necessary in order that the nursing professional may have a more human activity, as well as a way to improve the knowledge of the self, to value and place himself in the world20.
Nursing, as a profession, calls for self-reflection to effectively take care of the other. This is a profession that, especially because it is about caring for people going through psychological distress, requires attention, compassion and empathy. Nursing professionals in this situation may feel angry, sad, disappointed, and this can lead to feelings of guilt and anxiety, by being generally observed as incompatible with the professional profile21.
Thus, the ways of being of female nursing professionals in this study were presented when deponents showed themselves be-with other professionals in the ECU, whether co-presence or impersonally by taking care of everyone.
Ways of being to the care show that nurses need to understand and give sense to their actions in an authentic manner. The being of presence has its meaning in temporality or in its historicity. Presence is always its past and the historical path built from past experiences12.
Self-care of female professionals ends up simply not, effectively, happening, because women pour themselves to the care of clients and colleagues, and may forget the caring for themselves. On the other hand, they are presence in the daily lives of fellow workers, in the manner they relate well both in the ECU environment and outside this, showing a bond of friendship among professionals.
This study made it possible to reveal the mode of being of nursing professionals who work in an ECU. While they were in the way be-with the other, all those who live with and are cared for by them. The relational socializing with colleagues inside and outside the ECU proved true and mutual when they assert to be friends and companions one of each other and of all professionals of the health team.
The nursing care provided by these women was revealed in an integral way as they take care of both the users of the health service, and of their own colleagues. Thus, care goes beyond the health care and happens also when they promote support, do the best times for the other and absorb the problems of others. In this impersonality, while taking care of everyone, that is, of the other, there remains no possibility to take care of anyone else, that is, of herself.
The study may help women to reflect and understand the importance of taking care of herself in order to undertake nursing care to completion and also in order to feel complete in the taking care of their own health and well-being.
The results should be interpreted considering some limitations. The study presents only the nursing team's perspective, which indicates an important identification within the care process in caring for others. However, the other health professionals should be included for understanding the meanings of care of themselves in this process. It is also worth noting that the results are restricted to a single ECU.
The development of new studies on the subject, in other spaces of attention to emergency care, is recommended. It is expected that these results contribute to the care practice of nursing, encouraging the professionals to reflect on the implications in the process of taking care of themselves, encouraging a debate on the health of women working in the health sector.
1. Brasil. Presidência da República. Secretaria de Políticas para as Mulheres. Relatório anual socioeconômico da mulher. 1ª Impressão. Brasília: Secretaria de Políticas para as Mulheres, 2013.
2. Padoin SMM, Terra MG, Souza IEO. Mundo da vida da mulher que tem HIV/AIDS no cotidiano da (im)possibilidade de amamentar. Esc Anna Nery (impr.) 2011; 15 (1):13-21.
3. Santos TCF, Barreira IA, Fonte AS, Oliveira AB. Participação americana na formação de um modelo de enfermeira na sociedade brasileira na década de 1920. Rev esc enferm USP. 2011; 45(4): 966-73.
4. Backes DS, Backes MS, Lorenzini Erdmann, Büscher A. O papel profissional do enfermeiro no Sistema Único de Saúde: da saúde comunitária à estratégia de saúde da família. Ciênc saúde coletiva. 2012; 17(1):223-30.
5. Erdmann AL, Fernandes JV, Melo C, Carvalho BR, Menezes Q, Emarinony E, et al. A visibilidade da profissão de enfermeiro: reconhecendo conquistas e lacunas. Rev Bras Enfer. 2009; 62(4): 637-43.
6. Souza MG, Mandu ENT, Elias AN. Percepções de enfermeiros sobre seu trabalho na Estratégia Saúde da Família. Texto contexto - enferm. [online]. 2013; 22 (3): 772-79.
7. Ministério da saúde (Br). Portaria 1.020 de 13 de maio de 2009. Access on Jan 20, 2015. Available from: http://bvsms.saude.gov.br/bvs/saudelegis/gm/2009/prt1020_13_05_2009.html
8. Ministério da Saúde (Br). Portaria nº 104 de 15 de Janeiro de 2014. Access on Jan 08, 2015. Available from: http://bvsms.saude.gov.br/bvs/saudelegis/gm/2014/prt0104_15_01_2014.html
9. Calderero ARL, Miasso AI, Corradi-Webster CM. Estresse e estratégias de enfrentamento em uma equipe de enfermagem de pronto atendimento. Rev Eletr Enf. [Internet]. 2008; 10(1):51-62.
10. Marques GQ, Lima MADS. Organização tecnológica do trabalho em um pronto atendimento e a autonomia do trabalhador de enfermagem. Rev esc enferm USP 2008; 42(1): 41-47.
11. Jodas DA, Haddad MCL. Síndrome de Burnout em trabalhadores de enfermagem de um pronto socorro de hospital universitário. Acta Paul Enferm. 2009; 22(2):192-97.
12. Sebold LF, Carraro TE. Modos de ser enfermeiro-professor-no-ensino-do-cuidado-de-enfermagem: um olhar heideggeriano. Rev Bras Enferm. 2013; 66(4): 550-56.
13. Heidegger M. Ser e tempo. 7ª ed.; Bragança Paulista, SP: Editora Universitária São Francisco; 2012.
14. Carmo DRP, Padoin SMM, Paula CC, Souza IEO. O adolescente que cumpre medida socioeducativa: ser-aí-com no cotidiano e possibilidades para a enfermagem. Rev enferm UERJ 2014; 22(3):396-401.
15. Tuohy D, Cooney A, Dowling M, Murphy K, Sixsmith J. Overview of interpretive phenomenology as a research methodology. Nurse Res. 2013 Jul;20(6):17-20.
16. Paula CC, Souza IEO, Cabral IE, Padoin SMM. Movimento analítico-hermenêutico heideggeriano: possibilidade metodológica para a pesquisa em enfermagem. Acta Paul Enferm. 2012; 25(6): 984-89.
17. Ribeiro AC, Padoin SMM, Paula CC, Terra MG. O cotidiano do adolescente que tem hiv/aids: impessoalidade e disposição ao temor. Texto contexto - enferm. 2013; 22(3): 680-86.
18. Sebold LF, Carraro TE. Autenticidade do ser-enfermeiro-professor no ensino do cuidado de enfermagem: uma hermenêutica heideggeriana. Texto contexto - enferm. 2013; 22(1): 22-8.
19. Baggio MA. O significado de cuidado para profissionais da equipe de enfermagem. Rev Eletr Enf. [Internet]. 2006; 8(1): 9-16.
20. Silva AA, Terra MG, Motta MGC, Leite MT, Padoin SMM. Enfermagem e cuidado de si: percepção de si como corpo existencial no mundo. Rev. enferm. UERJ 2013; 21(3):366-70.
21. Preto VA, Pedrão LJ. O estresse entre enfermeiros que atuam em unidade de terapia intensiva. Rev Esc Enferm. 2009; 43(4): 841-48.