RESEARCH ARTICLES

Ethical perspective in care in pediatric nursing: view of nurses

Benedita Maria Rêgo Deusdará Rodrigues^I; Sandra Teixeira de Araújo Pacheco^II; Midian Oliveira Dias^III; Josiane de Lima Cabral^IV; Glaucia Ranquine Luz^V; Taís Folgosa da Silva^VI

^IDoctorate in Nursing by the Nursing School Anna Nery of the Federal University of Rio de Janeiro. Professor of the Children Department of the Nursing College of the University of Rio de Janeiro State. Brazil. E-mail: benedeusdara@gmail.com
^IIDoctorate in Nursing by the Nursing School Anna Nery of the Federal University of Rio de Janeiro. Assistant Professor of the Children Department of the Nursing College of the University of Rio de Janeiro State. Brazil. E-mail: stapacheco@yahoo.com.br.
^IIIGraduate of the 8^th period of the Nursing College of the University Rio de Janeiro State. Volunteer of the Research Project Ethics and bioethics in the context of pediatric nursing: implications for the social practice of nursing. Rio de Janeiro, Brazil. E-mail: dias.midian@gmail.com
^IVGraduate of the 8^th period of the Nursing College of the University Rio de Janeiro State, scholar of the Research Project Ethics and bioethics in the context of pediatric nursing: implications for the social practice of nursing. Rio de Janeiro, Brazil. E-mail: josiane_lima@ymail.com
^VMaster degree of the Post-graduation Program of the Nursing College of the University of Rio de Janeiro State. Brazil. E-mail: glauciaranquine@hotmail.com
^VIMaster degree of the Post-graduation Program of the Nursing College of the University of Rio de Janeiro State. Brazil. E-mail: taisfolgosa@yahoo.com.br
^VIIArticle derived from the Research Project Ethics and bioethics in the context of pediatric nursing: implications for the social practice of nursing financed by the Conselho Nacional de Desenvolvimento Científico e Tecnológico.

ASTRACT

The study aimed to analyze comprehensively how the nurse inserts the ethics and bioethics in the care of children and their families in hospitals. Qualitative study supported the social phenomenology of Alfred Schutz. The subjects were 9 nurses at a university hospital in the city of Rio de Janeiro. The phenomenological interview was used to capture the speeches with questions: When you take care of the child and his family, what do you have in mind with ethic in care? And bioethics? The speeches analysis led to the emergence of categories: To respect the child and to guide the family carer. This study points out the respect for people and the axis orientation as the daily practice of nurses to hospitalized children. It is highlighted the importance of appropriation of ethics and bioethics to subsidize a more critical, consistent, committed and appropriate attitude to the child and his family from a human dignity perspective.

Keywords: Ethics; bioethics; hospitalization; pediatric nursing. 

INTRODUCTION

Every day it is possible to see that new challenges are presented in the practice of health care professional, and specially of the nurse pediatrician. Such challenges are posed in terms of human life and are closely related to the adoption of decisions that require support of ethics and bioehticsVII with regard to the development of actions that involve the child and his family. Therefore, it is necessary to think about the construction of a scientific knowledge about the care of the child and his family with an emphasis on ethics and bioethics perspective to guide the actions of the nurse.

It is worth mentioning that the construction of knowledge in nursing is facing as an own knowledge, as modern science, socially recognized and legitimized. Nursing of continuous way appropriates own epistemology, as well as methodologies, autonomy and wide field of action¹.

In this context, the creation of the Statute of the Child and Adolescent (ECA), Law 8,069 of 19902 imposes to the professional a savoir-faire that inserts in the everyday practice in citizen health-child and his family as a being of rights. In this sense, the development of ethics and bioethics in the care in pediatric nursing is necessary based on respect for the uniqueness and human dignity.

The ECA in its chapter II, Art. 15 emphasizes that: "The child and the adolescent have the right to freedom, respect and dignity as human beings in the development process and as subjects of civil, social and human rights guaranteed in the Constitution and in laws"².

To do so, it is of fundamental importance that the nurses in conducting their daily practice take an attitude based on up-to-date knowledge that subsidize a safe, quality and performance consistent with the ethical and bioethical principles.

The nurse to perform child-hospitalized care should keep in mind that she is a being in development, and therefore she needs to be prepared to exercise her autonomy when adult. Thus, the professional contribution, at this moment, can do with simple actions such as, for example, allow for the participation of the child in the care of nursing as a way to make developing-stimulating the child's autonomy, respecting their cognitive development and their ability of understanding³.

To care for a child and his family in the hospital environment, the nurses act from their baggage of knowledge because of their academic training and their professional experiences and they use to perform their actions. Thus, it is important to highlight the significance of the experiences for the establishment of the knowledge that the subject possesses and which takes to solve the everyday actions⁴.

Thus, we consider that the care for the child is coated with special features that drive the Nurses to reflect on their preconceptions, from their formation and their previous professional experiences, that will influence the implementation of the assistance and that are constituted in the reproduction, often of their beliefs, values and in their way of being and acting. Each person is situated in a specific way in the world of life, what constitutes his biographical situation, interprets the world from their own situation in time and space, determined by the totality of experiences that he even constructs over the course of his concrete existence⁵.

From the exposed here, the objective of this study was to examine comprehensively how the nurse inserts the ethics and bioethics in the care of the child and his family within the hospitals.

LITERATURE REVIEW

The care of the child and his family is not limited to applying a technical procedure to fulfill a purpose purely mechanistic, but intends to provide full assistance, of quality and humanized in a scenario in which, often, are affective ties. Ethical care in pediatric nursing ensures the preservation of human dignity of the child and his family³.

The provision of adequate support for care directed to the child is tied to humanistic positioning taking based on the reinvigoration of ethical debates. In this perspective, the teaching of ethics and bioethics to nurses so that they can accompany scientific and cultural progress, aiming at the development of their responsibilities competently pervades by challenges in the area of health and nursing⁶.

It is necessary to undertake efforts to understand more clearly that the expertise in pediatric nursing must have his foundation in ethics and bioethics. Ethics and bioethics point a path, which proposes to change not only to thought, but also of actions to take. To this end, it is essential to recognize the subject in the social scope, in order to provide reflections with a view to the achievement of a practice in child-centered health, his family and his socio-spiritual and cultural contexts. In this sense, "the nursing assistance directed to ethical care the child encounters in bioethics a reflective path where the nurse can rethink their values, principles, attitudes and actions"^3:192.

In this way, it is good to reflect on the importance of the biographical situation for each person, i.e. "is the sedimentation of all previous experiences of this man, organized according to the usual 'possessions' of its stockpile of knowledge, which are his only possessions, given to him and for him only"^3:73.

From this reflection, we believe that access to knowledge built in everyday professional practice inter-subjectively, makes it possible to act adequately reasoned and better contextualized, generating new paths to be followed. Still, it is worth noting that the actions of the nurse pass by a social practice that brings one of the implications very carefully directed the human being as a subject of rights, aiming to promote their comfort and well-being.

In this sense, it is worth noting that the care takes place in a social relationship between the subjects who participate. "It adds to the factual, technical-scientific dimension that differentiates the practiced by common sense, in addition to guide on inter-subjectivity, on the knowledge and in the biographical situation of the professional caregiver"^5:739.

Therefore, to keep up with scientific and technological development implemented in the everyday life of the actions of the nurse, it is necessary appropriation of ethical and bioethical concepts that pertain to the search of updated scientific dimension to subsidize a more critical performance, consistent, committed and suitable for the child and his family from the perspective of human dignity. Understanding and the search for the solution of conflicts emerging in moral actions on the child in the hospital and his family founded on valuing human life as an inalienable right and uphold the experience as something meaningful of the relationship of who cares and is careful as an intentional design and inter-subjetivity.

That way, we can infer that ethics and bioethics illuminate the paths to be chosen to mediate the moral conflicts that exist in the practice of nursing. Bioethics can be an instrument of reflexive training in the field of nursing, providing support for decision-making, in front of moral conflicts, from the articulation of theory and the facts with which we encounter in everyday life, in order to stimulate epistemological discussions and practices⁶.

METHODOLOGY

Qualitative study with backing from phenomenology sociological Alfred Schütz3. The subjects were 9 nurses, who work in a teaching hospital of the city of Rio de Janeiro. The fieldwork was conducted from April to July 2012, through the phenomenological interview, which takes place in the form of a face-to-face meeting, to capture speech originating in the study subjects about what they think about the ethics and bioethics in the context of attention to child hospitalized and his family⁷.

The interview was guided by the following questions: When you take care of the child and his family, what do you have in mind with ethic in care? And bioethics? The meetings were previously scheduled, conducted during working hours of the people interviewed in the industry, in a reserved room, being the lines recorded and transcribed for later analysis.

The analysis took place in the context of categorization focusing on reason, i.e. the state of the things, the order that the action should promote. The conduct based on an intentional design and inter-subjetivity that is pre-designed to be accomplished. From the point of view of the study subjects, this class of reason refers to their future as an act designed as a future action that is characterized as something that is similar in its essence⁸.

The project was approved by the Research Ethics Committee of the institution with registration number: 3129/2011. After approval of that Committee, it was requested authorization of nurses through the informed consent (TFCC), which was read and commented by the searcher. It was also emphasized the autonomy of the subject to give up the interview at any stage of the study. After the subject accept the participation, they signed the TFCC before each interview.

The anonymity of the subjects has been complied using an alphanumeric code – interviewed (E1, E2, E3, ...) to identify them in their testimony.

RESULTS AND DISCUSSION

Nine nurses participated in this study with the university finished varying between 4 and 28 years; the activities in the area of child health standing between 3 and 26 years; only one not attended  graduation school. The expertise in pediatric nursing was a personal option for five and four, although they have not started the work with children by personal choice, they like what they do in the course of working with children.

The analysis of lines gave the appearance of the following categories: To respect the child and to guide the family carer. Nurses in their lines show us that, although in many cases, the child is subject to risks posed by the treatment itself, its central concern to take care of this child and his family is facing the ethical principles of doing no harm.

To respect the child

For nurses, the professional should keep in mind that the child is not an object or a simple working tool, but a human being with peculiar characteristics, which has a family and feelings involved.

 [...] We have to know that we're taking care of a human being and is not an object [...]. (E4)

[...] It is an involved even to think [...] who's there it's not just, my working tool. [...] It is a human being who has a family that has a lot of feeling there invloved. (E5)

[...] I think crucial, to respect the child. [...]. (E7)

[...] The first thing is to respect the child [...]. (E8)

Care as guiding axis of nursing, must be linked to the respect, involving attitudes of consideration to the other, providing an interactive, dynamic and process of involvement between them.

The child as a person in a training process must be protected against the violation of their rights, taking into account the principles of bioethics as guiding actions in nursing care⁹.

To respect the child during the process of hospitalization and his family get the nurse to recognize it as a being of rights involving the bioethical principles of autonomy, beneficence, non-maleficence and justice¹⁰. As for autonomy, to know the stages of child development is crucial to assist in understanding that the child can and should be stimulated to take part in the care, understanding and sending his opinion to facilitate decisions on the course of his treatment. These will be able to assist in their integration in the hospital institution to reduce the anxiety and fear characteristic of this moment.

The second principle, beneficence, determines that the actions of caring are carried out for the benefit of the child and his family, which is characterized as a favor, but as a claim of benefits and well-being with minors side effects^10,11. Non-maleficence imposes to the professional attitude to do good and do no harm, don't inflict injury intentionally. The action that is needed in this case is the protection of the child and his family¹¹. The justice directs that all children and their families are treated with fairness, no difference. In addition, can receive competent, quality care in an environment worth¹¹.

[...] in the care of the child is very little observed [...] the child as a thinking person and taking their decisions. (E3)

The scientific evidence corroborated that children have more understanding and perception about the ethical implications of their health than were known previously^12-16.

Scholars state that around 14 years old, children can take part in the decision-making of health care in a way analogous to adults¹⁷. In some jurisdictions, these children have the right to allow independently on health care, although some legal conditions be laid down¹⁶.

Younger children can also demonstrate remarkable abilities and preferences regarding their health. Although children may not have a legally recognized right to consent independently about their healthcare, the health team should consider the possibility to assent children whenever possible¹⁸.

Assent implies that health information must be provided to children, adapted to their ability of understanding, and his voluntary cooperation should be promoted as much as reasonably possible. The assent of the child request help promote attention and consideration by the child's moral perspective in relation to health care¹⁸.

When include the pediatric patient decisions, health professionals will be recognizing and respecting the growing participation and self-determination capabilities inherent in the moral development of the human being.

To guide the family carer

They highlight the need and relevance of the family-oriented carer related to procedures, namely, clarification about the assistance that is being held.

We have to be guiding and assisting [...] Then there's a whole base, all knowledge, because we end up getting involved with the family too much with the child and the family. [...] with the carer [...]. (E2)

 [...] passing the whole situation [...] what we are doing, what is being done, although the child may not understand, but is listening, the aunt is going to do that, the medication. and to explain to parents everything that is being done. (E4)

 [...] trying to clarify the family that sometimes the caregiving, despite being an invasive procedure

[...] So, I always try to say, look at the option is that you have the child care [...]. (E6)

 [...] To guide the family about what is going to happen to the child [...]. (E9)

When the care is for the child requires the nurse attention, active and dynamic care, involving the family, because the hospitalization mobilizes the completely family structure. The family along with the child, goes through a series of stress factors and often due to the sudden illness¹⁹.

Thereby, the reception, the interaction and communication with the family team are critical to minimize the suffering and anxiety. To orient the familiar carer, the nurse establishes a relationship of bond with the family, in addition to being a mediator between the team as a whole and this family.

At the time the nurse shares the child care with the family, providing this access to their knowledge. Thus, it is the reflection of the effectiveness of humanized attention requires not only professional expertise, but above all the living ethics to put himself appropriately in relation to the child and his family.

Recognizing the importance of the role of parents and addressing the parents/family individually, it becomes indispensable in the process of integration of children and parents in the inpatient units²⁰. The act of health professionals, in front of the child and his family should value, above all, respect, dialogue, the relationship between people, responsibility, creativity, design, intentionality, reciprocity and the inter-subjectivity.

It is worth noting that one of the limitations of the study was to deal with the complexity of the phenomenon of inter-subjectivity. Another refers to the limited set of participants and only one scenario that prevent the generalization of the findings.

CONCLUSIONS

The study shows the importance of the interaction of health professionals to act guided by ethical and bioethical principles in the context of attention to child hospitalized and their family. Thus, it should be noted that this process involves mainly features such as: respect, dialogue, relationship between people, responsibility, creativity, design, intentionality, reciprocity and inter-subjectivity.

This act refers to a daily practice, whose attitude enhances interpersonal relationships with the child and his family and the experiences of everyone involved to serve them in the perspective of their shortcomings.

The need for the incorporation of ethics and bioethics in the professional attitude is perceived on the technological advances of recent years in the face of the care which is not limited only to a diagnosis or a biological fact in the institutional setting, but the person, namely the child and each of his families, therefore, be singular and inserted into the world of life with habits, customs and different contextualization from its context.

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Recebido em: 27.01.2013
Aprovado em: 27.10.2013