RESEARCH ARTICLES
The welcoming within the surgical center under the perspective of the user and the National policy of Humanization Policy (NHP)
Mariana Nepomuceno GironI; Lina Márcia Miguéis BerardinelliII; Fátima Helena do Espírito SantoIII
INurse from the State Department of Health of Rio de Janeiro. Master in Nursing, Health and Society from the Post-Graduation Program in Nursing at the Faculty of Nursing at the Rio de Janeiro State University. Brazil. E-mail: marigiron20@yahoo.com.br
IINurse. Adjunct Professor from the Department of Medical and Surgical Nursing and the Post-Graduation Program in Nursing at the Faculty of Nursing at the Rio de Janeiro State University. Brazil. E-mail: l.m.b@uol.com.br
IIINurse. Adjunct Professor from the Department of Medical and Surgical Nursing and the Post-Graduation Program from the Aurora Afonso Costa School of Nursing at the Fluminense Federal University. Rio de Janeiro, Brazil. E-mail: fatahelen@terra.com.br
IVCutting from the Master’s Dissertation of Giron MN. The welcoming of users within the surgical center and the humanization of the everyday practices of the nursing care. Approved by the Post-Graduation Program in Nursing at the Rio de Janeiro State University, 2013.
ABSTRACT: The objective of this research was to analyze the expectations and experiences of users in the welcoming of the surgical center during the everyday practices of the nursing care. This is an ethnomethodological and exploratory study, developed with 18 users of the clinical and surgical units of a state hospital from Rio de Janeiro. The data were collected in 2013 through semi-structured interview; next, they were submitted to content analysis, which gave rise to the category: Expectations and experiences of users in relation to the surgical center. We have concluded that the welcoming of the user in the surgical center is important, although each one experiences such moment in different manners. It is worth highlighting that, in light of the guidelines of the National Humanization Policy, there is still the need for further dissemination within the hospital environment, as well as for the provision of courses for professionals, in the sense of strengthening the humanized actions in the health scope.
Keywords: Welcoming; Humanization of care; Care; Nursing.
INTRODUCTION
The onset of the Industrial Revolution, which entailed great transformations of the sciences, in the various fields of scientific knowledge, brought equally the material and technological progress; however, later, the effects started to reflect on the life of the human being. The changes so important to the history of mankind have triggered not only a technological revolution, but also a revolution of habits, customs and human values1,2.
The greatest consequences arising from these transformations arose in the human dimension, mainly observed in everyday life, in attitudes and in inhumane behaviors, which generated comparisons between the human beings and machines1-3. The disastrous effects took place in all areas of scientific knowledge; nonetheless, Nursing - as a profession focused on the care actions - keeps its principles based on actions that humanize the relationships of care and interactions with the subjects at different levels of complexity.
Humanizing is to understand the need for rescue and articulation with the subjective aspects inseparable from the physical and biological aspects. In addition to this idea, humanizing is to design a practice in which professional and user consider a set of physical, subjective and social aspects that comprise the health care. Furthermore, humanizing refers to the possibility of incorporating an ethical stance of respect for others, of welcoming the stranger and recognizing its limits2.
The National Humanization Policy (NHP) is complex, runs through different actions and managerial instances of the Brazilian Unified Health System (known as SUS)3-7 and, moreover, has been widely discussed in the training of young university students, future nurses, as well as in different institutional scenarios. Nevertheless, when putting into practice its guidelines in attending the population, one can realize that some services often are not prepared to welcome users, which denotes an imbalance between theory and practice.
The act of welcoming is not necessarily an isolated activity, but is configured in a set of health care activities, which consists in the constant quest for recognition of the health needs of users and ways to improve the solvability8.
The professional experience within the surgical center (SC) has helped to comprehend the difficulty of people upon experiencing surgical, acute or emergency situations, since, in addition to feelings of fear and insecurity, there is also change in self-esteem, anxiety and, frequently, frustration.
Accordingly, one can realize that these feelings are emerged over the care process and when entering the SC, mainly because many times the welcoming is not performed satisfactorily, taking into account that the individual has demands of physical, emotional and psychic nature and not always sees its most urgent needs in relation to issues involving the preoperative being prioritized.
Adding to the questions exposed above, the SC is an unknown and frightening space for many people, especially for those who have never been in that place. Furthermore, the supposed weirdness caused by the clothes used by all professionals and the procedures performed in that environment are surely generators of tensions.
Accordingly, one can understand that the welcoming of the user within the SC is a crucial care, as the health professional recognizes the human being by valuing its feelings, emotions and interacting in the best possible way, even through an affectionate gesture, such as, for example, holding one of the hands, giving a smile or blinking eyes. This favors the comprehension of a stressful moment, soothes emotions and anxieties, thereby promoting comfort and humanized care9,10.
Under the perspective of humanization, the person must be observed in its entirety, taking into account the uniqueness of its dimension as subject11. In this regard, the diversity of coverage of the NHP is commensurate with the dimension of care with which the nursing is committed to ensuring the promotion, protection of life care, well-being and health.
In this study, we address the human experiences of the users served in the surgical center, their influences, in the reality of everyday practices of care, the form of interaction of these subjects, the signs, the connotations, which indicates the intention of the speaker, its immediate intention, all symbolic forms, such as speeches, gestures, rules, actions and behaviors; simultaneously, interviewing them, as well as analyzing the subjectivities contained in the statements, in order to enable the nursing professionals to acquire knowledge to qualify their actions.
Thus, in light of the foregoing, the question is: how are the expectations and experiences of welcoming within the surgical center under the perspective of the user?
Due to all already mentioned issues, the welcoming of users within the surgical center was elected as the study object during the daily practices of care. From the three objectives developed in the dissertation, we have chosen for this study: to analyze the expectations and experiences of users in the welcoming of the surgical center during the everyday practices of the nursing care.
This article might help to subsidize the public managers and the nurses for their future actions, both in the level of development of public health policies and in the health care practice. Similarly, driving the nursing in relation to different forms of care so that people can overcome the impacts caused within the SC, since, when trying to understand their reactions, their feelings and emotions in the face of a surgical procedure, it will be possible to create more effective health care strategies that might meet the actual needs of care of users in the context of the SC.
THEORETICAL AND METHODOLOGICAL BENCHMARK
We have opted for the theoretical benchmark of the Ethnomethodology, and the justifications for its choice are due to its compatibility with the study object, with a research of qualitative approach, with the purpose of attending the collection and interpretation of data, beyond the confluence points in common, in which the researchers who use it seek to comprehend how individuals see, describe and jointly propose a definition of a particular situation. This method aims at studying the everyday of actions, of people, of certain communities, among others12,13.
The method allowed us to observe, interpret and describe how the welcoming takes place within the surgical center by means of the speeches of users, the clues observed between the lines of each speech, the gestures, the symbols, the movement and in the dynamics of care actions that are developed within the surgical center; in the plot of the day to day of the environment, in behaviors body movements, among others. Thus, we have tried to understand “what is different, universal, specific, distinct, stable and changeable, in a micro-social analysis of daily events, common in such units”14:15.
By complementing this idea, another researcher claimed to have followed the same orientation, by observing what was happening behind every gesture of the nursing professional and of the health team, during the contact with the users at the exact moment of a procedure, in the inter-relationships and interactions with them, thereby trying to realize the things that people do not see at the first time15.
The Ethnomethodology is characterized as an inductive method and aims at documenting, describing, explaining and interpreting the world vision, meanings, symbols and life experience of participant subjects and, in this study, how they face the current or potential phenomenon of health care and nursing. Furthermore, it is an empirical research of the methods that the individuals make use to give sense and, at the same time, conduct their actions on a daily basis such as: communicating, decision-making, reasoning, among others12,13.
Methodology
This is a descriptive and exploratory study, based on ethnomethodological principles, developed in a hospital unit in the period from May to July 2013. The surveyed unit is a hospital for emergency and urgency of medium and high complexity, belonging to the Network of the State Department of Health of Rio de Janeiro (RJ) and located in the metropolitan region. The study subjects were 18 users hospitalized in the units of medical clinic and surgical clinic of the hospital in the postoperative period. The criteria adopted for inclusion were: adults aged 18 years or over, irrespective of gender, race, epidermal color and religion; after being submitted to surgical procedures, regardless of the nature of the procedure, elective or emergency; being in favorable clinical conditions, lucid and oriented, interested in participating in all steps of development of the research voluntarily.
This research was conducted in line with the provisions of the Resolution nº 466/2012 of the National Health Council, which deals with researches involving human beings, and was approved by the protocol nº 276.54. The participation of patients in the study was conditioned to the signature of the Free and Informed Consent Form (FICF), after reading and comprehending of the ethical procedures about anonymity, objectives, advantages and disadvantages concerning the implementation of the research.
The data were produced through individual semi-structured interviews, with specific questions to the study, recorded on MP3 player, supported by a previously tested script and by participant observation. Nonetheless, for this moment, only data from the interview will be presented. The subjects were identified with the letter P, associated with the sequential number of participation, exemplifying: P1, P2, P3, and so on.
After the interview, the data were transcribed, organized, chronologically distributed and, according to the answers, were classified and categorized by following the method of content analysis16. Three categories were raised, of which only one will be addressed in this study: Expectations and experiences of welcoming of the user in relation to the surgical center.
RESULTS AND DISCUSSION
Profile of users
The study subjects were characterized by 18 users with several sociodemographic data. Regarding the age of the participants, they belong to the most varied age groups and are between 20 and 66 years. The majority of the users are in the age group between 51 and 60 years, representing 33% of the total of the interviewees. There is a predominance of the male gender, representing 56% of the research participants. As for the ethnicity, 72% of the participants are white, 17% are brown and 11% are black. The majority of the interviewed users showed a schooling level less than nine years of education, being that 33% had uncompleted elementary school and only 11% had complete higher education and post-graduation. Regarding the family income, 61% have income between two and three minimum wages, 22% between one and two minimum wages and 17% earn more than four minimum wages. As for the housing, 78% are residents of the city of São Goncalo, where the health unit is located, 17% live in the city of Niterói, which is a neighboring city that is part of the metropolitan region, and 5% live in the city of Rio de Janeiro.
Expectations and experiences of users in relation to the surgical center
The preparation of the user is held by means of the preoperative nursing visit, in order to explain about its stay in the SC and the moments that involve the transoperative period. Nonetheless, the surveyed hospital unit does not have preoperative nursing visit at the moment. Therefore, the user submitted to elective surgery comes to the SC with many doubts, as shown in the following reports:
I never underwent any kind of surgery, when he said he would give me an injection into the spine, I got terrified. I was trembling with fear, without see anyone, without knowing anything. I expected it was a more truculent thing, but it was so quiet. Quickly, I was in the waiting room (Post-Anesthetic Recovery Center), it was a great relief. (P2)
Surgery, I imagined that it was something out of this world, that’s why I preferred to make the dressing there in the operating room, since I knew I’d be much more protected than there in the ward. Formerly, I got scared when I talked about it, now I’ll have to go there again, I'm calm. (P4)
We really have a disturbing vision in relation to the public hospital, that is to say regarding the emergency, people say they are the best […] are more prepared. We get apprehensive [sic] because, firstly, I did not know what was going to happen, what was my destiny. (P10)
The nervousness is due to never have faced it, [...] I did not expect. Yesterday, I was good […] one talks that it cuts across the middle, another talks that it cuts from one side, then it will leaving you even more nervous. But everything has worked out. (P18)
For the Ethnomethodology, what matters is to seek, in the everyday life, the methods, the way in which people use them to give sense and, at the same time, perform their actions12. By associating beliefs and behaviors of the common sense of the users with previous statements, despite the negative experience, they managed to overcome the challenges of coping with the nervousness and the fantasies that emerge through the fear of the unknown and the lack of information. Moreover, the characteristics of the surgical center, the bureaucratic work and the technical-scientific nature of managerial activities often moves out the nursing professional from the scene, i.e., hinder its performance as the more qualified professional in the care process of the surgical customer.
In the above mentioned case, this situation generates a barrier in the relationship, in the communication and in the bond with the user at the time of weakness and, therefore, interferes in the quality of care, thereby triggering stress on people due to the fact that they do not receive the needed information and guidance. Accordingly, scholars argue that the preoperative period is the moment in which the person needs more information, support and human contact17,18.
Studies corroborate by emphasizing that the higher the degree of understanding of the user about what will happen to it in the perioperative period, the lower the degree of anxiety in relation to the surgical intervention19,20.
Therefore, by understanding that the welcoming is essential in the preoperative step of the patient and how the institution does not made the nursing visit viable, the information and demystifications about everything involving the surgical act must be conducted at the moment in which the user arrives at the SC.
Moreover, we present below other experiences of users served in SC, namely:
The surgery was pretty good, the place was good and the team treated me well, greatest fondness, I see people complain about it, so I spoke to my wife: congratulations to this hospital. I liked it, mainly there (SC) and here (ward) […]. I was worried, because I've just heard the people speak ill of public hospitals […] the fireman said: I won’t take you there, did you understand? (P3)
One thing I can say is that I got very happy with the care they gave me. From what we see, health is breaking down […] they hire firms, outsourcing professionals. I thought it’s very good; the doctors who came to serve me, who applied the spinal anesthesia. (P7)
I came here and I really got surprised by the environment, of hygiene, of care they gave me. Because, in São Goncalo, (another unit) I did not feel very well […] I never had a surgery, had never been admitted to a SC, then I thought it was all very good, clean. (P10)
Opposing to the negative aspects already previously reported by some users, the expectations of the last cited interviewees ranged around the quality of the surgical act itself, the received treatment, due to being a public hospital, the environment, cleanliness and care.
The NHP is guided by the concept of ambience, which refers to the physical space, as a place that aims at providing comfort, privacy and individuality of the involved subjects, thereby contextualizing environmental elements that interact with people, such as color, smell, sound, lighting and morphology, and producing comfort to workers and users. The space that enables the production of subjectivities, meeting of subjects, takes place through action and reflection on the work processes. It is the space used as a facilitating tool of the work process, which favors the potentiality of resources, as well as the humanized, welcoming and resolute care21.
Nonetheless, the reports of users are contradictory, since the majority reported positive experiences, namely:
You see, from the little I saw, it seemed to be good. So I do not know exactly the reason I spent most of the time unconscious, but the little I witnessed was excellent. (P4)
I give a Grade A to the Surgical Center, it was nice. They were abreast of me throughout the time. (P8)
For me, it was good; I have nothing to complain about that. But, sometimes it’s too cold inside there. (P16)
For me, it was perfect; they talked to me and explained about what was going to happen. That’s what I actually needed. (P18)
Even running against some aspects of the welcoming in the SC, in the viewpoint of the user, it was well attended, despite the nervousness. Specially, by the professionals working in surgery rooms, who have more contact with the users when positioning them in surgical tables, being beside, talking and supporting them. In this case, the humanization of care was expressed in the form of care, of understanding and of the practical knowledge of the professional who comprehended the actual needs of the user. Corroborating the above mentioned, the welcoming was comprehended as a way for the users are well attended and the professionals solve the health problems, thereby offering to customers a personalized care22.
Feelings and subjective aspects of users
In addition to the questions about the surgical procedure, the respondents express the feelings that go through the perioperative moment. Among them, 15 out of 18 users reported that:
I was afraid! You see all those things, you say, oh my God! […], however, once, until the hour of the anesthesia, I was so nervous that I thought I had felt a shock on my feet […] I spent too much time in the hallway, alone […] I was already amazed. (P1)
I was afraid […] every surgery might be the minimum that is, but it has a risk […] Then, that sensation that I could pass away, but I wasn’t desperate […] I was balanced. But I was anxious at that time. Will it hurt? Won’t? But everything worked out. (P11)
I got nervous […] I have a husband, children, grandchild […] the whole crowd there together with you, with my mother, my siblings […] I was really afraid […] was more afraid because of my family. (P13)
In Ethnomethodology, people search for clues, evidence and all that lies between the lines, or behind each gesture, each speech12 that can reveal how the fear was present with the majority and was individually shared with each subject. It was also observed in the expressions of the subjects, when they enter the space of the SC, facial connotations of nervousness, anguish, anxiety, tension, concern and body trembling. At that time, if the person is actually welcomed, it will feel comfort and fear will be momentary. Welcoming involves an availability of the professional to be present, thereby meeting the most urgent needs of the patient. These needs go beyond the physical and biological aspects and involve the subjectivity inherent to the human being.
Nonetheless, transforming the institutional culture and the work climate of professionals is not an easy question, in addition to being very complex, given that this type of change involves different ideologies and world conceptions.
Thus, it is a task for nurses, during the preoperative reception, to identify the needs of patients, with the purpose of working with different feelings, emotions, insecurities and questionings that permeate this process and that can often determine the experiences lived by the subjects19. It is worth mentioning that one of the limitations of this study is the reduced number of participants in one scenario only; furthermore, there is the question of subjectivity in the face of the complexity of the phenomenon of research.
CONCLUSION
The comprehension of the whole process of nursing care within the surgical center in the light of the NHP was made possible by the availability and sharing of experiences of users that showed, through their testimonies, the elements composing the welcoming, such as the professional/user interaction, the communication/dialogue, empathy, environment, comfort and infrastructure.
The practices of care within the surgical center often are not consistent with the NHP and the welcoming of subjects, due to the difficulties encountered in service and due to not having the preoperative visit, which is a fact that maintains the culture of that place. Thus, the reception is perpetuated without questionings about demands of users in the immediate preoperative moment.
Although much of the users of the surveyed service judge the treatment received within the SC in a positive way, the practices of care partially meet the guidelines set out in the NHP, regarding the ambience, welcoming and expanded clinic.
The environment of the surgical center, due to being a restricted environment, with specific machinery, garments and routines, is little known by the users, who, in general, know it by means of previous experience of surgeries or through images of cinema or television. Added to the expectations about the surgery and the feelings generated by that moment, among them the most prevalent is the fear and its multiple sides: fear of death, fear of the risks of surgery and fear of leaving the family members.
In the light of guidelines of the NHP, there is still the need for further dissemination within the hospital environment, as well as for the provision of courses for professionals, in the sense of strengthening the humanized actions in the health scope.
We highlight the possibilities of the Ethnomethodology for the investigation of emerging phenomena of the everyday of the nursing practice, thereby encouraging the study of the etnomethods.
In order to reach the guidelines of NHP, we recommend the permanent in-service education that must not only have the NHP in its theory, but to develop methods that can make it concrete and tangible, which might transform the reality of care of the user within the SC.
REFERENCES
1. Blainey G. Uma breve história do mundo. Rio de Janeiro: Fundamento; 2007.
2. Previat AR. Tempos Pós-Modernos: o legado de Charlie Chaplin. Rev Acd Multidisciplinar, Universidade Estadual de Maringá. [Internet] 2001; [citado em 09 nov 2013] Available at: http://www.urutagua.uem.br//ru09_sociedade.htm.
3. Capra F. O ponto de mutação: a ciência, a sociedade e a cultura emergente. São Paulo: Cultrix; 2006.
4. Ministério da Saúde (Br). Programa nacional de humanização da assistência hospitalar. Brasília (DF): Editora MS; 2003.
5. Ministério da Saúde (Br). Política nacional de humanização: humaniza SUS. Brasília. (DF): Editora MS; 2004
6. Ministério da Saúde (Br). Cadernos humanizaSUS - Atenção hospitalar. Brasília (DF): Editora MS; 2011.
7. Ministério da Saúde (Br). Acolhimento nas práticas de produção de saúde. Brasília (DF): Editora MS; 2006.
8. Ministério da Saúde (Br). Ambiência. Brasília (DF): Editora MS; 2010.
9. Schimith MD, Lima MADS. Acolhimento e vínculo em uma equipe do programa saúde da família. Cad Saúde Pública. 2004; 20: 1487-94
10. Waldol VR, Fensterseifer M. Saberes da enfermagem: a solidariedade como uma categoria essencial do cuidado. Esc Anna Nery. 2011; 15: 629-32.
11. Waldol VR. Cuidar: expressão humanizadora da enfermagem. Petrópolis (RJ): Vozes; 2006.
12. Ayres JRCM. Hermenêutica e humanização das práticas de saúde. Ciência saúde coletiva. 2005;10: 549-60.
13. Coulon A. Etnometodologia. Petrópolis (RJ), Vozes; 1995.
14. Coulon A. La Etnometodología. Madrid (Es): Ediciones Cátedra; 2005.
15. Coelho MJ. Cuidar/Cuidados em enfermagem de emergência: especificidade, aspectos distintivos no cotidiano assistencial. [tese de doutorado]. Rio de Janeiro: Universidade Federal do Rio de Janeiro; 1994.
16. Berardinelli LMM. A (IM) Posição silenciosa no cotidiano da enfermeira preceptora [dissertação de mestrado]. Rio de Janeiro: Universidade Federal do rio de Janeiro; 1998.
17. Bardin L. Análise de conteúdo. Lisboa (Port): Edições 70; 2009.
18. Nogueira MM, Soares E, Dutra GO, Souza BM, Ávila LC. Pre-operative: approach strategy in humanizing nursing care. R Pesq cuid fundam. 2011; 3:1711- 19
19. Silvia DC, Alvim NAT. Ambiente do centro cirúrgico e os elementos que o integram: implicações para os cuidados de enfermagem. Rev bras enferm. 2010; 63: 427-34.
20. Fonseca RMP, Peniche ACG. Enfermagem em centro cirúrgico: trinta anos após criação do sistema de assistência de enfermagem perioperatória.Acta Paul Enferm, 2009; 22: 428-33.
21. Costa P, Klock P, Locks MOH. Acolhimento na unidade neonatal: percepção da equipe de enfermagem. Rev enferm UERJ. 2012; 20: 349-53.
22. Ministério da Saúde (Br). Ambiência. Brasília (DF): Editora MS; 2012.
23. Macedo CA, Teixeira ER, Daher DV. Possibilidades e limites do acolhimento na percepção de usuários. Rev enferm UERJ. 2011; 20: 457- 62.