RESEARCH ARTICLES

Social representations about their own vulnerability developed by nurses caring for people living with HIV

Érick Igor dos Santos^I; Antonio Marcos Tosoli Gomes^II; Denize Cristina de Oliveira^III; Sergio Corrêa Marques^IV; Margarida Maria Rocha Bernardes^V; Ingryd Cunha Ventura Felipe^VI

ABSTRACT: The phenomenon of vulnerability permeates nurses’ personal and professional daily life. This study analyzed social representations about their own vulnerability among nurses caring for patients with Human Immunodeficiency Virus. Social Representations Theory provided the methodological framework guiding this qualitative, descriptive, exploratory study. Thirty nurses from a public hospital in Rio de Janeiro, Brazil, participated through semi-structured interviews. Thematic content analysis using QSR NVivo 9 software yielded, seven categories in all, with both vulnerability and empowerment emerging. It is concluded that, in its bases and outcomes, socio-cognitive reconstruction of vulnerability and empowerment is varied and changeable and, in movements that upset and restore balance, it embodies the vulnerability-empowerment dyad.

Keywords: Health vulnerability; acquired immunodeficiency syndrome; nursing care; communicable diseases; occupational health.

INTRODUCTION

Vulnerability^VII as a construct is presented as the product of different scientific and social perspectives on the problems of the human condition, especially in terms their illness and death. In line with the polysemy, complexity and usability of the vulnerability concept in various areas of knowledge¹, the healthcare terrain shows its problematic and conceptual approaches as fruitful. In recent years, the ideas of vulnerability has expressed facets which emphasize the social context of human groups^2-5, notwithstanding to their quantifiable aspects that could potentially produce the illness.

In this sense, the question that guides this research is: What are the representational constructs of vulnerability developed by nurses who care for people living with Human Immunodeficiency Virus (HIV)? As an object, it was defined in the socio-cognitive reconstruction performed by nurses about their vulnerability in care for people living with HIV/Acquired Immunodeficiency Syndrome (AIDS) and, as objective, analyze the social representations developed by nurses who care for patients with HIV about their own vulnerability.

The study in question is justified by the growing interest of the authors in the research of the problem of communicable diseases in the population groups, particularly in their symbolization processes. Now their relevance lies in the presence of vulnerability in knowledge / everyday of the nursing profession, which makes it necessary to develop research, propose care and action models for the promotion of workers' health to consider the phenomenon of vulnerability in their nature to be developed in its manifestations and characteristic dynamics.

METHODOLOGICAL THEORETIC REFERENTIAL

Taking as a basis the theoretical work of some authors^1-5, in this research, the vulnerability and risk are understood as partakers, complementary and trainers a system of dual lens, allowing the visualization of the health-disease-care under expanded and comprehensive perspective.As such, this review illuminates the dynamics of quantifiable variables or causality, as well as other more social, cultural, historical and psychosocial who not only part of the world scenario in which we live, but it has gradually been considered by the various areas that make up the healthcare field^6,7. It is noteworthy that vulnerability and risk, supported by their respective epistemological foundations, are not hegemonic among themselves, essentially. Their conjunction in the analysis in health research in nursing and points to a possible symmetry between qualitative and quantitative issues present in the production of disease in humanity.

When the provision of care to the client, it is often required for, professionals to engage in some situations, in addition to their physical capabilities, emotional and mental, which could end up weaken it⁸. Regarding the workload, it was found that nurses experience high levels of stress, which may culminate in progressive wear and exhaustion, which contribute to the occurrence of burnout⁹.

The experiences in the context of care may lead nurses to revisit their subjective universe from the time of care experiences with the person living with HIV / AIDS, and how, thereafter, the weaknesses of one can influence the other¹⁰.

As the theoretical and methodological path the Social Representations Theory was adopted¹¹, in its procedural approach^12,13. The study population was comprised of 30 nurses who performed their work activities in a municipal hospital in Rio de Janeiro, reference for the treatment of patients with HIV and tuberculosis. Professionals with less than six months of professional activity were excluded in the chosen scenario. This is due to the time factor is set as a determinant in the development of social representations. No other attribute is constituted as a criterion for justifiable exclusion.

The techniques chosen for data collection were the socio-demographic questionnaire to characterize the subjects and the semi-structured and in depth interview. Now a technical treatment of selected data was the thematic content analysis following systematization¹⁴ and operationalization by the software QSR Nvivo, version 9. This computerized tool was chosen because it proposes to instrumentalize the researcher in qualitative exploration, organization, analysis, and graphical presentation of information until then unstructured. Its operation based on free and computerized coding, distribution and storage of text clippings in nuclei categorical sense⁷.

The ethical principles for research with human beings were adopted and obeyed, in accordance with the norms of the Resolution no. 466/12 of the National Health Council. The protocol for the approval of the Research Ethics Committee of the Municipal Health Bureau (CEP SMS-RJ) received was No. 200/08.

RESULTS AND DISCUSSION

The subjects were mostly female (87%), belonging to the age group of 41 to 45 (27%), professed the Catholic religion (40%), with a partner (70% ), post-graduates (90%), 16 years or more of institutional activities (37%), 16 years or more of working together with HIV patients (30%), giving care at the time of data collection (63%) and with access to scientific information (77%).

The analysis instrumentalized by Nvivo 9 resulted in 1696 Record Units (RU) and 123 units of meaning, distributed into seven categories, which represent 100% of the analyzed corpus. Although construction of the categories has been based on the reconstruction of the social thought of subjects concerning the vulnerability, although empowerment emerged as the participant element with the same and the vulnerability seems to maintain high complexity relationships. Therefore, based on the property that empowerment has to clarify certain aspects of vulnerability, both will be described in the results of this study.

It is worth pointing out that the following discussion consists of a horizontal mapping of results obtained, and not vertical. The categories and their representativeness in percentage are outlined below.

 Category 1 - The presence of the vulnerability and empowerment in the memories of nurses who care for HIV-infected people

This category includes 342 RU and 22 units of meaning. It is equivalent to 20.1% of the analysis' total corpus. Its contents relate to different facets of unfamiliarity about HIV by nurses in the study at different historical periods. It is observed that there is a strong affective dimension of vulnerability in the memories of the subjects, which is presented in the form of fear of contamination and death:

Because it is normal for the survival of the human being. We have fear of something unknown and it is known that the death is ugly. Until then I did not understand it, so I remained closed. Then the feeling fear. Fear and the desire to preserve myself. (Subject 18)

This characteristic of fear of nurses seems to be coming from the fact that blood is intrinsic to occupational risks to which these professionals were exposed⁶.

To chart a comparison between access to scientific knowledge about AIDS early in the epidemic and in recent times, nurses reveal the lack of studies that could explain theoretically their practices and set out to find ways to address this deficit. The uncertainty seems to have motivated nurses to seek information to guide their care, becoming, in this way, more empowered:

Look, in fact, at that time, the literature was still very poor in relation to the disease. Today we have observed that there are manuals on AIDS [...] And I sought information through communication vehicles, such as television and radio. At the time, we did not have computers. Moreover, the literature was poor. (Subject 20)

Empowerment shown figuratively, also, the acquisition of professional knowledge and experience⁷. The nurses value the knowledge by leveraging their professional autonomy, guiding or improving the care provided.

The more knowledge we have, better the care will be. Then this will reflect directly in care. (Subject 14)

What made me change were, throughout these years, several courses and lectures. The taboo of beginning, the impact that I had in relation to HIV 15 years ago, decreased as the years passed. Then I could relax a little bit. Relaxing in order not to prevent me to relax, but do not stay with that fear which I had at the beginning. (Subject 19)

This category shows that the representation of vulnerability mobilizes internal forces to nurses for the progressive adaptation to reality⁴, which requires time of practical experience and the search for information⁷.

Category 2 - Vulnerability and empowerment in the hospital institution and its infrastructure

This category has 277 RU distributed in 21 units of meaning, and, thus, represents 16.3% of the analysis. In accordance with the data grouped in this category, the hospital infrastructure is seen as something whose disability affects both the nurse providing the care for the patient who receives the data. The vulnerability, in this case, presents two facets, which is formed by the discomfort present in the activity of caring and that by constraint upon the precariousness of care performed:

I think it important that we have a decent bed to treat not only the patient with AIDS, but as any patient. The beds have to be more modern. When we puncture, the patient is very awkward because the beds are very low. For both the professional and the patient it is uncomfortable. (Subject 3)

The labor organization and the process of hospital work reaching the nurses in their subjective and physical dimensions¹⁵. This way, the constraint exemplifies a subjective involvement work, while the discomfort expressed a physical dimension.

The vulnerability created by the lack of human and material resources in the daily work of the nurses in this study seems to move them to the completion of adaptations and improvising in care¹⁶. The empowerment, then, is manifested in the statements of the subjects in the practices referred to use in place of an input to another missing in the institution, beyond the restriction of nursing evolution to more severe patients, due to the disproportion between the number of patients and the nurses:

We do not have cotton, but we have gauze. We're not going to have alcohol, but we have other things to do the cleaning. (Subject 16)

Because sometimes you can't evolve all of the patients. Therefore, I try to always evolve the serious cases. (Subject 5)

Regarding the nursing workers, institutional factors that influence the quality of care and the health of the worker must be taken into consideration, such as the load and the work shift, the bureaucratic procedures that may generate wear, the nature of the work, the existence of personal protective equipment and the knowledge on how to protect yourself^7,15,17.

Category 3 - Between the risk and prevention: vulnerability and empowerment in the context of biological occupational accidents and adopted preventive practices

With 501 RU distributed in 27 units of meaning, this category is equivalent to 29.5% of the analyzed data. Discusses the occurrence of occupational accidents and the practices mentioned by individuals to deal with the imminent risk of contamination by HIV or other blood borne pathogens. The social actors on in discussion reveal the traces of vulnerability targeted losses in physical and mental resulting from occupational accidents. It is interesting that the nurses, although they have a cognitive dimension of empowerment in prevention provided by personal protective equipment (PPE), have reported difficulty using them for various reasons:

We know that we have to use (PPE), but don't use it [...]. I think that it is resistance. Even a vice. A bad habit. The habit of doing the wrong things. We are so accustomed to do it automatically. (Subject 5)

We believe that nothing will happen with us. (Subject 10)

All of the health institution should have a protocol for the cases of occupational accidents involving exposure to blood and body fluids containing recommendations prophylactic post-exposure and follow-up of this worker for at least six months after the exposure. It is important that the institutions schedule strategies for the adoption of protocols, aiming at the reduction of its underreporting¹⁸.

Category 4 - interpersonal Relations between nurses and people living with HIV/AIDS as mediators of the vulnerability and empowerment of both

Between the discursive content gathered in this category, it is possible to list the various modes of relationship maintained between nurses and patients, in the nurses' perspective. The manner in which these two groups relate may potentiate or reduce the perceived status of vulnerability and empowerment in the context of nursing care. This category is formed by 159 RUs, distributed in 13 subjects and holds 9.4% of the total corpus analysis.

The aggressiveness of the patient is viewed as a constant threat to nurses:

Many are aggressive with us. They think that because they are calling we have to serve them at that moment. My colleague was pregnant and took a slap in the face from a patient with AIDS, because he was angry. (Subject 29)

Regarding the empowerment, a manifestation of patient's trust in professional deposited, the presence of praise and appreciation of their practice by patients are present in the representations developed by nurses. For them, the work becomes better when the interaction with the patient is something positive, specifically when there is confidence.

[...] it is very rewarding for the patient to look at us and say: 'Oh, good! Today is the day of your shift. For me, I've won the day when they say this. I think that it is a prize! Because I think that, at this moment, it shows that they have confidence. (Subject 11)

Under these evidences, it is apparent that, despite the constant initiative of approximation, zeal, dedication and love on the part of the nurses^4,6,7,10,19 - which fits the postulates ethical and philosophical in nursing - there is, in moments of violence, an apparent disfiguration of nursing care in its foundations more ontological, derived from the difficulty faced by nurses to interact empathically with clients under their care.

However, the empirical data reveal a degree of ambiguity present in interpersonal relationships between nurses and patients. If the discourse of some study subjects patients may have a more aggressive behavior toward professionals - possibly derived from a higher degree of psychic weakness in coping with the illness process and the imminence of death - for others, patients behave opposite to the first way, and express recognition, trust and affection directed nursing staff assisting them.

Category 5 - The mental limits faced by nurses in their experience of working with HIV patients

This category is composed of 208 RU and 15 themes. Its universe corresponds to 12.2% of the total corpus analysis. There are analyzed the representational content relating to being a nurse in the field of AIDS and its meaning ambiguous. Nurses have traces of their vulnerability included in the representations of the profession, as well as wear and stress arising therefrom. The death of the patient in the care or your terminal condition are seen as difficult, threatening, distressing and mournful situations, as can be seen in this passage:

The issue of death was always very difficult. It is very difficult still, until today. Then, when I saw, that I knew that the patient was dying, I could not bear it. I suffered a lot! (Subject 10)

Nursing presents itself as one of the professions with high risk for wear and illness, especially when performing its actions within the hospital environment, because this is where the professional experience varying degrees of stress and suffering²⁰. It is understood that the work in the context of HIV simultaneously enjoyable and risky, which implies the occurrence of movements on the part of the worker to avoid suffering and to maintain your mental equilibrium^4,7,21.

Category 6 - The quest for spirituality and religiosity as bases of support for the professional life contextualized in AIDS

This category captures 23 record units, which have been grouped into three themes, composing 1.3% of total corpus analysis. In its content, one can identify the Divine as factor reshaping those communities compared to the hostility of the work activity in the context of HIV. The search for a status of empowerment more favorable, then, is marked by its routing instances to spiritual superiors, mediated by faith and religion.

The care of patients with HIV/AIDS is perceived as a factor that exposes the nurses to contamination, possibility this attenuated by faith. In this case, the Divine influence is conceived as a means of overcoming fear:

This issue of fear, as soon as I arrived here was very fast. Then I managed, thanks to God, to break with this (the fear) quickly. (Subject 15)

Religion and religiosity are here understood as more pragmatic ways that allow human access to a transcendental force. In this sense, religion is conceived by the subjects as a source of protection, support, acceptance, recovery or guide, oriented by a higher power, because of its existence:

When you have a religion, it is not possible to dissociate it from practical life. My religion is evangelical. Are rules that we have as our basis, which would be the Bible. It seems like a tyrant thing, with rules - that's the word, rules - but they exist so we can live in a better way. (Subject 4)

It can be ascertained that there is, in the representations of the vulnerability, the search for religion and therefore the Divine, symbolized by God magnetically in the representation of subjects. Both faith and religion provide a sense for the professional life, constituting itself as a source of encouragement, comfort and strength to face the uncertainty, the fear, the pain and the proximity of death promoted by AIDS. Then, the religiosity emerges as explanatory source for events, a support for coping with the difficulties and for the design of professional practices^7,22.

Category 7 - A vulnerability in the context of different types of relationships in personal life: the presence of risk as an organizing element of discourse

In this category are included 186 RU, distributed in 22 subjects, which represents 11% of the corpus total submitted to analysis. In it, are dealt with the different kinds of relationship in the personal life of nurses. Among them are the relations maintained with the family, with the society and with you, under the influence of labor activity in the context of HIV.

If prejudice as a weakening factor emerges from the discursive processes of subjects under the disapproval from family members and friends about the work with HIV patients in the affective life, prejudice also defines its marks and represents a threat to the continuity of relationships:

Until today still, encounter. When it is her boyfriend, for example, he asks 'What does she do for work'? 'I work with AIDS'. He is already half... Until really finding out what it is, a little complicated. (Subject 27)

When nurses do not use condoms in their relationships, there is a decision-justifying position, which aims to support the remedial actions. It is possible to notice that the justifications are focusing on qualitative disapproval of the condom as a method of HIV prevention.

I don't like condoms. I think that is why. I think that it is something fabulous, but they should invent something else because I don't think it is good. I don't know if because I'm 52 years old and I came from a generation that did not have the habit of using condoms. Therefore, I think that is why, because having a sexual intercourse without condom, I think that the pleasure is greater, the contact is best, the act of sex and penetration. (Subject 10)

This relates strongly to a manifestation of susceptibility in statements of the subjects. Simultaneously, individuals living with HIV/AIDS is conceived as someone of normal characteristics, healthy look and healthiness, which translates the invisibility of HIV as a factor that puts them at risk:

Today, unfortunately, who sees their face does not see AIDS [...]. (Subject 1)

The nurse, as human being, experiences the most varied crises, existential problems, unresolved conflicts and many other difficulties^2-4,6,10. In this sense, the process of self-knowledge is essential for the training of this professional^23-25. Note that the personal lives of nurses, as well as that of those around them, are in constant threat by the risk.

CONCLUSION

It is concluded that, in the social representations of the vulnerability to nurses, are present the lack of scientific knowledge about AIDS in the blaze of its epidemic, dealing with HIV per se, the precariousness of infrastructural conditions of the workplace, the disapproval and lack of support from some relatives on the activity, the unfavorable relations maintained between them and the patients under the care of nursing, the recognition of the risk of contamination and the imminent nature of occupational biological, in disuse of condoms and the invisibility of HIV in relations affective-sexual that keeps in their private lives.

The socio-cognitive reconstruction of empowerment, on the other hand, consists of ways of coping whose objective is the reduction of the vulnerability. The latter consists in the search for Divine support through religious institutions, in access to scientific information, on professional experience, in adaptations and improvisations of the work, the fragile and little institutional support for the exercise of the functions of a nurse, in satisfaction and processing the personal dimension offered by work in the field of HIV/AIDS and the protection provided by personal protective equipment.

This study, in spite of having reached the goal previously outlined, has limitations, such as the sample number limited to 30 deponents and their implementation in a single institution. From the study of the reconstruction of psychosocial vulnerability, emerged from the empowerment, which provided the substrate for the proposition that the vulnerability and the empowerment that engender mutually in movements of balance and counter balance, i.e. they constitute a vulnerability-empowerment dyad.

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