ORIGINAL RESEARCH

The symptom and its implications in nurses' clinical practice in intensive care units

Petra Kelly Rabelo de Sousa Fernandes^I; Karla Corrêa Lima Miranda^II; Manuela de Mendonça Figueirêdo Coelho^III; Arisa Nara Saldanha de Almeida^IV

^IPhD student in Clinical Care in Nursing and Health at the State University of Ceará. Fortaleza, Ceará, Brazil. E-mail: petrinha_kelly@hotmail.com
^IIPhD in nursing. Adjunct Professor of the State University of Ceará. Fortaleza, Ceará, Brazil. E-mail: kfor026@terra.com.br
^IIIPhD in nursing. Professor of the Metropolitan College of Grande Fortaleza. Fortaleza, Ceará, Brazil. E-mail: manumfc2003@yahoo.com.br
^IVPhD in Nursing. Professor of the Metropolitan College of Grande Fortaleza. Fortaleza, Ceará, Brazil. E-mail: arisanara@gmail.com

DOI: http://dx.doi.org/10.12957/reuerj.2017.14480

ABSTRACT

Objective: to discuss the symptom and its implications in the clinical practice of nurses in intensive care units (ICUs). Method: in this theoretical, analytical reflection study, the concept of "symptom" was approached in terms of how it arose in the field of medicine, through to the dimension of symptom considered in psychoanalysis. The proposal was then to reflect on the comprehension of symptom that permeates nurses' clinical practice in the ICU. Results: in order to know the symptom, it is necessary to know the subjects cared for, and to perceive them in their singularity, by listening focused on their life histories, so as to create the conditions in which the subject of the unconscious can appear. Conclusion: ICU nurses cannot limit their work process exclusively to the patient's condition in terms of illness, but must first ask themselves who this subject is, and what his or her life history is, to consider the unconscious dimension.

Keywords: Symptoms; nursing care; nursing practical; intensive care units.

INTRODUCTION

The concept of symptom is discussed in several fields of knowledge, and can be understood in different senses. When this concept is approached, it is usually associated with diseases, as if they were synonyms.

This perception shows a strong influence of medical practice and pathological anatomy, especially during the eighteenth century, when the medical gaze valued symptoms and signs. Symptoms were interpreted as the very expression of the disease, and the sign was valued for its ability to predict what would happen, to do anamnesis of what had happened and to diagnose what was happening at the moment¹.

The meaning of symptom for the medical clinic is always pathological, being a phenomenon that, by definition, is opposed to the state of health. Thus, as something of an invisible orbit, the disease becomes transparent by the symptom².

Following the model of natural history, classical medicine had as subject and object, respectively, the superficial look of the doctor and the plane space of classification of diseases. Defining a disease would consist in listing its symptoms and to do so it was necessary to abstract the patient from this context, which represents a medical practice of pathological species³.

Therefore, in order to establish the relation between the symptom and the illness, that is, the relation between the signifier and the meaning, the intervention of the medical perspective was necessary. This transforms the symptom into a signifier that immediately identifies the disease as its truth, thus making the symptom a sign².

However, this perception of symptoms in medicine differs from the perception of other fields of knowledge, such as psychoanalysis.

In psychoanalysis, symptom as signifier represents the subject itself. It does not reveal the truth of an organic disease, but it is the truth of the subject of the unconscious and refers to something that can be apprehended from the life history of each subject, and can be deciphered with the participation of the psychoanalyst, but which will only have meaning if identified by the subject itself².

Analyzing historically the context of the birth of the clinical practice, in which the medical performance was conducive, one can see why the sovereignty of the actions of doctors still continues prevalent in health services, also exerting a strong influence on other professional categories⁴.

It is possible to observe a strong influence on the performance of nurses who take on the principles of classical medicine and work with symptoms in the sense of medical semiology, identification of signs and symptoms in patients. By doing so, they reproduce the biomedical care model in the care provided to patients.

Analyzing this context in intensive care units (ICU), it is noticed that nursing care is focused on biological interventions, and symptoms are therefore related to diseases, disregarding their relationship with the subject.

In addition to empirical observations, most of the studies carried out in ICUs do not discuss the care for the person but are rather directed to the knowledge of pathologies, clinical guidelines, care protocols, use of technologies and clinical assessment scales.

This care provided by nurses is known to have a fundamental role in the follow-up and recovery of critical patients. However, what is often observed is the prioritization of pathology and treatment over the patient and his life history.

It is understood that patients admitted to ICUs need more than care to the physical state, the body and the disease; above any disease process, the patient is a human person and is not only endowed with biophysiological needs, but by demands that cannot be fully satisfied, he is constituted by a void, a constitutive lack of the desire to be².

This biological care provided considers the subject as an individual, an indivisible whole, which can become complete when his needs are supplied. Therefore, it does not acknowledge the subjective division by which the subject sustains the desire, but it is there where something is missing that the subject is, that missing signifier, that void of representation in which the desire is manifested².

From this perspective, nurses can redirect their care in search for interventions that are not restricted to medical diagnosis and therapy, but that involve issues related to the subject, his life history and his relationship with himself and with the others.

This study, therefore, aims to discuss the concept of symptom and its implications in the clinical practice of nurses in ICUs.

THEORETICAL BACKGROUND

Since the anatomical-clinical paradigm in the eighteenth century, the disease began to be defined in medicine based on symptoms and signs, and the symptom was interpreted as the very form of manifestation of the disease¹.

In medicine, symptom is endowed with meaning, but it is incumbent upon the physician to give its meaning, with the aim of eliminating it. In turn, in psychoanalysis, symptom is also endowed with meaning, but the psychoanalytic clinic takes it into another dimension and demands its redefinition⁵.

Symptoms do not refer to diseases that have some anatomopathological substrate, neither refer to a generalizable meaning or a pathological meaning². Symptoms have a meaning and relate to the experiences of the subject, and to the life of the person who expresses them⁶.

The trajectory of the symptom to the unconscious was made possible by the study of a nineteenth-century neurologist named Sigmund Freud on the neuroses. Freud identified that the symptoms of hysterical patients did not correspond to an organic change and therefore did not have a rational explanation. However, by listening to these women, he discovered that their speeches revealed something of a different order that, although unknown to the speaker, had a meaning regarding the truth of the subject. Therefore, the concept of the unconscious emerges here².

Neuroses have been understood as the expression of conflicts between the self and the drives which, due to their incompatibility with the integrity or with the ethical standards of the self, are repressed and prevented from becoming conscious. But repression easily fails, and the repressed libido, which has been repelled by reality, seeks other avenues of satisfaction. The result is a symptom⁷. Thus, the symptom represents a substitute for the impulsive satisfaction, being a consequence of the process of repression.

Thus, as a formation of the unconscious, it is something that escapes the unconscious and reaches the conscious in the form of symptom in order to perform some experience of satisfaction, corresponding to a repressed impulse of the subject.

Freud clarifies the indirect way, via unconsciousness, by which the libido manages to find an outlet of real satisfaction, the symptom, even if it is an extremely restrained satisfaction and barely recognized as such. Thus, the symptom repeats, in some way, an experience of satisfaction⁸ .

However, the formation of symptoms does not only represent satisfaction but also anguish. Freud established the highly significant relation between the generation of distress and the formation of symptoms, verifying that the two processes represent and replace each other. He concluded that the generation of anguish came first, and the formation of symptoms came later as if the symptoms were created in order to avoid the state of distress⁹.

Therefore, the symptom is the paradoxical place where the subject, unaware, has his satisfaction and also his suffering⁷. It thus represents both pain and relief, both suffering for the self and relief for the unconscious. Relief, because it is a partial form of tension retained in the unconscious to be manifested.

The symptom represents a malaise that imposes itself on us and challenges us, being an involuntary act produced beyond any intentionality and any conscious knowledge¹⁰.

The symptom, for Lacan, comes to be understood as joy, which represents that satisfaction that sustains the subject¹¹. This satisfaction appears to address the structural lack of the Other of language. The subject in his constitution discovers himself to be lacking and believes that he has come to complete the Other, but he discovers the lack also in the Other, and from this creates a mechanism to buffer that anguish that constituted it, the symptom¹². Thus, the symptom carries a satisfaction that does not cease to be manifested, but at the same time, can never reach plenitude.

The symptom can be understood as the result of a structure marked by a lack, representing the truth that points to this inherent lack. There would reside the "incurable" aspect of the symptom¹³.

What Freud finds in his clinical practice is that symptoms carry within themselves a satisfaction that makes treatment difficult. Thus, after 1920, symptoms started to have two sides: that of a message, amenable to interpretation, and that of drive satisfaction, which is what resists analytical treatment¹³.

Hence, psychoanalysis understands symptoms differently, without the intention of eliminating them but rather of deciphering them, and indicating to the subject how he can deal with his symptom.

METHODOLOGY

This is a theoretical study of reflective analysis about the concept of symptom and its implications in the clinical practice of nurses in ICUs. To weave the study, the concept of symptom was addressed from the way how it arose in the field of medicine, to the dimension of symptoms considered in psychoanalysis.

For the discussion of the concept of symptom in medicine, reference was made to the book "The birth of the clinic"¹. The approach of symptom in psychoanalysis was carried out based on the reading of the texts "The discovery of the unconscious"², "The Sense of Symptoms"⁶, "The ways of the formation of symptoms"⁸ and "Anguish and pulse life"⁹, as well as other psychoanalytic references.

In order to approach the clinical practice of nurses in ICUs, scientific articles were collected in the SciELO database using the following descriptors: care; nursing and ICU. A total of 57 articles were found, and 17 articles were selected after a first reading of abstracts, as they were pertinent to the theoretical basis for the reflection proposed in the study.

The inclusion criteria were articles published in the last ten years, written in Portuguese and available in full length, that presented in their discussion considerations on intensive care, especially in ICUs. The exclusion criteria were articles that, although addressing the theme, did not meet the purpose of the study.

The selected articles were evaluated through content analysis, to identify the general care and the perception of nursing care in ICUs. After that, a reflection of the understanding of symptoms that permeates the clinical practice of nurses in the context of ICUs was carried out, based on the experiences of the researcher in the practice field and supported by the selected studies.

RESULTS AND DISCUSSION

Based on the analysis of the articles, care protocols, clinical assessment scales, and clinical guidelines were identified as important tools to ground the assistance in the pursuit of better quality care and reduction of variability between services and professionals, once they summarize and systematize the best scientific evidence^14-17.

Moreover, the adoption of diagnostics and the Systematization of Nursing Care (SNC) allows the use of a unique and standardized language that favors the communication process, the compilation of data for to plan care, the development of research, and the professional teaching-learning process, as well as provides scientific support to care measures^18,19.

Intensive nursing care involves dedication and vigilance and requires technical-scientific knowledge of pathologies^20,21 and of invasive procedures^22,23, highlighting the monitoring of vital signs, rigorous water balance, monitoring and collection of laboratory tests, dressing changes and care related to adverse events as main care measures^24-27.

Technologies have emerged as resources to support healthcare activities in the hospital setting, contributing to the improvement of the quality of health services and altering the diagnostic-therapeutic process, particularly in ICU settings²⁸.

Before this clinical and pathological scenario of ICUs, some reflections about the nursing work process become relevant in order for the work not to become mechanized and inhumane. It is necessary that ICU professionals be instrumented to act beyond clinical situations^29-30.

It is understood, therefore, that nursing care in ICUs is geared towards biological aspects, and symptoms are perceived as anatomo-physiological alterations, having as main intervention their elimination for the achievement of cure.

Implications of the understanding of symptom in clinical practice

It is understood that the assistance to diseases and the treatment of patients is very important, but the question is: who is this patient beyond his pathology? Do nurses perceive this person? Where do the nurse's eyes focus? On the subject or on the disease?

Although it seems obvious that the nursing's focus, as an art of caring, is on the subject, in the reality of ICU settings, there is a noticeable focus of nursing care on biological interventions such as the clinical follow-up and treatment of the pathology, and the performance of regular tests, which promotes the invisibility of the subject, which is increasingly objectified and reduced.

What often occurs in the daily life of health services is a subjection of those who seek care to the knowledge of those already ready, in which the professional already knows in advance what each person must do or avoid to achieve a cure. Scientific knowledge represents the truth about the subjects, and they are not holders of any knowledge. Reducing the subjective experience to pathological issues is to ignore that the subject, although inhabiting a body, is not reduced to such body³¹.

It is understood that patients under intensive care do not only seek a clinical follow-up of their pathology, but also professionals who may embrace and understand them beyond the process of illness, as subjects with subjectivities and singularities.

It is possible to rethink the clinical practice of nurses in ICUs based on a redefinition of the SNC, so that this may be not only an instrument guiding the nursing practice and that its operationalization may not contribute to the exclusion of the subjectivity of patients, but that may rather seek to recreate, beyond biological issues, a space where other issues of the subject may be manifested.

It is understood that in order to the clinic to take place as true knowledge, it is necessary that nurses get rid of any position of totalizing knowledge and adventures through the unexpectability of each encounter, each intervention³².

Thus, it is of fundamental importance to think about what is our notion of subjects and of how they relate with themselves and with others, because it is this conception that will guide and ground the clinical practice of nurses³³.

Therefore, instead of limitation, we propose comprehensiveness; in the place of the reductionist model, complexity, with awareness that knowledge about the subject is not within everyone's reach and will not be available to anyone, except for the reintroduction of a questioning about the subject, his history, and his signifiers³¹.

The possibility of a clinical practice focused on the care of subjects may be the first step towards a fertile ground where nursing can develop its potential. It is possible to think of a health model that moves from the interventionist way, whose main objective is to cure, to another, whose primary objective is caring³².

Thus, ICU nurses should not limit their work process exclusively to the ill condition of the patients and to the management of equipment; first of all, they must ask who these individuals are and which is their life history, considering their dimension of unconscious that constitutes them.

CONCLUSION

The present reflection showed that it is necessary to look beyond the medical clinic, not only aiming at biological treatment, but also enabling the emergence of other issues that relate to the subject's life history.

It is understood that nursing care goes far beyond the process of illness, because a relationship between subjects is implied, in which both are transformed in this interaction. By thinking on the care to the subject as a fundamental element of nursing practice, it will be possible to break with the pathological and technicist view of the traditional model of health care and, therefore, innovate and renew the nursing care in ICU settings.

Noteworthy as a limitation is the fact that this study is theoretical; it is necessary to develop other field studies focused on the subjectivity and uniqueness of nursing care in ICUs.

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