ORIGINAL RESEARCH
Cardiac catheterization: experience faced by hospitalized patients
Tamires Diogo Alves de LiraI; Melissa Negro-DellacquaII; Victor Emmanuell Fernandes Apolônio dos SantosIII
I
Nurse. Specialist. Welfare nurse at the Agamenon Magalhães Hospital.
Recife, PE, Brazil. Email: tami.alves1@gmail.com
II
Pharmacist. PhD. Professor of the Department of Health Sciences at the
Federal University of Santa Catarina. Araranguá, SC, Brazil. Email:
melissanegroluciano@gmail.com
III
Nurse. Master. Professor of the Nursing Department of the Federal
University of Ceará. Fortaleza, CE, Brazil. Email:
victoremmanuellbr@gmail.com
DOI: http://dx.doi.org/10.12957/reuerj.2017.15608
ABSTRACT
Objective: to describe the experience faced by patients undergoing to cardiac catheterization in a public hospital in Recife. Method: descriptive study, with qualitative approach. Narrative interviews were used as data collection instrument. Sample consisted of seven patients submitted to cardiac catheterization. Data analysis was anchored from the Blumer's Symbolic Interaction. The study was approved by the Research Ethics Committee of Agamenon Magalhães Hospital under the number 01536912.9.0000.5197. Results: after statements analysis, the following categories emerged: fear as initial symbology of the cardiac catheterization; the heart as a symbol of duality between life and death; the omnipotent figure of the phisycian in the decision on the patient's life; and expectations of post catheterization. Conclusion: patients undergoing catheterization face feelings of anxiety, fear and insecurity, but also hope and new prospects for the future.
Keywords: Patient; symbolism; nursing; cardiac catheterization.
INTRODUCTION
The universe of cardiovascular diseases represents a major public health problem. Acute Coronary Syndrome (ACS), which brings as initial complications angina and acute myocardial infarction, account for 10% of hospital admissions in the Unified Health System (SUS) and approximately 30.7% of deaths in Brazil1. In the case of ACS, cardiac catheterization (CC) can be used for diagnosis or therapy2 and may trigger some complications of lower or greater severity, whose prevention or reversion requires the action of an active professional team3.
In this context, before undergoing the procedure, the individuals may experience a series of feelings, among them insecurity4 associated with the strong symbology represented by the heart in the perspective of cardiopatic patients5.
Observing this scenario of stress and fragility of the patients, the question raised here was: what feelings are experienced by these patients after undergoing a CC? Reflecting on the theoretical framework that best fits the objectives of this research, the need to understand the speech of each of the patients, the meaning of their opinions, fears and anguishes, and the way in which they live and see the reality around them, was perceived. Thus, the objective of the present study was to describe the experience of patients undergoing cardiac catheterization in the light of Symbolic Interactionism.
LITERATURE REVIEW
CC is an interventional procedure most commonly used to identify and evaluate ACS in adults. The procedure provides information on the extent of a valve stenosis or regurgitation, left ventricular dysfunction or other cardiac changes2.
The laboratory of hemodynamics is the sector that has the structure for the execution of these methods, and being characterized thus as a service of high complexity. The qualification of the team working in this unit is fundamental to prevent or reverse complications inherent to any procedure of this level, which may be of lower or greater severity3.
In this context, the condition of illness brings to the affected individual the sensation of loss of control, dependence, incapacity and insecurity. The difficulty to maintain independence and privacy depersonalizes the hospitalized patient4. In view of this, it is expected that practically all patients be apprehensive in the moments preceding the catheterization5.
Just as emotions and stressful episodes affect the heart, changes in heart function can also trigger changes in the psyche. Studies have shown that patients with cardiac diseases about to undergo invasive procedures have a high prevalence of anxiety, fear and even depression3. Practically all of them are apprehensive in the period precedeing the catheterization due to the complexity and the risk of the procedure, besides the possibility of being submitted a surgical intervention6.
This mixture of emotions generated by doubt and lack of clarification requires that nurses play the role of mediators between the objectivity of technological technique and human subjectivity5 . Thus, Symbolic Interactionism has an approach that can fill this gap, since it studies how people see situations, what meaning these episodes have for them and how they lead their lives through interaction with other individuals and with the communities7. This theoretical framework particularly appreciates the meaning that human beings attribute to their life experiences, in which the symbol is the central concept, used for thinking, communicating and representing8.
METHODOLOGY
The study is of the descriptive type with a qualitative approach anchored in the theoretical assumptions of Symbolic Interactionism, an approach that focuses on the nature of the meanings, values, beliefs and individual or collective attitudes within the environment in which the phenomenon is experienced9.
In this sense, Symbolic Interactionism is a perspective of social psychology that emerged in the late nineteenth century as a theory elaborated by Herbert Blumer based on the fundamental elements of Mead's analysis: self, action, social interaction, objects and joint action. It is therefore a theory that deals with human behavior and social interaction8,10.
Symbolic Interactionism presents the following basic concepts: the actions of the human being toward things occur in function of what such things represent for him; the meaning of these things arises from the social interactions of the individual; the individual develops an interpretive process to deal with the things around him, and in that process, the meanings are manipulated and modified10.
The study scenario was the Laboratory of Hemodynamics of the Agamenon Magalhães Hospital (AMH), in Recife, Pernambuco, Brazil. The AMH Laboratory of Hemodynamics performs on average 120 cardiac catheterizations per month, including coronary angiography and percutaneous transluminal angioplasty. Its team consists of nine physicians, three nurses, six nursing technicians and three radiology technicians. The research was carried out with seven patients in the period from May through June of 2012 who had been indicated to undergo diagnostic cardiac catheterization and who willingly accepted to participate in the study.
Sampling followed the data saturation criteria. Sample termination by theoretical saturation is frequently used in qualitative research and consists in suspending the inclusion of new participants from the moment the researcher perceives a redundancy or repetition of ideas in new data obtained11. Its main criterion is not numerical, although it is almost always necessary to justify the delimitation of the multiplicity of people who is going to be interviewed and the size and choice of the space12.
We included all patients over the age of eighteen years with an indication of percutaneous diagnostic catheterization and who were undergoing the procedure for the first time in order to avoid that previous negative or positive sensations could influence the speech of patients, making the symbology of the first time more coherent with the proposed objectives13.
Patients who, despite meeting the inclusion criteria, were totally bedridden by medical indication, with hemodynamic instability or altered mental status were excluded. Patients with percutaneous therapeutic catheterization were not included because that was a more specific procedure, with longer stay time, and greater risk of complications.
The researchers went to the units where the patients were hospitalized to request that they returned in a period different from that of the hemodynamics for data collection. This visit of researchers to the units occurred after 24 hours, due to the need for immobilization to avoid complications, and before completing 48 hours, to keep the symbolic memories about the procedure alive. The following guiding question was raised for data collection: in relation to the CC, what is the meaning that this procedure has for you?
The narratives were recorded in MP4 system (average of 12 minutes each) and simultaneously transcribed verbatim in a Word 2007 document, with care to avoid missing any relevant information. After transcription, the narratives were analyzed in an Excel 2007 spreadsheet according to the steps of Bardin's content analysis.
Four categories were listed in the study: I) Fear as symbology before cardiac catheterization (Subcategory: fear generated by lack of knowledge, and Subcategory: fear generated by the influence of interpersonal relationships); II) The heart as a symbol of duality between life and death; III) The omnipotent figure of the physician in the decisions regarding the life of the patient; and IV) Expectations post-catheterization.
The work was approved by the ethics committee of AMH under the number 01536912.9.0000.5197. In order to maintain secrecy and confidentiality, letters and identification numbers were randomly assigned to patients: I1, I2, I3, I4, I5, I6 and I7 (interviewee 1, 2, 3, 4, 5, 6 and 7).
RESULTS AND DISCUSSION
The study included seven patients, consisting in three women and four men. Five of them underwent femoral CC and two radial CC. Most of the interviewees resided in the rural area of the state of Pernambuco.
After the reading of the narratives, they were analyzed under the light of Symbolic Interactionism. The analysis originated four categories as follows.
Category I: Fear as symbology before cardiac catheterization:
Fear is a state in which the individual presents an emotional disturbance in the face of a situation perceived as dangerous. Imagination and belief give consistency and meaning to fear, which can also be influenced by cultural variables. Fear is present in normal human development, in changes and in unexpected experiences13,14.
In the narratives, fear was the result of different motives, but the most significant for the interviewees were: fear generated by lack of knowledge about CC and fear generated by the influence of other people, which represented the two subcategories developed below.
Subcategory: Fear generated by lack of knowledge:
The fear posed by having to ungergo a CC emerged in almost every speech. The reports of interviewees who imagined that an incision would be made during the CC show the lack of educational actions aimed at these patients, as the following statement shows:
[...] the doctor said, you're going to do the procedure today [...] and I kept quiet [...] I entered without knowing anything and suddenly, a woman appears cleaning the procedure room, and there you go! I thought they would open and cut me; [...] For being the place that I would lie down, I would be defenseless [...] At no time did I get a chance to speak [...] and you're terrified because you do not trust those people very much. (I4)
This feeling may also be linked to the invasive character of the procedure itself, the uncertainty about the result and the myths that permeate it:
I thought that when the thing was inserted (catheter) into the person's leg [...] it would hurt a lot [...] The worst part is that it actually hurts! I thought that it could leak into the heart, rip everything inside. It is something of lay people really, who know nothing on the matter [...] I thought it was going to feel very bad, I had no idea, I do not even know how to put into words what I thought. I thought it was something from another world [...] but the worst is that nobody explains anything! This is a very serious thing [...] that shouldn't be done like this, in any way [...] It is within your heart [...] If the heart leaks [...] How will I survive? (I2)
When subjected to an experience, individuals create a meaning for that experienced based on their social interactions. Then, they direct their actions according to the meaning they created10. Several negative meanings can emerge from a negative experience. This message is conveyed within a cycle of social interactions. It is possible to observe the effect of these negative experiences in the narrative below:
Look, when I got to the door, a feeling of fear overtook me [...] It is something terrible that one has to face [...] And you have no choice. I'd rather have anesthesia, thay I had surgery, and I'd just wake up when it was over. (I1)
The literature mentions the importance of recognizing the psychosocial aspects of each patient that may influence their reactions to the unknown procedure and of the approach adopted by nursing professionals toward the needs expressed by the client5. Many factors make it difficult for nurses to contact the patient in advance, further increasing their anxiety and that of their relatives3.
Subcategory: Fear generated by the influence of interpersonal relationships:
Besides ignoring the steps involved in the procedure, the influence of others who already bring with them previous experiences exacerbated fear and anxiety in many patients:
My whole fear was caused by a friend here in the room [...] He would speak very bad of this catheterization [...] He said that it did not always work [...] And other people told me: - Look, the worse is no one ever died there. - You are misinformed; a woman died that day. (I4)
When confronted with the opinion of other patients, and/or with negative facts, the subjects experienced moments of anguish and nervousness:
There was a woman in the emergency who was doing well [...] Walking, talking and smiling [...] when she went to do this catheterization, she died [...] How can that be? The family crying and the doctor and the nurses do not care to explain why? My goodness, that's why i got nervous. (I1)
Within a process of social interaction, the activities of others intervene as negative or positive factors in the shaping of behavior10. Before the acts or opinions of others, a person may abandon, reconsider, intensify or replace a purpose or action, as shown below:
And the worst of all, people who have already gone through catheterization, they bug you [...] My brother-in-law for example, he went to have a catheterization, and the whole family got together, I thought he was going to the moon. (I2)
Interaction refers to the interpersonal and intrapersonal aspects, that is, the interaction of the individual with others and with self, through rules, values, beliefs and motivations10.
Category II: The heart as a symbol of duality between life and death:
The emotional impact that the coronary disease brought to these patients was notable, for the heart is often considered the core of life 15.
I think it's our life [...] another part may be suffering, but if the heart is not good, how will it be, my struggle to survive? If the heart is affected, it seems that everything collapses. (I3)
In the above speech, the importance that the subject gives to the heart is noticeable. From the point of view of Symbolic Interactionism, the nature of an object is composed of the meaning that such object has to the individual. This meaning in turn is the fruit of social interactions between people10.
I was so afraid of having a heart problem! People who have heart problems, any fright can make the person die. I was scared. (I1)
Thus, in the face of heart diseases, the heart is brought to the physician as the most valuable good in life. Performing an invasive examination represents a life-threatening experience for the patients15. In the view of patients, the heart is an organ of formidable symbology. It is seen both as a material and emotional organ and these aspects affect each other through physical and/or psychological changes16.
Men see our heart, they see everything! And then we come out alive! (I3)
Long before discovering the real function of the heart, men already considered it as the organ that is the motor of life, courage and reason. Culturally, today this organ also represents the abode of emotions 15. Therefore, the process of becoming sick has the potential to greatly weaken the cardiopath person, who interprets such disease differently from when a disease affects other organs. This gives heart diseases a greater relevance. This feeling is perceived in the following speech:
In my case, if I did not feel the throb I feel here, I would not be here. I have another problem, but it can be worse than this, the most important, my certainty and my will is first the heart to be well, and then I will see the rest. (I3)
Category III: The omnipotent figure of the physician in the decisions regarding the life of the patient
For some subjects, doctors presented a very high importance in this process, being mentioned several times in the interviews. The figure of these professionals is often so overestimated that the patients attribute powerful characteristics to them, while seeing themselves secondary and at the mercy of the care provided by doctors. Thus physicians keep defining the ways and procedures to be taken while patients take on a passive stance in this process17. The speech below demonstrates these feelings:
We are in the hands of the doctor, but also, first God. In my point of view, doctors are the most important people I know because they fight for our lives[...] And just to know that it's all in the hands of two men and get out of there alive, this touches us [...] to me, that means everything. (I2)
A paternalistic relationship between doctor and patient is created, in which the former provides little information about the health state and possibilities of treatment and the second feels dependent on the ideas and judgment of the doctor17.
Because the doctors are there to help us; because I would not be helped as much as I am being helped here. (I5)
Because we got in there, and we got scared with the equipment. But we know that it is not the equipment that will solve our problem, the doctors will [...] I was paying attention all the time, but the most interesting thing for me was the doctors. (I2)
When human beings interact with other people, they take into account the actions of others and what they represent and based on these observations, they define their own behavior10. Therefore, before the physician, who is seen as an omnipotent being, the one who can save his life, the patient clings to this individual in such a dependent way that the physician now starts to guide the course of the patient's life.
Category IV: Expectations post-catheterization
The speeches reveal the trust in the treatment and a strong desire to recover health on the part of the interviewees. Thus, the expectations after the catheterization are related to the directions that their lives will take from that moment on. After catheterization, some interviewees were hopeful and willing to go through the next stage, the angioplasty.
I was afraid, I arrived, but I came here willing to start a new life to the mistakes I've been doing, with sedentarism [...] I'll end all of that [...] Wednesday I'll be there again. I will do two angioplasties, one in the Wednesday and then they will schedule another date that is not yet known to me. (I2)
But everything went well! I hope this other one that I will do (angioplasty) solve this situation, I trust in God, using their hands (doctors' hands) as an instrument and everything will be okay. (I3)
Humans act according to their own definitions by guiding themselves and redirecting themselves according to the very perception of their life 10. It is necessary that individuals maintain their plans and trajectories so as to envision a sense of continuity in their lives. However, such trajectories can no longer be the same as those adopted previously; they need to be re-signified. The impossibilities of the body impose such re-significations, which are not easily constructed by individuals18.
The hope of healing and the awareness of the need to adapt to the new habits that the disease forces them to acquire were also perspectives narrated by some subjects.
Today? I think of getting well [...] I've been through so much [...] And getting well would be one of the best things in my life. (I6)
Thoughts about the future and the new challenges were also mentioned:
Ah, it will change, because I use to be a housekeeper and now I won't be able to do this activity any more [...] I'm not feeling bad, neither well, I'm thinking that I have to follow this rule now, if things have to change, we'll change. What can we do? Accept. (I7)
The mix of feelings generated especially by the lack of knowledge regarding the procedure by the patient is noticeable. This situation requires the participation of nurses, not only in the issue of basic nursing care.
The nursing team recognizes the importance of basic care for patients, and they are aware that these care measures are the duty of the nursing team. However, the responsibility for certain care measures is commonly delegated to caregivers19. In this sense, it is important that, in addition to the basic nursing care, the psychosocial aspects of each patient be recognized, a fact that may influence his reactions to the unknown procedure5.
CONCLUSION
The study pointed out that CC is an examination that conveys fear, anxiety
and insecurity to many patients. The evolution of techniques and tools of
interventional cardiology have allowed performing a greater number of
procedures with greater effectiveness and safety. However, many myths still
permeate the minds of patients, as they are linked to the strong meaning
that the heart represents for these people: the core of life. Providing to
users clear instructions before the procedure is critical to prevent or
soften these feelings, contributing to the patient's well-being. The
nursing team has the knowledge, ability and communication skills and
understanding to provide these guidelines.
Nurses are therefore a fundamental professional category in the search for actions aimed at the integral assistance to patients, including the instruction of patients pre-, trans- and post-procedure moments. In order to do this, it is necessary to understand human actions and reactions, considering the cognitive structures and organizations, the social origins and the forms of interaction and the combination of these actions.
One of the main limitations of this study is the sample and the observation period, but these limitations should serve as a starting point for other studies on the subject.
REFERENCES
1.Ministry of Health (Br). Health Care Department. Datasus Health information. Mortality. [website]. Brasília (DF), 2016, [cited on March 8, 2018]. Available from: http://www2.datasus.gov.br/DATASUS/index.php?area=0205&id=6937
2.Davidson CJ, Bonow RO. Braunwald: Treaty on Cardiovascular Diseases. 10ª ed. Rio de Janeiro (RJ): Elsevier; 2017.
3. Grazziano ES, Bianchi ERF. Level of anxiety of clients undergoing cineangiocoronariography and of their companions. Rev. latinoam. enferm. (Online). 2004 [cited on March 8, 2018]; 12(2): 168-74. Available from: http://www.scielo.br/pdf/rlae/v12n2/v12n2a04.pdf
4.Pupulim JSL, Sawada NO. Nursing care and invasion of the patient's privacy: an ethical-moral issue. Rev. latinoam. enferm. (Online). 2002 [cited on March 8, 2018]; 10(3): 433-8. Available from: http://www.scielo.br/pdf/rlae/v10n3/13353.pdf
5.Freitas MC, Oliveira MF. Nursing care for elderly people who undergo cardiac catheterization: a proposal based on the Calista Roy adaptation model. Rev. bras. enferm. (Online). 2006 [cited on March 8, 2018]; 59(5): 642-6. Available from: http://www.scielo.br/pdf/reben/v59n5/v59n5a09.pdf
6.Lima LR, Pereira SVM, Chianca TCM. Nursing diagnoses in patients after cardiac catheterization - Orem's contribution. Rev. bras. enferm. (Online). 2006 [cited on March 9, 2018]; 59(3): 285-90. Available from: http://www.scielo.br/pdf/reben/v59n3/a07v59n3.pdf
7.Moreira DA. Symbolic interactionism: The nature of qualitative research. In: The phenomenological method in research. São Paulo: Thomson Pioneira; 2004.
8.Dupas G, Oliveira I, Costa TNA. The importance of symbolic interactionism in the nursing practice. Rev. Esc. Enferm. USP. (Online). 1997 [cited on March 10, 2018]; 31(2): 219-26. Available from: http://www.scielo.br/pdf/reeusp/v31n2/v31n2a04.pdf
9.Minayo MCS, Sanches O. Discussion on the article by Minayo & Sanches. Cad. Saúde Pública (Online). 1993 [cited on March 10, 2018]; 9(3): 239-62. Available from: http://www.scielo.br/pdf/csp/v9n3/04.pdf
10.Blumer H. Symbolic interactionism: perspective and method. Barcelona: Hora SA Editora Distribuidora; 1982.
11.Fontanella BJB, Ricas J, Turato ER. Sampling by saturation in qualitative research in health: theoretical contributions. Cad. Saúde Pública (Online). 2008 [cited on March 11, 2018]; 24(1): 17-27. Available from: http://www.scielo.br/pdf/csp/v24n1/02.pdf
12.Minayo MCS. Sampling and saturation in qualitative research: consensus and controversy. Rev. pesq.quali. (Online). 2017 [cited on March 12, 2018]; 05(7): 1-12. Available from: http://rpq.revista.sepq.org.br/index.php/rpq/article/view/82
13.Novaes, A. Essays on fear. São Paulo: SENAC; 2007.
14.Roazzi FCB, Federicci MR. The issue of consensus in social representations: a study of fear among adults. Psic. teor e pesqui. 2002 [cited on March 11, 2018]; 18(2): 179-92. Available from: http://www.scielo.br/pdf/%0D/en/v18n2/a08v18n2.pdf
15.Prates PR. Symbol of the heart. Hist. ciênc. saúde-Manguinhos. 2005 [cited on March 8, 2018]; 12(3): 1025-31. Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0104-07072011000200006
16. Santos LFR, Pereira MIF, Martins CV. Heart disease and emotions: conversations between psychosomatic and analytical psychology. Self. Rev. Inst. Junguiano 2017 [cited on March 12, 2018]; 2: 1-15. Available from: https://self.ijusp.org.br/self/article/view/14/pdf
17.Nascimento PGJ, Guimarães TMM. The doctor-patient relationship and its psychodynamic aspects. Rev. bioét. 2003 [cited on March 09, 2018]; 11(1): 101-12. Available from: http://revistabioetica.cfm.org.br/index.php/revista_bioetica/article/view/152
18.Wottrich SH, Quintana AM, Camargo VP, Beck CLC. "The heart's manifest'": Meanings attributed to the disease by cardiac pre-surgical patients. Psic. teor e pesqui. 2015 [cited on March 12, 2018]; 31(2): 213-9. Available from: http://www.scielo.br/pdf/ptp/v31n2/0102-3772-ptp-31-02-0213.pdf
19.Passos SSS, Sadigusky D. Nursing care for dependent and hospitalized patients. Rev. enferm. UERJ. 2011 [cited on March 10, 2018]; 19(4): 598-603. Available from: http://www.facenf.uerj.br/v19n4/v19n4a16.pdf