RESEARCH ARTICLES

Nursing care for women with myocardial infarction: promoting sociocultural comfort through care-research

Keila Maria de Azevedo Ponte^I; Lúcia de Fátima da Silva^II

^IPhD student of the Graduate Program in Nursing and Health Clinical Care at the State University of Ceará. Master in Clinical Care. Scholar of the Higher Education Personnel Training Coordination. Sobral, Ceará, Brazil. E-mail: keilinhaponte@hotmail.com. 
^IIPhD in Nursing. Adjunct Professor of the Graduate Program in Nursing and Health Clinical Care at the State University of Ceará. Nurse at Messejana Hospital Dr. Carlos Alberto Studart Gomes. Fortaleza, Ceará, Brasil. E-mail: lucia.fatima@uece.br.
^IIIArticle extracted from the master's thesis entitled Clinical nursing care technologies for comfort women with acute myocardial infarction, State University of Ceará, held on 23/12/2011.

DOI: http://dx.doi.org/10.12957/reuerj.2014.15693

ABSTRACT: Held in 2011, this study aimed at describing nursing care to women with acute myocardial infarction for sociocultural comfort promotion. A qualitative study of the research-care type based on the Theory of Comfort, it was conducted with nine women staying at public hospital in Sobral, Ceará, Brazil for acute myocardial infarction. It used semi-structured interviews, participant observation, field diary, and content analysis. Nursing care focused on sociocultural comfort was characterized as readiness to care, to foster care, to establish bond and trust; additionally. it meant to favor interaction and good rapport between families and hospital staff, as well as to accommodate care to the culture of those research subjects receiving care. In conclusion, that care provided wellness and improved adaptation to hospitalization in the case of women with acute myocardial infarction.

Keywords: Nursing; comfort; myocardial infarction; women’s health.

INTRODUCTION

The search for care, as well as for comfortIII, is inherent in the human being, but when it comes to people becoming ill in the hospital, comfort care becomes a process and a result of work done by nurses.

For the process of nursing care, it is important to know the culture and habits of the people cared, thus launching care strategies for their individual needs, in addition to actions that allow approaching the healthcare professional to the patient who is being cared, aiming to provide comfort. In this context, it is necessary to identify and analyze the care that promotes socio-cultural comfort, considering the current context of illness and the possibility of maintaining everyday habits.

Comfort has been studied by researchers, both nationally and internationally. From this perspective, Katherine Kolcaba sought to deepen the subject to perform extensive literature review in order to better define the term¹.

Thus, it is emphasized that a key part of development of nursing as a profession comes from the expansion and application of its theories that support the specific knowledge, allowing building the basis for the practice².

Therefore, the aim of this article is to describe nursing care to women with acute myocardial infarction (AMI) to promote socio-cultural comfort.

THEORETICAL

The theoretical framework of this study is the Comfort Theory. In this theory, comfort means immediate and holistic experience, strengthened by the satisfaction of relief needs, desire and transcendence in the contexts: physical, psychological, socio-cultural and environmental¹.

To follow the recommendations of the theory, the nurse assesses the patient holistically in order to identify needs for comfort and, simultaneously, implements interventions at the time that evaluates the satisfaction of comfort provided by each action performed. Activities that promote comfort are enhanced and the patient is prepared, consciously or unconsciously, to develop behaviors that seek the welfare, creating comfort measures¹.

The comfort in the socio-cultural context, presented by Comfort Theory, refers to the provision of support in interpersonal, family and social relationships, including aspects related to the financial, education, personal health care and the cultural traditions¹.

In order to enhance and optimize the studies involving nursing theories, qualitative research has been enabling investigation that allows the implementation of strategies to participants. For this study, we chose to adopt care-research, in which method and results are obtained by performing direct care to the person being searched³.

METHODOLOGY

This is a qualitative study of care-research type, based on Comfort Theory. To narrow the care-research, one needs to follow five steps that follow: approach to the object of study; meeting with the researched-cared being; establishment of connections of research, theory and practice of care; clearance between researcher-caregiver and the researched-cared being; and analyzing what was seized³. The steps of the study were based on comfort^1-4.

Data collection occurred from April to June 2011, at the Hospital do Coração of Sobral-Ceará-Brazil. During this period, 66 people with a diagnosis of AMI were admitted. The inclusion criteria were: patients with a diagnosis of AMI; female; 18+; being the first hospitalization for AMI and admission between 5 a.m. and 12 p.m. We identified 18 women, nine of which were excluded for the following reasons: death on admission, entrance between midnight and five o'clock in the morning; and because it was not their first hospitalization. Thus, nine women with AMI attended this study, under the researched-cared condition.
There were four meetings with each of the study participants, the first at admission and the others in the following days, which lasted 4 to 6 hours, each one. Data collection occurred through semi-structured interviews, participant observation and field diary.

In the first contact, the researcher-caregiver performed the survey of personal and medical history of each researched-cared woman, as well as holistic and periodic evaluations, in order to know the participants in the study, and identify needs for comfort and implement comfort measures⁴.

The identification of comfort needs occurred through the guiding question: what can I do to provide comfort at this time? The nursing care that provided comfort were encouraged in order to develop behaviors of seeking health, as proposed by Comfort Theory.

There was appreciation by the Research Ethics Committee of the State University of Ceará, as the proponent unit, being approved under protocol number 10727050-3.

The organization of information was performed through content analysis, focusing on the theoretical framework. Participants were identified by the term researched-cared, or RC, followed by the number of the entry order of each woman interviewed.

In the pre-information analysis, we identified the relevance of the aims of the study, homogeneity and representativeness of the content. In the exploration of the material, similar information was grouped in four categories emerging: Showing available to provide care, promote affection and establish connection and confidence; Instigating moments of meeting with families; Promoting interaction and good relationship with the hospital staff; and Accommodating the care to the culture of the researched-cared women.

In each category, the comfort care is listed in the socio-cultural context implemented by the researcher-caregiver to researched-cared.

RESULTS AND DISCUSSION

Categories of socio-cultural comfort that emerged in the investigation were: Showing available to provide care, promote affection and establish connection and confidence; Instigating moments of meeting with families; Promoting interaction and good relationship with the hospital staff; and Accommodating the care to the culture of the researched-cared women.

Showing available to provide care, promote affection, and establish connection and confidence

To promote comfort in the socio-cultural context, it was essential to establish link between caregiver and cared being. Therefore, this study showed the importance of the presence of professional caregiver, discussing, providing information and being available for better interaction in the care process. Sometimes, holding the hands of the surveyed-cared woman was a way to provide security, promote the creation of bonds and provide comfort.

It was observed that the dialogue between researcher-caregiver and researched-cared women was a way to give them comfort. This was observed in speeches, even on the first day of contact and care.

I have already enjoyed very much your conversation [...] just to see you, I feel comfort. (RC9)

You know, everything is very fine; just your delicacy [...] only your presence, it is too good. (RC6)

You know, just your conversation, here, with me, that is a comfort. (RC8)

These statements were more present in the following days of contact, when they started to know the researcher-caregiver and gained confidence, including through physical contact, by holding their hands and demonstrating satisfaction with the relationship established.

The demonstration of pleasure with the care was manifested in the last days of meeting. It was satisfactory for the researcher-caregiver to recognize that women in this study were happy with the attention given to them.

You know that I loved when you were going there, to visit me, I did not want you to leave, I just did not say, not to hinder you [...] you are too good, I felt very good to be with you. (RC4)

[...] my husband went away very pleased with you [...] I told him that you are watching me, looking medicines, doing research, seeing what I want to feel comfort. If I could take her home, I would do that [...]. (RC6)

The researcher-caregiver resorted to implement strategies to get better interaction and confidence and, consequently, social comfort of the researched-cared, dialogued about a good outcome and checked whether the procedures performed had been successful. So, it is needed that the professional keep optimistic and encourage the cared person to also keep this way.

The care and the availability of the researcher were other measures that provided comfort.

I think just your affection, which is a very good thing [...] my comfort is to be with you. (RC3)

Just you, here with me, it is a comfort. (RC8)

When I see you coming, it aready gives me comfort. (RC2)

The practice of routine care for women in the coronary care unit and research revealed that respondents felt need for communication and demonstrated interest in sharing social life, desires, features and other aspects of life.

The results of this study showed that the companionship of the researcher-caregiver, at times, was sufficient to provide comfort to women suffering from AMI, so there is need of appreciated of moments of contact between health professionals and diseased person. This interaction, besides promoting comfort, enables the creation of empathy ties, wrapped in trust, respect, care and attention.

Being available for women, hearing their stories and being present was comforting for the surveyed-cared women, and the supply of important guidance on what was happening, the health condition, besides providing clarification to questions also was considered as crucial. This information enabled tranquility and comfort.

To strengthen the interaction between caregiver and client, it is important to warm relationship of affection and empathy through care, so that both communicate, establishing trust for the client to talk about their troubles and get strength to recover⁵.

In the care process, it is also necessary empathic relationship between people involved, as well as communication, sensitivity, commitment, emotions and feelings².

In a way, the behavior of bond and trust between researcher-caregiver and researched-cared is desirable in this research methodology, since it favored the interaction, expression of desires to be cared for, enabling implementation of clinical nursing care.

Instigating moments of meeting with families

Other factors contributing to comfort and that presented relevance to clinical nursing practice were: the presence of the family with the ill person and the family support in guidance and clarification of doubts.

Some considerations on these aspects were observed during the presence of the family of a client. At the time, her daughter showed affection to her, stroked her head, gave her kisses and held her hands. Such attitudes were significant for both the patient and to family and health professionals who understand the satisfaction and the socio-cultural comfort of the people involved.

The researched-cared women seemed comfortable with the presence of family, moments wrapped of emotion and expression of mutual crying. During this social relationship, anxiety and sadness of a participant were perceived, when at the time of the visit, none of the family attended. Aware of the family context, the researcher-caregiver tried to comfort her.

During the presence of family, women showed happiness, used to report what had happened in the hospital, including about the presence of the researcher-caregiver. Farewells were surrounded by affectivity and favored sending messages.

Tell everybody I am fine. (RC4)

The researcher-caregiver tried to provide comfort to the socio-cultural researched-cared women, encouraging demonstrations of affection, as well as favoring the entry of more family per visit, since only two people were allowed. This exception was made with the permission of health professionals responsible for the sector, on those occasions.

The support that the researcher-caregiver dedicated to family and carers of the researched-cared also provided comfort. Thus, the first contacts with the families of the researched-cared were dedicated to provide information about the disease, the visiting hours, performed procedures and clarification of doubts.

In the most serious medical conditions, the researcher-caregiver sought to clarify the case to family members, although she had stimulated the optimism and faith in God, in order to create an atmosphere of faith and hope.

We state here the need for nurses to be attentive to visitations, since in these occasions, discomforting family situations can be inappropriately taken to patients. The son of a researched-cared woman, during the visit, presented an unpleasant relationship problem with neighbors to the mother. Confronted with this, it was necessary intervention by the researcher-caregiver to remove him from the patient and guide him about the desirable behavior for the time of the visit of people with AMI.

Another important issue addressed by the researcher-caregiver, with the research-cared women, which gave them comfort in the socio-cultural context, was the information on presence of family members in the hospital. In addition, she also kept the family informed about the clinical course of loved one.

After any news related to the clinical condition of the woman hospitalized, and after the hemodynamic procedure, the researcher-caregiver sought by relatives of the researched-cared women, in order to give them news. She took advantage of the occasion to suggest contribution to the care process. Before hospital discharge, the researcher-caregiver involved family in the guidance on the necessary information about the lifestyle suggested for women with AMI.

The demonstration of gratitude towards the researcher-caregiver was explained by the relatives of the researched-cared women.

 What you have done for us, there is no way we can pay. It is a favor, so we should pay all life, only God Himself to pay it, because you played the role of a son, there is no money in the world to pay it. (RC9)

The contact of the patient with the family was also presented in this study as a providing comfort, by remembering home as a natural wellness environment. Thus, during hospitalization, the affection and attention received by family members are care that result in feeling of comfort⁶.

Family relationships contribute to the feeling of comfort in the socio-cultural context. However, when people with illness do not have this support network, nurses are responsible for providing comfort in this context¹.

Based on the above, we exalt the importance of the nurse to guide and monitor closely the visit to inpatients; preventing people to expose sensitive issues for hospitalized patients. These guidelines should include the accommodation of family members of patients in intensive care.

It is stated that health professionals must keep sincerity in explanations provided to the families of people who they care, however, it is recommended the instillation of faith and hope. Thus, the maintenance of faith, hope and respect the patient's beliefs are essential for nursing care⁷.

Therefore, the admission of the patient in intensive care has an impact on quality of life of their families, who need objective information on the clinical picture of the hospitalized person and, moreover, aims to be heard, be present, receive comfort care and have suffering acknowledged⁸.

Thus, it is worth mentioning the importance of promoting comfort to the families of hospitalized people, because they remain in the corridors of wards, waiting for the time to visit⁹.

Promoting interaction and good relationship with the hospital staff

The effective relationship with hospital staff was present in this study and promoted socio-cultural comfort. Without distinction, it was observed that the professionals of the coronary unit expressed interest in meeting the needs of women, keeping them as comfortable as possible.

Professionals in the hospital have offered differentiated services, trying to establish dialogue with the inpatient, as well as their carers. Several times, it was possible to see how these attitudes are fundamental to the establishment of socio-cultural comfort, mainly because it was a highly technological environment of the coronary unit.

One day in the second meeting, it was revealed through interviews, the interaction occurred between searched-cared women and the hospital staff that provided comfort.

I talked a lot to the girls here [nursing staff]. (RC9)

Everything is perfect, the girls attend well, I call them and they are always here [...] there is a dark-colored girl [nursing auxiliary] that does not lack here, is always here, watching and adjusting things. (RC6)

People are educated, the service is wonderful, they know everything, no one sees anyone angry. (RC3)

So, women studied showed satisfaction with the care provided by team members, favoring comfort in the socio-cultural context.

It is important that the intensive care unit nursing professionals have training in the area and appreciate to work in this environment, since they care for critically ill patients, who rely on technological resources and lack of attention and responsibility¹⁰.

Accommodating the care to the culture of the researched-cared women

To provide socio-cultural comfort, it is essential to know the culture of the person being cared for, adapting it to the hospital environment. Therefore, as meetings between researcher-caregiver and cared beings occurred, these aspects were investigated.

Thus, knowledge of the everyday lives of people who are under health care is essential. In the context of this study, it was observed that women with myocardial infarction felt the absence of people that, in their daily lives, gave them attention. Therefore, as a means to provide them with socio-cultural comfort, the researcher-caregiver took time to keep up next to them, listening to them.

A personal context in which social relations are involved is the cleaning. In this sense, there was awkwardness when the completion of the bed bath.

Bath right here in bed [...] brushing teeth, we do not do, [...] but when I leave here, I go back to normal. (RC2)

We highlight strangeness about the oral hygiene, restricted the use of mouthwash at that coronary care unit, due to the inability to store personal items.

It was also necessary to know the culture and the daily lives of people who were being cared for, as the habit of resting for, from there, implement strategies and means that would enable comfort in the hospital. There was difficulty to bed rest, when usually in the Northeast, Brazil, sleep in hammocks.

The relaxation position was also highlighted.

Since I am used to lie down and sleep on my side, it is weird to lie belly up, it is very bad to be so. (RC1)
I cannot sleep here because I do not like bed nor clarity, at home I sleep in a hammock [...] I do not like the lights on. (RC4)

Given the inability to lay in the hammock, better accommodation strategies were sought in bed (use of lateral position) and was tried to minimize the brightness of the environment.

As for food habits, it was observed wishes to take coffee at night, and prefer food intake in higher temperature.

 If you could have a coffee, it would be good. (RC5)

As far as possible, these desires were satisfied. Another important cultural aspect was the language used in the hospital environment, which is often different from the own vocabulary of hospitalized people. In this sense, we tried, by the dialogue with women with myocardial infarction, to use accessible language so that they could understand.

One of the difficulties referred to the use of technical terms.

They came to visit me and said I was in the semi, what is it? [...] I did not understand anything they said. (RC9)

It was explained to her that it was a unit of semi-intensive care, in which people with more stable clinical condition are hospitalized.

Knowing cultural aspects relating to beliefs and values of patients, is relevant, especially for providing guidance about the behavior that people should take, after hospital discharge. Knowing these habits helps health professionals, particularly nurses, to negotiate healthy habits of living well with their clientele.

From this perspective, it is important for the caregiver staff to know the costumers’ culture to facilitate the provision of comfort care and family traditions, customs and the particular language of each person cared should be included in the context of caring¹.

One of the aspects presented in this study was the discourse of health professionals. They use technical terms when communicating with people who they are caring for, without adaptation to the everyday language of that person, implying, therefore, erroneous information interpretations¹¹.

Based on the above, the perception of comfort is linked to the choice of clinical care appropriate at each moment; therefore, it is essential that nurses, managers and teachers stay aware of the process of professional training and clinical practice in order to raise awareness the nursing professionals to meet the comfort needs of patients in their care¹².

This is in accordance with the research priorities for nursing, which involves adjusting the focus of research on what is essential to provide visibility to their own knowledge of the profession, which is the nursing care as theoretical category, directed to people who are being cared for, to the skills of the professional and to the large cross-national problems, in order to better define the disciplinary field and the interdisciplinary aspect of this field of knowledge¹³. 

The actual relationship between researcher-caregiver and researched-cared women was satisfactory, given the certainty that the research-care process was promoting welfare to the inpatient and thus promoting comfort, object of this research.

CONCLUSION

Nursing care, evidenced in this study, that promoted socio-cultural comfort were: showing available to care, fostering affection, establishing connection and confidence; instigating moments of meeting with families; promoting interaction and good relationship with the hospital staff and adjusting assistance to the patients’ culture. This care provided welfare and better adaptation of women with AMI facing hospitalization.

In view of the above, comfort care in the socio-cultural context, based on the Comfort Theory, through the research-care method, was performed as the relationship between researcher-caregiver, and researched-cared women and their families occurred, satisfying, as far as possible, individual needs.

As to the limitations of this study, we can cite the impossibility to make some kinds of care, because of the routines and/or protocols established in the inpatient unit and also the fickle stay of the researcher with the researched-cared women, considering the loss of contact between a meeting and another.

Thus, it becomes important to engage in further research on the comfort as a result of clinical nursing practice, especially those that actively involve the subject of care. As a professional care, the nurse is able to know and provide welfare in different contexts of the health-disease of the human person.

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