ORIGINAL RESEARCH

Being an intensive care nurse: identity elements present in the field of social representations

Rafael Celestino da Silva^I, Márcia de Assunção Ferreira^II, Thémis Apostolidis^III

^I Doctor's degree in Nursing. Assistant Professor, Department of Fundamental Nursing, Federal University of Rio de Janeiro. Brazil. Email: rafaenfer@yahoo.com.br
^II Doctor's degree in Nursing. Full Professor, Department of Fundamental Nursing, Federal University of Rio de Janeiro. Brazil. Email: marcia.eean@gmail.com
^III Doctor's degree in Psychology. Director, Social Psychology Laboratory, Aix-Marseille Université. France. E-mail: themistoklis.apostolidis@univ-amu.fr

DOI: http://dx.doi.org/10.12957/reuerj.2018.20787

ABSTRACT

Objective: to recognize the identity aspects present in the social representation of nurses about the care practices for the client hospitalized in intensive therapy. Method: field study, qualitative, descriptive and explanatory, based on the theory of social representations and on the social identity concept. After approval by the Research Ethics Committee, interviews were carried out with 21 nurses working in the assistance of an intensive care unit in a federal hospital, using a semi-structured guide. Data were submitted to the content analysis. Results: social identification and enhancement of the group itself, and social comparison and stereotyping of the outside group are evidenced, which are: the ways of using the technologies, the delineation of the typical patient figure, as well as the attributes of the ideal nurse, the sense of work, the intra and intercompany relationship. Conclusion: it is recommended the reorganization of the field of social representation from interventions under identity elements.

Descriptors: Nurse care; intensive therapy unit; social identity; social psychology.

INTRODUCTION

Considering the theory of social representations, the development of human thought is based on the various group insertions of actors in social, historical, political, and cultural fields, among others¹. This insertion of individual members into a social space produces a sense of belonging, from which identity is defined. Therefore, social representations (SRs), through practices, raise the issue of social identity, which expresses a stand and a way of being in the world ², being part of the context of knowledge.

Discussions on this identity theme involve different disciplines. In the field of education, for example, the methods for building the professional identity of basic education teachers have attracted some interest, considering the social representations of this profession. Such methods are related to historically determined cultural and social structures from which teachers have reconstructed their identity³.

In collective health, this concern is related to the professional performance and identity of the "new sanitarian," in view of the creation of undergraduate courses in public health. When investigating the perceptions of undergraduates and graduates of these courses, even though most of them did not initially have an interest in this area, the experiences acquired during the program allowed them to build a sense of belonging, which is related to the identification with political and social elements and values of practice in this field⁴.

In nursing, the focus of this study, the production of knowledge about this theme is based on the analysis of professional identity development. A study conducted a philosophical analysis of this identity and reported that it emerged from the Nightingalean model in 1860, when definitions were proposed regarding what nursing was or was not⁵. This professional identity has been developed throughout the socio-historical construction of this profession, as reported in a study with graduates of a nursing undergraduate course in the 1970s about the purpose and meaning of being a nurse at the moment of professional choice. The identity of these professionals covered: nursing as a second option; care as synonymous with doing; the social stigma of the profession; the possibility of insertion in the labor market and social ascension⁶.

Some areas of nursing practice, such as the specialized fields, also hold discussions about a professional identity of nurses to understand and explain their behavior and actions in these scenarios of care provision, for instance, in intensive care units (ICUs).

Some authors argue that a clear professional identity is observed in this environment, of unique character, which includes all health agents related to such environment. When choosing to work in an ICU, a specific identity that is common to several professional categories is defined in contrast to other hospital sectors: the intensive care worker's identity⁷, a profile that demands specific competence, sharing of common values, and control over those who act there. Nurses are united by a sense of belonging that helps them ensure meaning to the world, deal with daily life issues, and establish communicative relationships.

Poor understanding of this social identity encourages the creation of stereotypes about nursing care in ICUs, which is the focus of this study. These stereotypes are organized based on questionnaires found in the literature about the behavior of intensive care nurses, marked by moments when the patient is seen as an object, depersonalizing care relationships and worrying about high complexity technical actions^8,9 as well as implications of such actions for safety^10-12.

In this sense, this study was conducted considering the need to learn more about the elements that influence professional actions for the adoption of intervention strategies on these elements to improve the quality of care. A previous study about SRs of ICU nurses on their practices observed these representations are organized around the ICU technology and patients, creating styles of care that are suitable for this scenario¹³.

Given the above, the question is: What identity aspects are observed in social representations of caring practices towards ICU patients by nurses working in this environment? The objective of this study was to identify the identity aspects present in SRs of ICU care practices of nurses working in this environment.

THEORETICAL FRAMEWORK

The study was based on the theory of social representations and the concept of social identity. In the perspective of social psychology developed by Deschamps & Moliner, identity is a subjective, dynamic phenomenon that results from a two-pronged observation of similarities and differences among oneself, other people and certain groups¹⁴. SRs compete for such identity that is common to individuals, which, in turn, fosters social identifications and differentiation based on affiliation and belonging to a social group. Thus, the social categorization between who we are and who we are not helps to understand and organize reality, determining identity¹⁵.

In this perspective, the study frameworks are justified, as they will be applied in an attempt to understand how the processes of categorization and social comparison occur, from which the identity and practices of ICU nurses are defined, establishing interfaces with SRs developed by these nurses regarding their practice.

METHODOLOGY

This is a field study with a qualitative descriptive-explanatory approach and application of the procedural dimension of the theory of social representations. The field was a federal hospital in the municipality of Rio de Janeiro, and the ICU section of this institution. Of all 24 nurses working in this ICU, 21 were directly involved in patient care and present during the study period. The other three nurses were excluded because they were on vacation or leave.

Data were produced through individual interviews. The interviews were conducted in the ICU, in the afternoon, lasting on average 1 hour and 30 minutes. A script was used to collect sociodemographic data to characterize the participants and a semi-structured questionnaire was used to explore the theme, with questions addressing the daily practice of nurses in the ICU, patient care style, use of technologies, among others.

Data from the interviews were analyzed by thematic content, after conducting the following stages: identification of the most frequent and significant themes, organization of the groups of meaning, and categorization, allowing the definition of two axes of analysis. This study was approved by the research ethics committee of the studied institution, under protocol 35/10. The participants' anonymity was respected as nurses were identified using the word Nurse followed by an Arabic number, according to the order of their interview. Data production occurred from January to June 2011.

RESULTS AND DISCUSSION

We: element of belonging of ICU nurses

Social identities are shared by those who hold the same social positions, who have a sense of belonging in common and similarities. This social identification was present in data of 17 registry units (RU) and was identified when interviewees referred to their care practice, characterizing an intensive care nurse, that is: a professional who seeks strategies to provide quality care to patients, incorporating the use of technologies and constant improvement of knowledge that explains such use.

One of the elements that supports intragroup similarity and encourages a sense of belonging is the use of technologies in patient care, observed in 14 thematic RUs. In this sense, nurses give great importance to this component of their identity, in which using technologies and giving them appropriate value mean acting in line with the expected practice of ICU nurses.

The emotional component of this sense of belonging directed to the group itself emerges when ICU patients' recovery is achieved. They show positive appreciation of being part of this group and acting in such a scenario, demonstrating satisfaction with the work developed and a high level of commitment. This theme was present in 9 RUs.

This positive feeling explains nurses' preference for patients classified by them as presenting a more serious condition, to protect the in-group and strengthen the affiliation of its members. With this choice, nurse participation in patient recovery is more visible, when compared to a patient in a less serious condition.

They: between differences and stereotypes

Similarities bring important consequences to the perception of the groups. This happens because the more an individual identifies with a group, the more this person can differentiate this group from the others. Thus, the effect of contrast is seen as a result of intensified differences between the categories, where the in-group is appreciated and the out-group is depreciated, assigning common features or stereotypes to such contrast. Appreciation is perceived when they address the recognition of ICU nurses, ensuring them the status of professional of greater knowledge in 12 RUs, and designing requirements considered as essential for ICU nursing care in 14 RUs.

The definition of spaces inside and outside the ICU is another example that illustrates the depreciation of the out-group. It becomes clear when the comparison is made in relation to the other members of the multidisciplinary team that do not work exclusively in this sector and constitute the structure outside the ICU.

The dialog between the in-group and the out-group, we versus they, ends up being portrayed in the discussion about the image of the intensive care nurse, which was observed in 16 RUs. A positive self-image is observed among the ICU nurses (in-group), whereas among the other nurses there was a trend of negative evaluation of the ICU nurses (out-group).

This identity issue has been considered by experts in SRs as a central element of this theory, especially in the organization of the field of SRs, since the individual projects the social identity into the object it represents¹⁶. A classic study in which the discussion of identity is evident is that of cross-cultural representations of AIDS ¹⁷.

In this study, the author shows that a sense of defense supports the creation of SRs of AIDS, based on the following logic: Not me, not my group; that is, the subjects seek to divert attention from the threat of AIDS to "I" (internal group), changing their view to other people, those who receive the responsibility due to their origin and development (external group – the one who is threatened and who threatens)¹⁷.

More recently, other groups have received attention from researchers regarding these intergroup relations, for example, gypsies and rural people. In this case, they attempted to analyze the intergroup relations between gypsy and rural women and learn more about the representations and practices built in in-group and out-group relations¹⁵.

The representation of the gypsy out-group is based on fear and perception of the gypsies as cursed people. The representation of the rural out-group among the gypsies is unclear, but reinforces a tendency to create a positive self-image for the appreciation of their group of belonging in comparison to others. Regarding the in-group representations, positive elements are observed when building the social identity of each of these women¹⁵.

This example illustrates the role of identity in everyday life and how it interferes in social relationships with others. These relationships are guided by the processes of identification and differentiation which, in turn, mediate the meanings attributed to oneself and the others, attesting the connection between SRs and identity¹⁸.

Regarding this study theme, results from other studies support data reported in this study. One of them was produced from an ethnographic study conducted in the ICU of a public university hospital⁷. Among the axes of analysis, ICU workers appear as a professional identity, in which a group of elements supports the construction of such identity.

At the highest level of the hospital is one of these elements, that is, the participants reported great satisfaction with working in a sector considered as an excellence service, in a hierarchical position superior to other hospital services, with high-level professionals, greater organization of service dynamics and multidisciplinary team. In addition, they reported a self-image of heroism, a savior, which increased their sense of gratification when patient recovery was achieved⁷.

Being an ICU nurse/top-level professional is another element of the identity of ICU nurses. Superlatives are used to describe this professional, always above the peers, who are seen as less skilled, or even ignorant. Their self-image is superior to that of their colleagues, due to the knowledge they have and skills to handle technology⁷. Although they disagree with the elite/ top-level image their colleagues have of them, which increases the distance between them and their peers, they feel proud of their role⁷.

The ICU workers' sense of belonging to a group is reinforced by other experts, who show that the creation of an identity with the ICU by nurses is related to the elements that produce the feeling of pleasure in these professionals, which are: helping patient recovery, handling ICU equipment, continuously seeking to improve, and being recognized for the work developed¹⁹. This aspect of satisfaction and pleasure at work is reinforced in a study that was conducted to understand the perspective of physicians about health and work in the neonatal ICU of a public hospital. In the interviews conducted for the study, the participants highlighted their satisfaction with working in the ICU, mainly because of the idea of having more control over complications in the condition of ICU children due to the use of equipment²⁰.

Regarding the superlative knowledge of ICU nurses, seen as one of their identity pillars, it was considered the essence of the representation structure of intensive care for mobile ICU health professionals²¹. The technological dimension of nursing care practices in the ICU has been the focus of a number of national and international studies, which value the need for ICU nurses to pay attention to these technologies in their daily activities^22-24 to help maintain the life of patients and express their knowledge, reinforcing their professional identity and the importance of technologies in intensive care units.

One example of the need to pay attention to technologies is seen in a study that analyzed equipment faults while nurses were handling them, reporting operational problems of infusion pumps and batteries of artificial ventilators, besides errors of the professionals linked with equipment design. These results highlight the importance of nurses performing technovigilance – proper management of ICU equipment – to prevent incidents and risks to patient safety²⁴.

Considering the data and the understanding of the concept of social identity, these representations are influenced by aspects of identity, on the one hand: social identification and appreciation of the in-group, such as the vigilant and interventionist attitude of intensive care nurses, the use of technologies/machines in patient care, the positive feeling of recovering a patient in serious condition chosen to receive care, the professional recognition based on knowledge; and on the other hand: social comparison, which stereotypes and depreciates the group of nurses who do not work in the intensive care unit, and vice versa.

In this case, the established profile of an intensive care nurse based on knowledge leads to a negative evaluation of other professionals, considered from the outside, which is the starting point for conflicts between teams. Consequently, it also generates the opposite movement of depreciation of the ICU nurses, who are seen as mechanical, technological, inhuman.

Care humanization in intensive care units is also a major concern in the literature of this field, and the focus of different studies ^9,25,26. One of these studies is about the relationships of nursing professionals with patients and their relatives in an ICU based on the concepts proposed by Paterson and Zderad²⁵.

The authors report a relationship of power of nursing professionals to the patients and distance from relatives, without a dialogical relation that values encounter and subjectivity. Therefore, they conclude that care humanization is required, allowing patients and their families to express objective and subjective dimensions²⁵. Such appreciation of the subjective dimension, which strengthens commitment and accountability, is also highlighted in another study as one of the elements that can promote nursing care humanization in the ICU²⁶.

Therefore, images of professional classification are constructed based on this identity, establishing intensity metrics that classify professionals as: more/less capable, clearly marking the position of each group and respective practices, which influences the relationship between them.

CONCLUSION

The identity components obtained in this study relate, in the field of social representations, to other normative, affective and symbolic elements and contribute to the meanings attributed by these professionals to their care practice in ICUs. These SRs are wrapped in the social identity of intensive care nurses that includes guiding elements of technology use, definition of a typical ICU patient and the attributes of an ideal nurse, the meaning of work, and intra- and inter-team relationships. This group of factors is linked in order to configure care practices of nurses, ensuring a particular meaning to the social category of being an ICU nurse.

Theoretical limitations of this study have been identified because its results are associated with the study context, showing possibilities for studies on identity in new scenarios, with more subjects, increasing the power of generalization. In view of the above, the category Being an ICU nurse reveals aspects that may be the focus of interventions that promote the practical application of the study results.

In this perspective, by understanding the SR field as a structured group of meanings, knowledge and information, and considering identity as part of such group, it can be reorganized using reflective groups that allow the interference of some elements of the identity that gain relevance after data analysis: in technologies, when overvalued in distance customer care management; in ICU patient typification, which consequently underestimates patients in less severe conditions, more alert and their subjective complaints; and in the superlative of ICU nurses, which underestimates the knowledge of other professionals and are a cause of conflicts.

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