ORIGINAL RESEARCH

The refusal of care by patients in emergency situations: nursing professionals' experiences

Theresa de Araújo Abreu^I; Lina Márcia Miguéis Berardinelli ^II; Mauro Leonardo Salvador Caldeira dos Santos^III

^I Nurse. Master degree Student of the graduate program of the College of Nursing at the University of the State of Rio de Janeiro. Brazil. E-mail: louise.theresa.araujo@gmail.com.br
^II Nurse. Associate Professor, graduate program of the College of Nursing at the University of the State of Rio de Janeiro. Brazil. E-mail: l.m.b@uol.com.br
^III Nurse. Associate Professor, graduate program in Health Care Sciences, Universidade Federal Fluminense. Rio de Janeiro, Brazil. E-mail: mcaleo@uol.com.br

DOI: http://dx.doi.org/10.12957/reuerj.2016.26000

ABSTRACT

Objectives : to examine nursing personnel's experiences regarding refusal of care by patients in emergency situations; to identify the feelings they express in view of such refusal. Method: in this exploratory, qualitative, descriptive study of 18 nursing professionals at a municipal hospital in Rio de Janeiro, data were produced in 2016 using a questionnaire of open and closed questions, the subjected to content analysis. The project was approved by the research ethics committee (Protocol No. 52543815.9.0000.5259). Results: three thematic categories emerged from the analysis: The paradox and the dilemma: to refuse or consent to care; Reactions and feelings about refusal of care; and the present relevance of the issue. Conclusion: the refusal of, and consent to, care embody a dissonance in theory and practice. This poses a dilemma that needs to be analyzed ethically in that care entails receiving and treating.

Keywords : Treatment refusal, nursing care, emergencies, ethics nursing.

A long time ago the nursing literature explained that, in order to work in urgency and emergency units, professionals needed skills and manual dexterity, so they should have technical competence to carry the activities in those areas of care. Currently, the scenarios keep following this logic - fast, effective and technical service, however, there are expanded requirements towards the evolution of scientific knowledge and appreciation of human rights, respect for human dignity, compassion, solidarity and the theoretical and philosophical fundamentals of caring, integrating a set of skills beyond the technique in relation to do-assist the human being.

Nursing in its daily life and in the contemporary world, finds itself before several ethical dilemmas, and in order to these dilemmas to be solved with the supremacy of ethics, it is necessary that the nurse try to listen attentively and look determined when providing care, always paying attention to the peculiarities of the patients¹.

The dilemma rises when the professional finds himself before a patient who refuses a care or treatment, which is strictly necessary for the speedy recovery of health. This reality leads to questions: How to respect the decision of a patient, when this decision puts his or her health at risk? How to leave the patient's life at risk, when it is possible to restore their health? These dilemmas make nursing professionals uncomfortable daily, and therefore they should be discussed in order to find best solutions.

In this sense, considering the introductory reflections one may wonder: if nursing is responsible to ensure and promote the life of human beings, what should professionals do when they come across this situation? What are the feelings expressed by nursing professionals when they face the refusal of the patient to receive care in urgent and emergency situations? How do the nursing staff reflect on the topic of refusal to receive nursing care in emergency units?

Thus, the study object is: The meaning of the refusal of care by the patient in urgency and emergency situations from the perspective of the nursing staff. And aims to: Gather the experiences of nursing staff in relation to the refusal of the patient in receiving care in urgency and emergency situations; Identify the feelings expressed by nursing professionals when they face the refusal to receive care.

LITERATURE REVIEW

The Ordinance No. 1600/11 of Ministry of health (MH) states that the emergency unit are designed to receive and assist appropriately all patients who require emergency or urgency care. The goal of this unit is the quick assessment of these patients, the prompt stabilization of the clinical status presented or the admission by the hospital².

And, in this environment, the refusal of the patient to receive nursing care is a constant reality. It can occur due to several factors such as fear of diagnostic procedures, the ignorance and the existence of the free exercise of autonomy are a constant part of the experience of nurse staffs to face refusal in the hospital environment. Other factors may influence the acceptance or refusal to receive care, such as the educational level, the suffering, the negative feelings, the types of injuries, adverse reactions and the perception of the quality of care received³.

Nurses, who work for the purpose to provide welfare and the restoration of human life, when surprised by the refusal of a care often cannot understand very well why the person to make that decision, and, especially, when it comes to someone who needs such care the most. When this happens, there are different reactions, such as frustration, anger, among other feelings on the part of who's providing the care. Then a dilemma rises; should the professional be loyal to the autonomy of the patient or the need of care?

These circumstances alone lead to some reflections. At first, it is considered that it is the patient's call to refuse any kind of care, as stated in the Ordinance No. 1820 of MH, from 8/13/2009, article 6, item III ⁴. In this ordinance, the patient must be informed about the proposed treatment and he or she must seek to understand and accept it, being this individual also an actor responsible for his/her life, therefore, it is the patient's call to refuse the service, since he/she assumes responsibility for the decision.

It being understood that emergency and urgency care are decisive for the establishment or restoration of the health of people, the nurse, as well as the health team, should seek to identify and address possible problems that may rapidly endanger the patient's life⁵.

METHODOLOGY

This is an exploratory, descriptive study of qualitative approach. The scenario was a midsize hospital, reference to emergency calls in the West Zone in the municipality of Rio de Janeiro, during the month of April, 2016.

The study subjects were 17 nursing team professionals, being 14 technicians and four nurses. Inclusion criteria were: nurses and nurse technicians who are part of the nursing staff, working in emergency units for at least 6 months, regardless of sex, ethnicity and religion and who accept to participate in the survey, as described in the Consent Form (CF). Exclusion criteria were determined based on: employees who were on sick leave at the time of the survey, premium leave at the time of the survey, and those employees who are not fixed in the emergency unit.

This research was carried out considering the provisions of the resolution in 466/12 of the National Health Council/MH, which deals with the Regulatory Guidelines and Standards of Research in Humans. First approved by the immediate Chief of Nursing, the Central Administration and thereafter forwarded and approved by the ethics and Research Committee (CEP) with the Protocol number 52543815.9.0000.5259.

The data were produced through individual questionnaire with open-ended and specific questions on the demographic characteristics and the theme, such as: Do you agree that this topic is pertinent in emergency units? What most calls your attention when you see yourself in a situation of refusal of the patient to receive care? Do you think search on this subject can help the nursing staff to deal with this situation?

These printed questionnaires were distributed to the participants and collected in the unit and work shift, needed to achieve the research objectives, and be familiar with the opinion of participants.

Then, the data were organized, distributed chronologically according to the answers, sorted and categorized according to content analysis proposed by Bardin, gathered as a set of techniques for communication analysis ⁶. Such analysis includes both manifested content that belongs to the subject field, as well as the latent, that correspond to those that are apparently not in the message, i.e. are in the symbolic field.

Then, relevant content was identified, namely, the excerpt that have marked the statements because they are similar or different. After the identification of the units of registration (UR), the data was grouped by content convergence, originating three categories of corpus of analysis, called: 1) The paradox and the dilemma: to refuse and consent receiving care; 2) Reactions and feelings of the professionals about the refusal of patients to receive care; The relevance of the theme today.

In order to ensure the anonymity of the information gathered, the participants' nurses were identified by the letter E, the letter T for the technicians, accompanied by their number sequence in the study. Then the data were analyzed in the light of the specific literature^1-20.

RESULTS AND DISCUSSION

Survey respondents were the nursing professionals, both nurses as nursing technicians in the polytrauma sector, who have agreed to participate in the research. Altogether there was 18 participants, being 3 (18%) nurses and 14 (82%) nursing technicians, and among them there were 13 (76%) women and 4 (24%) men. The age range of the participants varies from 31 to 45 years old. As to the ethnicity of the participants, 5 (30%) were brown, 5 (30%) black and 7 (40%) white.

Out of these participants, in relation to the workday, most of them have only one job, that is, 11 (65%) of the participants with one job, on the other hand 6 (35%) have two jobs. The workday of those with only one job, varies from 30 to 40 hours a week, because the municipality offers a complement of load time of 10 hours for those who need to supplement income, enabling greater labor force supply to the hospital.

The paradox and the dilemma: refuse or consent to receive care

This category emerges from 28 UR and offers the reasons the nursing professionals think and reflect about the refusal of patients to receive care and the reasons for this denial. Here are the testimonials:

On the ER, where the first services are provided, is where the largest number of refusal occurs because patients have not yet accepted their condition. (T5)

Most of the time the patient is not aware of the importance of nursing care. So, it is very important the nursing professional to provide information of the importance of nursing care for the recovery of the patient. (T13)

[...] the refusal could be linked to socio-cultural and institutional issues, because nursing can have a favorable contact with the client, running into other issues that are above nursing care. These issues may be rush to pick up a child at school, hunger, some pressing appointment, absence of the doctor. (T5)

Both sides should be educated. Both, the professionals, who must to be aware of their rights and duties, as well as the features and limitations of the system, and the patients, who receives and refuses care. (T10)

Collaboration can only exist if the admittance process is carried out through a co-responsibility process with all professionals for patients' health, since admittance actions must be carried out by a multi professional and interdisciplinary performance with professional able to provide holistic care, who is qualified and trained, who shows a welcoming attitude established between patients and professionals on behalf of continuity and quality service^{7, 8, 9}.

The refusal can occur for several factors cited by the participants, even some are unusual, such as sociocultural issues, scheduled activities; the task of nursing to provide comfort, security, transmit confidence and information, so that the thoughtless refusal - with harm to the patient, can be avoided.

Therefore, it is necessary that the team follow to the humanistic and legal principles of the Code of ethics of nursing professionals, essential orientation for healthcare. In article 27, the following prohibition is clear: "Run or participate in health care without the consent of the person or his legal representative, except in imminent risk of death". Therefore, the right to freedom and the autonomy of patients should be respected until the moment that that the decisions of the person assisted do not cause immediate danger of losing his life, since the greater good is the right to life, which nursing professionals should not measure efforts to protect ^10.11.

Thus, the right to refuse care is not absolute, and can only be observed if the patient enjoys the fullness of their mental faculties and is not on the verge of death. This fine line between respect for refusal and the necessary intervention to preserve life is deepened in ethical dilemma and requires an effective professional discernment¹².

The process of care should include dialog through a sensitive, intuitive care that meets emotions and insights that emerge from communication. Besides considering and valuing the patient experience through an attentive dialog that may assist in understanding both in the causes of health problems, as well as in the search for solutions these issues. Thus, one must respect the autonomy and dignity of each patient when they present their fundamental ethical principles. So, the nursing professional must show respect for the patient's knowledge and their autonomy, freedom and creativity^13,16.

To better clarify the importance of ethics in the workplace, it is worth remembering the homo laborans, that after the Industrial Revolution had to transform his work on effectiveness and efficiency to meet the demands of production goods, and now faces the dynamics of science of reason and of technological advances. Despite these advances, the homo laborans should not dismiss the will to fight for a better care, an ethical care. The human being cannot despise the noises of apparatus and machines, but rather, he or she must pay attention to the voice of his neighbor, which dispenses the care¹⁴.

Reactions and feelings about the refusal to receive care

The category in question emerges from 23 UR and seeks to analyze the feelings of professionals about refusal. Below, you can see the testimonials from professionals about feelings they have when they face refusal to receive care:

Yes. Because most of the time the refusal raises stress, indifference and sometimes anger on staff. (E3)

I think the patient refusing the care at that moment if he or she is confused. He doesn't understand the real need of care. I feel uncomfortable with such an attitude. (T2)

Depending on the result of data collection, it could cause the reflection on the part of professionals and not revolt by the refusal. (T12)

What most strikes me is knowing that the patient is having access to care and immediate treatment, and still refuses to accept them. This could cause future damage to his health. (T8)

There are also testimonials from professionals that catches our attention:

What strikes me most about the team is the joy and satisfaction to be one less patient to take care of . (T1)

Learn how to receive a "no", how to accept a "no, and learn how to not to put the "no" as the reason for better arguments and information. (T11)

It is observed that there are contradictions in some testimonials, and that people are not always prepared to hear a no, especially under the circumstances of an emergency. Nursing, as a profession that deals directly with taking care in different stages of life and levels of complexity, doesn't expect a negative attitude on the part of the person who needs care.

When dealing with direct care to patients and family members, nursing professionals expose themselves to different cultural contexts until they understand this public. This relationship might generate stress, feelings of frustration, coldness and indifference in the professionals ^15,19.

Thus, it is important to have a watchful eye to this professional for him or her to be physically and psychically healthy in order to be able to take care in a humanized way. Since the environment of an emergency can bring much work-related stress for requiring the professional high productivity under pressure of time and complexity of the tasks^15,20. It is necessary to build and provide psychological support and continuing education so that this professional can be free to express their feelings and questions, to overcome doubts and erroneous conduct coming from a professional breakdown or lack of training.

The nursing professional must develop a listening skill that must be the characteristic of every health worker, which means to develop the ability to listen carefully to the people, noting that the process of narrating a fact can contribute to the change in the way to envision and act on any situation, especially when the professional is facing a situation of refusal of the patient to receive some care¹⁴. In this case, the refusal to receive care can happen due to the lack of knowledge, dialog and listening intently and actively can remedy the problems that may arise from noises of the communication between the professional and the patient.

The following are related the testimonials of professionals about what they think of reasons that lead patients to refuse receiving care:

Because most of the patients who refuse care, do it for lack of information . (T10)

Due to lack of knowledge care is denied, which is remedied when the team is willing to sensitize him about the fact, sometimes. (T5)

The lack of patience or refusal to wait for their turn to arrive. They want quick serve without considering that the most serious case is always a priority in the public service and in any health service. (T10)

It is complicated when the patient is a layman, because he's right on their body and treatment, on the other hand the team has responsibilities and duties towards the life of this patient. The impression is that he doesn't know the importance of the care provided. (E1)

The lack of awareness of patients about the care provided by nursing, and how important it is . (T13)

In relation to lack of knowledge, it is believed that it can contribute to a worsening in the quality of life of patients, since it can lead to social isolation, lack of self-care, increase in co morbidities due to ignorance of signs and symptoms and, finally, the lack of adherence to the treatment required, because the patient can't understand the magnitude of the need of the proposed treatment. The patient's knowledge about his health condition is a determining factor for adherence and treatment success¹⁸. Thus, the refusal to receive treatment can happen due to ignorance of the patient and his real situation and about the importance of the treatment in the emergency unit.

The opinion about the lack of knowledge of the need and importance of receiving care comes up in many lines of the participants, which demonstrates that the professionals believe that through proper information it is possible to overcome refusals, only occurring in a clarified manner, providing effective care.

The lack of knowledge can be related to the refusal without having the appropriate knowledge and information that is relevant to two aspects: at first, refusal can occur by ignorance of the details of the interventions, and then by insecurity in relation to the professional or the institution. This may contribute to the rejection, due to lack of information ³.

It is important to know how to deal with refusal, how to approach it, the best way to get around it, so that the feelings and expectations of the professional will provide a humane and legal assistance.

The relevance of the theme today

This category arose from 38 UR and concerns about the study regarding the contributions that this study can bring to the care offered to patients.

The search can help, because we don't feel comfortable when the rejection happens and we don't know how to use the means to deal with the situation for the patient. (E2)

Through this research, nursing professionals can know and understand the reasons why the patient refuses the nursing care. (T13)

Research can help us to draw new approaches and clarification on the importance of care . (T8)

The research tends to enlighten professionals and users about the functioning, rights, duties, and structure of the health system . (T10)

It is s relevant because it gives us the chance to assess and maybe help the patient at that moment of difficulty; when the patient often doesn't realize that his refusal can harm him in the future. Nursing can help with it. (T2)

Despite being an environment in which emergency service requires efficiency, care should still be the link between the professional and the patient. In this perspective, the nursing staff need to prepare to provide a service with agility and skill, with logical reasoning, to establish priority and intervene consciously and safely in patient care, without leaving aside the careful sensitivity care requires^7.

Nursing is a profession that has as main instrument role to take care, this activity is the backdrop to offer the customer a worthy and committed service. And a great challenge for nursing is working with ethic and subjective dimensions allied. By respecting humanistic values, feelings, and limits of the individual who receives the care and the one who provides. The science of care is the combining of knowledge, technical skills, ethics, organization that goes beyond intuition, experience and sensitiveness²⁰.

CONCLUSION

Nursing is a profession that faces daily challenges. The research has the very relevant role to improve the practices so that they are applied in order to provide recovery and satisfactory promotion of health.

During this study, it was possible to notice that different feelings are generated at the time of the refusal of care per patient in an emergency and which reasons nursing professionals give to this behavior. Some feel devalued, constrained, indifferent or even angry. Others have shown that this refusal can take place because of several factors, such as lack of knowledge about their current situation, out of fear or for lack of an effective participation of the multi professional team.

It was noted that participants had the conviction that the research related to this subject can come to assist them in the care with the patients who refuse care in emergency situations, since it is this a daily fact with wide field of exploration, to generate evidence to assist in the improvement of the care provided. Thus, the study discusses the subject in cognitive and aesthetic dimensions of care, how to act in nursing with science technique and art. Namely, deepens the reflection of how the care provides a break in reality and on the main object of nursing: the ethical care.

REFERENCES

1.Rodrigues BMRD, Santana JS, Pacheco STA, Ciuffo LL, Gomes APR, Rosa JS, Cardoso JMRM. A ética no cuidar em enfermagem: contribuições da fenomenologia sociológica de Alfred Schütz. Nursing Magazine UERJ. 2011. 19(2):236-41.

2. Ministry of health (Brazil). Ordinance No. 1,600, of July 7, 2011. Reshapes national policy of attention to the emergency room and sets up the network of Attention to the emergency room in the unified health system (SUS). Brasília (DF): Ministerial Office; 2011.

3.Salazar AB. Rechazo de los pacientes del cuidado enfermero. Invest Educ Enferm. 2011; 29(3):343-52.

4. Ministry of health (Brazil). Ordinance No. 1,820, of August 13, 2009. Rules on the rights and duties of users of healthcare. Brasília (DF): Ministerial Office; 2009.

5.Azevedo ALCS, Scarparo AF, Chaves LDP. Assistance and managerial actions of nurses in traumatic emergency rooms. Invest Educ Enferm. 2013;31(1):36 - 43.

6.Bardin L. Análise de conteúdo. Lisbon (Pt): Editions 70; 2016.

7.Guedes MVC, Henriques ACPT, Lima MMN. Greeting in an emergency room service: users' perception. Rev Bras Enferm, Brasília 2013; 66(1):31-7.

8.Silva JA, Bolpato MB. Proposal for deploying host protocol of admittance with evaluation and risk classification in the emergency sector. Interdisciplinary: Univar Electronic Journal. 2013; 9 (1):85-9.

9. Giron MN, Berardinelli LMM, Espírito Santo FHE. The admittance in the operating room in the perspective of the user and the national policy of humanization. Nursing Magazine UERJ. 2013; 21(2):766-71

10. Federal Nursing Committee. Code of ethics of nursing professionals. CONFEN resolution No. 311/2007. Brasília (DF): COFEN; 2015.

11. Regional Nursing Council of São Paulo. Menu: Blood transfusion in Jehovah's witness patient. Decree No. 068/2013 - CT: São Paulo: COREN-SP; 2013.

12. Consalter ZM, Jaremczuk p. right to life versus refusal to get vital treatment. Prisma Jur.(São Paulo), 2011; 9(1):35-53.

13.Silva LD, Beck CLC, Tavares JP, Budó MLD, Silva HS. O enfermeiro e a educação em saúde: um estudo bibliográfico. Rev Enferm UFSM 2012; 2 (2):412-9.

14.Buzzi AR. A filosofia e o cuidado da vida. Petrópolis (RJ): Vozes; 2014.

15. Silva JLL, Dias AC, Teixeira LR. Discussão sobre as causas da Síndrome de Burnout e suas implicações à saúde do profissional de enfermagem. Rev Chia. (Colombia) 2012; 12 (2):144-59.

16.Bueno LX, Benedet AS, Salum NC. Vivência dos profissionais de enfermagem frente a dor: uma estratégia de humanização do cuidado. Electronic magazine on Health Management. 2012; 3(3):999-12.

17.Martins JT, Bobroff MCC, Andrade AN, Menezes GDO. Equipe de enfermagem de emergência: riscos ocupacionais e medidas de autoproteção. Nursing Magazine UERJ. 2014; 22(3):334-0.

18.Salci MA, Maceno P, Rozza SG, Silva DMGV, Boehs ASE, Heidemann ITSB. Educação em Saúde e suas perspectivas teóricas: algumas reflexões. Texto Contexto Enferm. 2013; 22(1):224-30.

19.Bonin CDB, Santos RZ, Ghisi GLM, Vieira AM, Amboni R, Benetti m. Construction and validation of the Knowledge questionnaire for patients with heart failure. Arq Bras Cardiol. 2014; 102(4):364-73.

20.Maria MA, Quadros FAA, Grassi MFO. Systematization of nursing care in urgent and emergency services: feasibility of deployment. Brazilian Nursing Magazine 2012; 65(2):297-303.