ORIGINAL RESEARCH

Nurses' self-perception when communicating difficult news to inpatients and relatives

Iraci dos Santos^I; Lenilce Pereira de Souza da Silva ^II; Sandra Teixeira Araújo Pacheco^III; Marléa Chagas Moreira^IV; Leandro Andrade da Silva ^V; Alexandre Vicente Nascimento^VI

^I Nurse. Titular Professor of the Nursing School, Fundamentals of Nursing, Universidade do Estado do Rio de Janeiro. Brazil. E-mail: iraci.s@terra.com.br
^II Nurse. Master's Degree of the Postgraduate Program in Nursing of the Universidade do Estado do Rio de Janeiro. Brazil. E-mail: lenilcesilva@gmail.com
^III Nurse. Assistant Professor of the Nursing School, Universidade do Estado do Rio de Janeiro, Brazil. E-mail: stapacheco@yahoo.com.br
^IV Nurse. Associate Professor, Postgraduate Program in Nursing, Universidade Federal do Estado do Rio de Janeiro. Brazil. E-mail:marleachagas@gmail.com
^V Nurse. PhD and Master's Degree of the Postgraduate Program in Nursing of the Universidade do Estado do Rio de Janeiro. Brazil. E-mail: proflandrade@gmail.com
^VI Nurse. Professor. PhD of the Postgraduate Program in Nursing of the Universidade do Estado do Rio de Janeiro. Brazil. E-mail: alexvicentesilva35@gmail.com

DOI: http://dx.doi.org/10.12957/reuerj.2017.30003

ABSTRACT

Objective: to examine nursing professionals' imaginations as a dimension of their self-perception when communicating difficult news to clients and their families. Method: after research ethics committee approval (protocol 1.708.125), the sociopoetic approach was applied as method in a study conducted from August to September 2016 at a hospital in Rio de Janeiro, in which 12 nursing professionals participated in the artistic practice "Living in Geomythical Places", guided by the question: If communicating difficult news were a geomythical place, what would it be like? The resulting data were analyzed using thematic category analysis and described in the classificatory study. Results: three categories were delimited, expressing the communication of difficult news as: a frightening experience; a positive experience; and an experience of overcoming. Conclusion: in the participants' imaginative dimension, the communication of difficult news to clients and their relatives was characterized as a difficult situation to face. Further studies of the communication of such news should be conducted using theoretical and philosophical conceptions and new frames of reference to give greater visibility to this issue.

Keyword: Nursing; social skills; communication in health; caution.

INTRODUCTION

Difficult news are not only directed at clients and their families. Health professionals are the first to receive them, having to process them in a timely manner to pass on to the sick and their families¹. Emphasis is placed on the determination of the medical diagnosis, the formulation of the prognosis, and the communication of these to the people; these are activities of the legal competence of the physician, supported by specific legislation regarding the subject. Similarly, each professional category will have specific competencies². However, although the communication of these news is a task practically unavoidable for the doctor, it is present in a special way in the life of any health professional, which can cause intense and painful feelings³. A situation that makes difficult news everyone's responsibility.

The way difficult news are conveyed is a key point. A cultural issue involves the client's difficulty in asking the doctor questions. Because of shame, cultural limitations, difficulty in understanding technical terms or other subjective limitations, the fact is that in the daily routine, often the speech of this professional needs to be decoded in simpler terms so that clients can assimilate what was said by the doctor⁴.

Even though it is the duty of the physician to communicate the diagnosis and prognosis to the patient, and that the form of such communication must be known by all health professionals, doctors and medical scholars point out to the importance of nursing in this context, recognizing in these professionals their highlighted role, since they are the ones who spend most time with clients and their families⁵.

The communication of difficult news is an extremely delicate action both for those who receive it and those who transmit it. This action causes feelings of disruption, fear, anxiety, uselessness, discomfort, and disorientation. Due to the fear of being verbally assaulted, professionals tend to develop, over time, escape mechanisms, which makes communication less and less careful; thus, highlighting the role of nursing with clients and family members who receive difficult news, and emphasizes the importance of the assistance provided by these professionals⁶.

The authors emphasize the importance of a communication based on empathy, affection, and attention to the verbal and non-verbal signals of those who receive it. For them, nursing care is paramount in the process of communicating difficult news because it is based on a humanistic attitude, in which the client is seen as a being worthy of care, solicitude, diligence, and zeal. In practice, they experience the feelings of responsibility, concern, and close involvement with clients⁶.

Considering the importance of preparing health professionals to deal with this communication, it is necessary to think that the way this happens can directly interfere in the quality of life of: clients, their relatives, and health professionals. Therefore, the object of study has been formulated: - Self-perception of the communication of nursing professionals regarding giving difficult news for hospitalized and family clients.

To elucidate this object, the research problem was considered: how do you perceive yourself when communicating difficult news about clients with difficulty in recovering health and/or the possibility of eminent death? To answer this question, the goal was to analyze the imaginative dimension of nursing professionals about their self-perception when communicating difficult news to clients and their families.

THEORETICAL REFERENCE

Death involves much more than the objective questions of its definition. In the trajectory of Western civilization, the act of dying has become a sad moment in many ways: it is solitary, mechanical, and inhumane. These subjective issues made it difficult to determine technically the exact time a person dies⁷.

When people take courses in healthcare, certainly the motivation is not for the possibility of dealing with situations of death or the mourning of relatives and friends of the individual who died. It is understood that the motivation to act in this area is driven by the desire to help clients to be well, fighting diseases, assisting that person in performing activities that contribute to the promotion or recovery of health, as well as to prevent diseases⁸. For this author, there are many possibilities, which have been summarized in the attempt to explain why the difficult news generate suffering to those who receive it and the health professionals who need to communicate it.

One of the main reasons that hinder the communication of this news is the cultural issue involving the difficulty of asking the nurses and the doctor questions⁹.

At times when the disease progresses and there is a depletion of healing resources, the communication management among health professionals, clients, and their families becomes more difficult. The vulnerability to which they are exposed and the lack of preparation of these professionals to be confronted with situations of finitude and death becomes evident, creating another reason for the difficulty of communicating difficult news. At such times, these experts warn that there is a need to avoid omission, false promises of cure, and indications of technological resources that are unable to guarantee an increase in people's survival or an improvement in their quality of life⁹.

This is often a phase in which the health professional starts to focus on the equipment and parameters available. Concentrating attention on the machines is a visible and desperate attempt by this professional to reject the client's imminent death, so appalling and bothersome and at the same time his/her own mortality⁸.

Regarding the sociopoetic approach

The sociopoetics is an approach in the knowledge of the person as a political and social being. It is considered a different form of research ¹⁰. It is a philosophy, a social practice, and an act of caring, educating, and researching. It has application in the areas of education, psychology, sociology and human, social, health sciences, which includes nursing¹¹. Considering that people possess knowledge (intellectual, sensitive, emotional, intuitive, theoretical, practical, gestural), it is argued that the sociopoetics promotes a collective construction of knowledge because it is an act produced by researchers and research participants. The collective construction of knowledge defines sociopoetics as an innovative methodological proposal^11-13.

For such authors, the method identifies the potential in the knowledge of the participants of the research, causing them to leave the condition of research subjects and be transformed into participants, co-researchers. The option for sociopoetics is based on the valuation that the method offers and gains fundamental importance in the collective construction of knowledge. The individual, who in most of the traditional researches is someone from whom the researcher collects information, data, here becomes the main element for the development of the research.

Jacques Gauthier, creator of sociopoetics, says that this approach of the human being as a political and social being is a continuation of the maturation of Paulo Freire's Pedagogy of the Oppressed, which this renowned pedagogue has developed throughout his life¹⁰. The institution of the Researcher Group (RG) comes from the conceptions of the Institutional Analysis, a René Lourau trend. The development of the stages of the sociopoetical method is anchored in the Dialogical Theory and its four principles, created by Paulo Freire: collaboration; union for liberation; organization; and cultural synthesis. This can be observed in the union for the organization, production, analysis, counter-analysis, and validation of the knowledge obtained by the RG in the implementation of the phases (6 to 7 sociopoetical workshops of this method) to sociopoetics, an approach in the knowledge of the person as political and social being, considering it a different form of research¹¹.

From the institutional analysis, sociopoetics is related to the empowerment of the co-researchers to the totality of the data production, making use of the citizenship of the RG in the exercise of the right to decide on their ideas and points of view¹¹. It is emphasized that sociopoetics, as a research practice, works with the imaginative dimension of people; it also emphasizes the cognitive strength and creativity, seeking to reveal the repressed, hidden, and creative unconscious of institutional analysis ^12,13.

METHODOLOGY

The sociopoetics has been chosen, an approach in the knowledge of the person as a political and social being, considering it a different form of research¹³.

In applying the sociopoetic approach, five philosophical principles are developed during the stages/workshops: institution of the RG - analytical device of the sociopoetic method, that is, to consider the members of this group as co-researchers, next to the institutional researcher; to emphasize the importance of dominated cultures and resistance of the categories and concepts they produce; to emphasize the importance of spiritual and human sense, of forms and contents in the process of knowledge construction; to understand the importance of the body as a source of knowledge; to value the role of artistic creativity in learning, in knowing and in researching ^12,13.

The theoretical foundations and philosophical principles of sociopoetics, already described, have been applied. The Municipal Hospital Souza Aguiar (MHSA), in the city of Rio de Janeiro - Brazil, was the research field. The name Souza Aguiar was a posthumous tribute to Francisco Marcelino de Souza Aguiar, former mayor of the city¹⁴. The MHSA is a reference in the care of people with severe illness, in an emergency, being considered the hospital with the largest public emergency in Latin America ¹⁵.

The research took place in seven stages of sociopoetical workshops, from August of 2015 to September of 2016. The eight participants selected for the composition of the RG and the development of the stages of data production were the nurses, technicians, and nursing assistants working in the HMSA, who met the established criteria: to be a nurse, technician or a nursing assistant; to have a statutory employment contract or CLT agreement; and the possibility and commitment to compose a RG and to participate effectively in all phases of the research process. It should be emphasized that the sociopoetics works with the imaginary revealed in artistic techniques.

Institution of the researcher group - analytical device of the sociopoethic method

There was negotiation between the institutional researcher and the participants, aiming to institute the RG, to define the research-generating theme, to schedule the days of the sociopoetical workshops, and to choose the sensitivity dynamics and the research techniques. The RG accepted the generative theme: communication of difficult news to the hospitalized clients, and the dynamics and technique of research. During the research, each co-researcher was considered an active being, capable of acting and intervening in all stages of the research, from the production of the data, the analytical and transversal readings of the data, and the socialization of the knowledge produced by the group^{16: 41}.

The master dissertation project was submitted to the Research Ethics Committee (REC) of the research field, being approved under the protocol number 1.708.125. The co-researchers were informed of the opinion approved by the REC, signed the Free and Informed Consent Term, being guaranteed the respect, privacy, anonymity in the dissemination of the data produced by the participants¹⁷.

Development of sociopoetic workshops for data production

This is a dissertation cutout¹⁸. A research technique was developed after the realization of relaxation dynamics, aiming at the incentive of the imaginary of the members of the RG¹².

The Geomythical Place Experience (GPE) was applied in creative practice in order to stimulate the senses of the RG and favor the revelation of new knowledge. After the production of data, the co-researchers analyzed and presented their productions, written and verbally. With the authorization of these, the statements were recorded in full, aiming the researcher's analysis and transcription, and the counter analysis of the RG, in the following workshop. Sociopoetics, as a research practice, emphasizes cognitive strength and creativity, revealing the unconscious repressed, hidden, and especially creative. A theoretical foundation applied in the workshops was the mythopoetic listening of René Barbier, recognized as sensitive and therapeutic listening, allowing the RG: to research, to interpret, to criticize, and to autocritize¹¹.

Since then, the estrangement is proposed as a way of producing new subjectivities, important for the collective construction of knowledge and in research^17,18.

Out of the 16 geomythical sites, eight have been used: earth, well, bridge, failure, tunnel, labyrinth, path, and rainbow. The GPE application considered: the numerical identification of each participant in the group; dynamics of sensitivity and relaxation; participants' answers to the questionnaire formulated. The workshop was developed in 2 hours.

Analysis / counter-analysis / validation of the data produced

The production of the data is followed by the explanation/analysis by the co-researchers of the interpretations aroused to it. The meanings attributed by the RG to its productions were registered, in order to facilitate subsequent analyzes. After this moment of individual explanation/analysis, there was a collective analysis of the whole production performed by the RG, aiming at discovering the structure of individual and group thinking of the participants, valuing their heterogeneity. After the individual and group analyzes of the RG members, the researcher/facilitator made his analysis of this production. This stage occurred in isolation by the researcher, who identified the invisible thought structures embedded in the acts, verbalizations and writings of the group, trying to find out what the production set tried to communicate ¹¹.

The thematic categorical analysis was applied, specific to the sociopoetical method. After this analysis, the results were described through the sociopoetic classificatory study – which highlights the oppositions, dichotomies, alternatives, and choices that exist in the production of the RG. The counter analysis occurred when the institutional researcher presented his analysis to the GR, which is subject to suggestions, criticisms, alterations or agreement of the analysis performed. This stage represents the moment when the facilitator presents the data produced, the analysis of the co-researchers and their own analysis, and meets with the RG in order to obtain their evaluation as well as asking questions of clarification. The validation of the knowledge produced by the co-researchers was the penultimate stage of the sociopoetic method; in this, the set of data produced by the RG was analyzed and legitimized as a product of a collective construction.

The last step of the sociopoetic method was the socialization. At this stage, the RG presented the results of the investigation regarding the application of the GPE.

RESULTS AND DISCUSSION

The data produced by the RG is presented, using the GPE and applying the Sociopoetic Classificatory Study. It should be emphasized that it groups similar responses, identifies what is common and/or different in the collective content given to each place, revealing unconscious structures of the RG imaginary¹². Thus, 29 individual themes have been delimited and grouped in three analytical categories, which can be observed in Figure 1.

FIGURE 1 . Thematic categories produced with the Experiences of Geomythical Places. Rio de Janeiro, September 2016.

It was verified, in the thematic categories, to be the most prevalent the Difficult News Communication: a frightening experience; less frequently the Difficult News Communication: a positive experience; and it reached an intermediate frequency of overcoming Difficult news communication: an experience of overcoming, according to Figure 1.

Difficult news communication: a frightening experience

This category represents the thinking structure of the RG, it was composed of 12 individual themes: darkness; insecurity, fear, uncertainty; fissure; sadness; scary experience, not knowing where to go; a ground without floor; depth; brake; experience scary, not finding what you need; risk, difficulty; unable to face obstacles; difficulty in facing obstacles.

Difficult news reporting as a scary experience has been found in all the selected geomythical places. Although structurally different, it is observed that, unlike the aforementioned category, in all of them the communication presents itself in a negative way. Dealing with the emotions of clients and family members in situations of serious illness, death or imminence of death triggers in professionals, feelings of insecurity, fear, uncertainty and sadness. Therefore, communicating difficult news to them is seen as an adverse situation, implying a cause of suffering in their daily practices. The fear that the transmission of a difficult situation causes in the participants is usually attributed to the fact that this news brings them to their own challenges and finitude. It is like looking into yourself and seeing yourself as flawed, finite, fragile, and mortal⁸.

It would be like something that might have stifled me, because I would not know where to go. (Speech from the RG)

It is alerted to the understanding that involves the process of communication between health professionals and their clients/relatives. In addition to the aspects mentioned above, it is emphasized that all communication involves dealing with objective issues - the commitment to pass on content, fact, information, but also subjective issues: the feeling we have when we stand before the other; what we feel before the information to be transmitted to people¹⁹.

Difficult news communication - a positive experience

Category composed of nine themes: objectivity; intensity of positive energies; childhood recall; security, planning; peace, tranquility, happiness; pardon; affection; hope; clarity, sharpness. It was identified the existence of an intermediate portion of nursing professionals who were able to relate the communication of difficult news to nine individual topics as a positive experience. Difficult news reporting as a positive experience was found in all the selected geomythical places. Reflecting on the structure of these places, it is observed that, although different, they have given this communication a positive meaning.

With many paths and easy access. Long, clear and of great access. Colorful with defined arcs. (Speech from the RG)

Regarding this experience, the importance of the health professional to be involved in the difficult situations through which patients and their families are exposed to the threatening conditions of life is highlighted. It is necessary to let the hardness, recrudescence, numbness, insensitivity or any other adjective of that kind be replaced by the one affected by having to face the confronting situation of the other²⁰.

Difficult news communication - an overcoming experience

Category composed of eight themes: desire to overcome difficulties; reconstruction; search for problem solving; calm to solve what is confusing; need for assistance; live with failure; need a time to think; a way to grow.

In eight of the individual themes, we can see a portion of the co-researchers linking the communication of difficult news to an experience of overcoming. They thus demonstrate their concern and interest in the subject, seeking greater capacity to deal with the difficult problems to be faced in their daily practice. It is noteworthy that the communication of such news as an overcoming experiment was found in the geomythical places selected in this investigation. Although they are different in their structure, in all of them the communication refers to the desire to overcome difficulties. Besides these difficulties, it is said that breaking difficult news is a gradual process, for which we were not educated, which could justify considering it an experience of overcoming²¹.

Something deep I would need to climb to reach the light. It would be a dark place that I would find the light as I walked. (Speech from the RG)

Reflecting on the difficulties involved in dealing with the nursing team regarding the suffering of people weakened by the conditions of severe illness and/or imminent risk of death, the feeling of overcoming referred to by the co-researchers can be understood as a positive way of dealing with this communication²².

The attempt to cross the line to achieve the result. It would be like going out to seek clarity and solve the problem. (Speech from the RG)

It is noticed that, even recognizing the difficulties involved in the task of announcing such situations, these professionals consider it important to overcome such difficulties.

Closed, but with the end and exit search option. Confused, but calm to reach the chosen destination. Difficult but sad, however, necessary for further growth. (Speech from the RG)

It is emphasized that the overcoming mentioned by the co-researchers is related to the capacity not to try to avoid suffering itself in the face of the suffering of others. The difficulties these professionals face in dealing with difficult situations, notably illness, death or imminent death, are gradually faced with greater security²².

Dark and deep, but it has an end. A light at the end. (Speech from the RG)

In summary, these professionals need to identify that the capacity to care goes beyond the technical aspects of diagnosis and treatment for which they were prepared in the academy, but also for the human aspects, implying, in this way, the occupation, concern, responsibility and affective involvement with the other²².

CONCLUSION

This paper ratifies the importance of the topic of communication of difficult news as part of the experience of nursing professionals, because they are involved with these difficulties during the care of clients/relatives. The adequate communication/relationship of these professionals reflects positively on the quality of life of these people. Through the basis of the thematic and theoretical-methodological references applied in this research, it was possible to understand the meaning of the professionals' communication forms in the face of difficult news for hospitalized/family clients. Therefore, it was reflected on this literature, considering its relevant aspects in relation to nursing care.

It is emphasized that the sociopoetics enabled the development of the research and revealed the subjective meaning of what was sought to know more - the forms of nursing care in difficult situations. For being a research involving a profession recognized as the science of the sensitive, which is nursing, the adoption of this reference, which adopts artistic practices for data production, combining art and sensitivity, has proved to be an important tool/technology for the development of the practice of research, education and care in nursing/health.

In view of what has been experienced in the realization of the sociopoetical workshops, the possibility of simultaneously applying the theoretical foundations and principles of Philosophy and Sociopoetic Theory stands out. However, the importance of beliefs and attachment to the family and social culture as well as to the vocational training of the RG members, who are still unprepared to deal with the difficulties of living and especially with questions about death and die, should be highlighted. Thus, the imaginative dimension of the RG can be justified by the inexistence of social and empathic abilities perceived and/or referred by them and, therefore, the general and specific objectives of this research was obtained.

REFERENCES

1.Instituto Nacional de Câncer (Br). Comunicação de notícias difíceis - compartilhando desafios na atenção à saúde. Rio de Janeiro: INCA; 2010.

2.Congresso Nacional (Br). Lei n.º 12.842 de 10 de julho de 2013. Dispõe sobre o exercício da Medicina e dá outras providências. [cited on Jan 27, 2016]. Available from: https://www.planalto.gov.br/ccivil_03/_ato2011-2014/2013/lei/l12842.htm

3.Pires AP. Comunicação de más notícias. Serviço de Psicologia/HCPA e Núcleo Interinstitucional de Bioética. Atualizado em 1998. [cited on Jan 27, 2016]. Available from: http://www.bioetica.ufrgs.br/masnot.htm

4.Pitombo LB, Neri R. Grupos Balint-Paidéia: uma experiência da gestão compartilhada da clínica ampliada na Rede de Atenção Oncológica. In: Instituto Nacional de Câncer (Br). Comunicação de notícias difíceis: compartilhando desafios na atenção à saúde. Rio de Janeiro: INCA; 2010. p.47-54.

5.Gomes CHR, Silva PV, Mota FF. Comunicação do diagnóstico de câncer: análise do comportamento médico. Rev. Bras. Canc. 2009; 55(2):139-43. [cited on Jan 27, 2016]. Available from: http://www.inca.gov.br/rbc/n_55/v02/pdf/07_artigo4.pdf

6.Andrade CG, Costa SFG, Lopes MEL, Oliveira RC, Nóbrega MML, Abrão FMS, et al. Comunicação de notícias difíceis para pacientes sem possibilidade de cura e familiares: atuação do enfermeiro. Rev enferm UERJ. 2014; [cited on 27 jan. 2016] 22(5): 674-79. Available from: http://www.e-publicacoes.uerj.br/index.php/enfermagemuerj/article/view/5748/12304 . doi: http://dx.doi.org/10. 12957/reuerj.2014.5748

7.Kübler-Ross E. Sobre a morte e o morrer - o que os doentes terminais têm para ensinar a médicos, enfermeiras, religiosos e aos seus próprios parentes. 9ª ed. São Paulo: Editora WMF Martins Fontes; 2008.

8.Silva MJP. Comunicação de más notícias. O mundo da saúde; 2012; 36(1):49-53.

9.Penello LM, Magalhães P. Comunicação de más notícias: uma questão se apresenta. In: Instituto Nacional de Câncer. Comunicação de notícias difíceis: compartilhando desafios na atenção à saúde. Rio de Janeiro: INCA; 2010.p.23-36.

10.Santos I dos, Gauthier J, Silva LA, Gomes RG. Contribuições da sociopoética à uma perspectiva estética do pesquisar/cuidar/educar em enfermagem. Revista Eletrônica de Enfermagem. 2013; 15(1):12-4. [cited on Sep 20, 2015]. doi:10.5216/ree.v15i1.15136. Available from: http://revistas.ufg.br/index.php/fen/article/view/15136

11.Petit SH. Sociopoética-Potencializando a dimensão poiética da pesquisa. In: Adad SJHC, Petit SH, Santos I dos, Gauthier J,organizadores. Tudo que não inventamos é falso- dispositivos artísticos para pesquisar, ensinar e aprender com a sociopoética. Fortaleza (CE): EDUECE; 2014. p.19-40

12.Santos I dos, Gauthier J, Figueiredo NMA, Petit SH. Princípios filosóficos da Sociopoética. In: Santos I dos, Gauthier J, Figueiredo NMA, Petit SH. Prática da pesquisa em ciências humanas e sociais: abordagem sociopoética. São Paulo: Atheneu; 2005. p.19-39.

13.Fleuri RM. A abordagem sociopoética. In: Santos I dos, Gauthier J, Figueiredo NMA, Petit SH. Prática da pesquisa em ciências humanas e sociais: abordagem sociopoética-Prefácio. São Paulo: Atheneu; 2005.p1.

14.Lucena F. História do Hospital Municipal Souza Aguiar. [cited on Jul 13, 2016].

Available from: http://diariodorio.com/história-do-hospital-municipal-souza-aguiar

15.Prefeitura do Rio de Janeiro. Urgência e emergência. [cited on July 13, 2016]. Available from: http://www.rio.rj.gov.br/web/sms/urgencia-e-emergencia

16. Gauthier J. A valorização das culturas dominadas e seus efeitos científicos e filosóficos -as duplagens culturais. In: Santos I dos, Gauthier J, Figueiredo NMA, Petit SH. Prática da pesquisa em ciências humanas e sociais: abordagem sociopoética. São Paulo: Atheneu,; 2005. p. 41-81.

17.Silva LPS. Autopercepção da comunicação de profissionais de enfermagem diante de notícias difíceis e clientes hospitalizados: estudo sociopoético. [dissertação de Mestrado] Universidade do Estado do Rio de Janeiro; 2017.

18.Gauthier J. A sociopoética. In: Gauthier J. O oco do vento: metodologia da pesquisa sociopoética e estudos transculturais. Curitiba (PR): CRV; 2012. p. 71-103.

19.Jesus PBR, Santos I dos. Perspectiva estética/sociopoética ao cuidar de clientes com autoimagem alterada devido a afecções dermatológicas. In: Adad SJHC, Petit SH, Santos, I. dos, Gauthier J, organizadores. Tudo que não inventamos são falsos-dispositivos artísticos para pesquisar, ensinar e aprender com a sociopoética. Fortaleza (CE): EDUECE; 2014. p.61-80.

20.Silvério RCF. O luto dos profissionais de saúde que ousam compartilhar seus afetos. In: Instituto Nacional de Câncer (Br). Comunicação de notícias difíceis: compartilhando desafios na atenção à saúde. Rio de Janeiro: INCA; 2010. P.131-40

21.Silva MJP. O papel da comunicação na humanização da atenção à saúde Rev Bioetica. 2009; [cited on Aug 09, 2016]. 10(2): 73-88. Available from: http://revistabioetica.cfm.org.br/index.php/revista_bioetica/article/view/215/216

22.Neri R, Marinho S. Do tratamento ao cuidado: o relato de uma experiência de grupo Balint-Paidéia. In: Instituto Nacional de Câncer (Br). Comunicação de notícias difíceis: compartilhando desafios na atenção à saúde. Rio de Janeiro: INCA; 2010. p.97-106.