RESEARCH ARTICLES

Phenomenological understanding of intensivist nurses in light of the humanistic thought of Paterson and Zderad

Loraine Machado de Araújo^I; Lorena Machado de Araújo^II

^I Nurse Specialist in Occupational Health Nursing. Department of Nursing, Federal University of Rio Grande do Norte. Natal, Rio Grande do Norte, Brazil. E-mail: Loraine-machado@hotmail.com
^IINurse. Master Student from the Post-graduate Program in Public Health at the Federal University of Rio Grande do Norte. Specialist in Occupational Health Nursing. Natal, Rio Grande do Norte, Brazil. E-mail: lorena_araujo_@hotmail.com

DOI: http://dx.doi.org/10.12957/reuerj.2015.3318

ABSTRACT

This qualitative, descriptive study to understand nurses' perceptions of the process of caring for patients in an intensive care unit was conducted at the university hospital in Natal, Rio Grande do Norte, from January to February 2009. The phenomenological approach was based on the Humanistic Theory of Paterson and Zderad. The study group comprised seven nurses, from whom data was collected by semi-structured interview. Data analysis, following Bardin, revealed the categories: time and space in day-to-day nursing; the existential encounter between nurse and patient; dialogical care in the therapeutic relationship; intersubjective transaction regarding suffering; and coming-to-be in the relationship between professional and family. The study revealed that nursing remains care-focused and considers inter-subjective relations as linking nurse, patient and family in this context.

Keywords: Nursing; intensive care unit; humanization of care; nursing theory.

INTRODUCTION

Care is a component of human life and involves, in an existential dimension of being, an attitude among humans related to the feeling and valorization of life experience. The care occurs in this human inter-subjectivity in a genuine encounter between professional and the being taken care of in a movement of complementary of feelings, actions and reactions¹.

In the intensive care unit (ICU), nursing care is established in a different way because of its specificity. From this perspective, life support machines such as mechanical ventilators, intra-aortic balloons and heart monitors are technologies that require from nursing skills to care². In this sector, marked by technological advances, caring seems to be related to such machines, making the assistance, at times, contradictory^1,3.

Thus, given this reality, it is evident that listening, presence and sensitivity are required to effect the understanding of the patient in everyday practice of care in ICUs, in order to enable the real existential dimension of each participant in this relationship. Thus, humanistic values must be present in the care process, enabling the actions experienced in the daily nursing to become holistic¹. Since the art of nursing is the individual's ability to perceive the expression of feelings of others and empathize with them, it is necessary proximity to the patient's subjective experience, providing a basis for this relationship⁴.

From the need for more extensive debate, authors resorted to the Humanistic Theory of Paterson and Zderad, which from its premises allows a closer relationship between nurses and patients as existential experience, evidenced by the expressiveness and potentiality³.

In this sense, inter-subjectivity overcomes technology from the understanding of reality through the lived experience, reflection and relationship, allowing the opening so that humans can experience the world and themselves in full¹. Henceforth, the objective of this study is: to address the humanized care provided by the nurse to the patient hospitalized in ICU, guided by the Humanistic Theory of Paterson and Zderad.

THEORETICAL FRAMEWORK

The Humanistic Theory of Paterson and Zderad assumes that the science of nursing develops from experiences between nurses and patients, and the meaning of this experience is the starting point for the establishment of an inter-subjective relationship. According to this theory, the care provided by nursing seeks to achieve welfare and being more, necessarily setting a unique encounter between human beings (you and me), guided by a call (need) and an intentional response (care)⁵.

In this context, nursing has in phenomenology an important contribution to its thinking and its doing. The nurse must be prepared to come-to-know, in which self-knowledge is necessary, and also to be receptive to the unknown, willing to be surprised and to know the patients' experience from the transcendence of the professionals themselves, remembering, reflecting and experiencing the I-Thou relationship⁶.

Nursing actions are characterized by a lively dialogue, which is surrounded by meeting, relating and being present. It is from this dialogue that nursing will conciliate reason, sensitivity and subjectivity in the act of caring⁵.

According to the Humanistic Theory of Paterson and Zderad, the human being does not exist in an abstract manner, socially and historically decontextualized. Instead, we are in constant relationship with each other in a genuine attitude. This means that if we value the subject in their uniqueness and subjectivity, we recognize them as an existential being⁷. In this sense, it is impossible to provide care in isolation, because it is an interactive process between the caregiver and the one that is taken care of, and it develops through the availability, reliability and acceptance⁸.

Based on the Humanistic Theory of Paterson and Zderad, care implies being open to the other, available and devoid of any judgment in a reciprocal basis and being able to identify through verbal or nonverbal signs the emerging needs of others, serving them properly⁹.

Thus, considering the relationship between the self and the other is a relationship of observer and the observed being, in which phenomenology raised the subjective experience, as an essential part of systemic interaction of the organism with the environment, leading to forms of care and modes of experience, including developments or reactions of self and the world¹⁰.

METHODOLOGY

This is a qualitative, descriptive study, with phenomenological nature in the light of Humanistic Theory of Paterson and Zderad³. The research scenario was a university hospital in Natal-RN in the ICU sector, from January to February 2009. According to the guidelines and ethical criteria of Resolution No. 196/96 of the National Health Council, the research was conducted after the authorization by the institution, as well as approval by the Ethics Research Committee of the Federal University of Rio Grande do Norte, under the Opinion No.079/2009.

Participants were seven nurses, chosen by convenience, including all those who worked in the ICU, until obtaining theoretical saturation. It was defined as inclusion criteria having been working in that sector for at least two years, and those who did not fit into the previous criterion were excluded. Nurses voluntarily participated in the study after the detailed clarification of the study's purposes, as well as the signing of the Informed Consent Form (ICF).

Authors used as data collection instrument a semi-structured interview following the phenomenological approach, according to the guiding question: With regard to the humanization, talk about your experience in ICU care. To complement the understanding of the issue, they were also questioned about previous experiences on the humanization.

Statements were recorded after the authorization of respondents, by ensuring the confidentiality and anonymity, and later transcribed and analyzed. To identify the participants in the research, we used the numbers 1 to 7, according to the order of the interviews, preceded by the letter N corresponding to the role of nurse.

To understand the speeches, authors used the content analysis technique, in the form of thematic analysis, according to Bardin¹¹. This phase was carried out in three stages: pre-analysis (floating reading of transcribed data); exploration of the material (selection of participants' speech and organization of categories) and treatment of results (interpretation).

Authors chose the philosophical/phenomenological approach based on the Humanistic Theory of Paterson and Zderad because it presents a methodology consistent with the existential analytic dimension³. Phenomenology seeks further research and understanding of the essence of lived experience and how the individual perceives the phenomenon in his/her existential practice, giving thus a more accurate interpretation of everyday perceptions.

RESULTS AND DISCUSSION

The statements showed situations and circumstances that culminated in the construction of five categories entitled: Time and space in the practice of nursing; Existential encounter between nurse and patient; Dialogical care in the therapeutic relationship; Inter-subjective transaction in face of suffering; and The coming-to-be in the professional/family relationship.

Time and space in the practice of nursing

The ICU has incorporated to care a technological apparatus increasingly sophisticated, but to ensure a quality care is also necessary to add comprehensive care¹². According to the testimonies, nurses consider the ICU a favorable environment for the development of care actions and the team collaborates positively to the realization of the humanized work.

I think the sector is organized, where we have conditions to meet the patient at the time he needs [...]. The staff is also very organized and likes to take care. (N3)

The ICU is a place where nurses can actually work, since the number of patients is smaller, so the nurse can get closer and have a better understanding of their evolution. (N1)

However, the admission process directly affects the routine and autonomy of the patient, and causes distancing from family and friends, experienced by a separation of being-in-world, unveiling sensations of fear about the disease and treatment¹³. The hospital, thus, is characterized as a stressful situation, not only because of the dynamics of the unit, but also to be correlated, in the imagination of people, with suffering and death ⁵.

People say that the ICU is a place of death; sometimes patients come in with fear. But it is not so, here is a place of life. Only those able to survive come to ICU. (N7)

Thus, in an ethical dimension, every action involves values, commitment and responsibility. Regarding ICU patients, care is associated with their vulnerability, since they are dependent on the care and on the moral commitment of the person who is taking care of them in a way of being-in-the world¹⁴.

Existential encounter between nurse and patient

Nurses understand that caring is something more than the assistance; it is not restricted to the techniques and routine care, but requires a vision that goes beyond the biological aspect, emphasizing the sense of being of the patient and the concern for all aspects of care¹⁵.

When I draw blood, I always inform them, because hearing is the last thing they lose. I always try to consider the psychological aspect . (N1)

Carrying the concept of coming-to-be more and better to the ICU, the nurse acts as a support so that the patient feels increasingly welcomed. This occurs by relating simultaneously with the subjective and objective aspects of the situation experienced, respecting their physical and emotional conditions⁵. This can be seen in the following statement:

If the patient has a stunned look, I try to encourage him to tell me whether he is in pain to be medicated. (N4)

Often the ICU patient is away from any decision as to their lives, their illness and their bodies, being the lack of family and social isolation one of the main causes of anxiety. Nursing, that helps to maximize the possibility and the ability of patients to make informed choices, seeks to provide care response⁵. Thus, an individualized plan is needed in order to improve their well-being¹³. An example of this plan can be found in the following speech:

Sometimes, when the patient does not accept food and the family comes to visit, they try to give food. (N4)

According to the Humanistic Theory of Paterson and Zderad, the authentic encounter between nurse and patient may result in comfort, to the extent that there is engagement with the other in true relationships. This causes a person to feel cared for, respected, safe and secure, so they can experience a feeling of harmony with themselves and with the environment⁵. In the statement, the nurse expresses the way she seeks to meet the patient:

I comfort the patient trying to minimize the anguish and anxiety, [...] showing that I'm not there only to puncture. (N5)

This means knowing and understanding the processing of emotional responses or reactions resulting from the meaning given to the disease and implementing coping strategies to do so. And this encounter involves a network of inseparable connections that, contextualized within a reality, gives meaning to the experience of caring¹⁶.

Dialogical care in the therapeutic relationship

It is known that communication can positively influence nursing actions, which can take the form of verbal and nonverbal calls. The nurse must be open to all experience and be able to realize these calls, to intervene and dialogue, promoting inter-subjective relationship between those who care and those who are cared for⁵. Although there are some difficulties, nurses claim to overcome them.

Conscious patients say what they are feeling, unconscious patients you can see in their eyes, even without words. (N3)

In this existential encounter, it is important for nurses to seek to know the other in an attitude of being-with-the-other so that the relationship happens positively and trust is established⁵. When considering the patient's perspective of the world, the nurse can meet their real needs and minimize the trauma of hospitalization and treatments¹⁵. Therefore, in a therapeutic perspective, the nurse/patient relationship is guided on the previous experience of the subjects¹⁷.

We always try to listen to the history of the patient, but often they are intubated and unable to speak. So the nurse tries to approach and interact. (N7)

The nurse should really see what the patient needs. Is it necessary to test every day? It causes suffering to the patient without prognosis. (N2)

Given these considerations, it is observed that nursing care requires from professionals skill in helping people overcome their problems, relating to others and facing what cannot be changed^17,18. In fact, every action requires the presence of sensitivity and the spirit of giving, as shown in the nurse's speech:

You always have something to do for an ICU patient, and this makes me approach them. (N3)

Inter-subjective transaction in face of suffering

Closer approximation of nurses with patients is related to the long length of stay in the unit, which often provides the projection of patients' suffering for the professionals¹⁹. Therefore, as a strategy for not developing emotional involvement and to better cope with anxiety in an I-it attitude, professionals tend to keep a distance. From this, it is necessary that the professional knows how to differentiate the limits of therapeutic involvement, as evidenced in the speeches of nurses.

It was a challenge to learn how to care for more complex patients [...] dealing with death and the family's anxiety. (N4)

The ICU environment is unhealthy, sometimes I'm a nervous wreck, always listening about death and suffering [...]. We can't help being involved, we need a support. (N6)

In these testimonies, there is the need for support in order to establish an emotional balance of the professionals for the effective performance of their functions, facing the well-being and being-better of the patient.

There are situations that shock us too; we cry [...] I feel very bad. (N1)

We deal with death in the ICU, but it is not that we are adapted. We try to get along better with that, acting in a milder way, especially not to bring more suffering for the family that is already desperate. (N6)

The coming-to-be in the professional/family relationship

It can be considered that the physical and social environment of the ICU has stimuli that can also be a source of stress for the family, who also experience insecurity, anxiety, distress and depression⁵. In this sense, the attitude of professionals should not only focus on patients, but also in the family.

The family is important, but humanization is not only letting the family stay with the patient in the ICU 24 hours a day. (N7)

The visit nears the patient to the family, but some come only bring problems. In this case, nurses must intervene; humanizing sometimes is to take the family away. (N2)

It is also important consider developing a healthcare model in which the relationship nurse/family in an I-thou attitude is set as active and critical space, emphasizing a humane approach¹⁷. The approach to these experiences of the patients' family members, involving the host, is precisely to recognize their subjectivity and their importance in monitoring the patient, incorporating it as an important focus of care²⁰. This relationship stands out in the following statement:

We establish links with both to the patient [...], and to the family [...], in the visiting hours they look for us...we cannot help but to get involved. (N5)

Nurses must, therefore, assume themselves as a central pillar for the family, giving clear and accurate guidance and establishing an effective relationship of help. An essential point to qualify this care is precisely to recognize the subjectivity and the importance of those accompanying the patient ²¹. Thus, nursing care involves relationships with family and the social environment of the patient, as by getting to know them, nurses will be able to see them holistically and give them an integrated assistance¹⁵.

CONCLUSION

Nursing theories are considered fundamental epistemological contributions to the construction of knowledge and professional practice, as they direct the clinical model of nursing and enable professionals to describe aspects of care reality, assisting the development of the triad theory, research and practice. Thus, it is believed that the use of nursing theories relies on the definition of the role of nursing, on the quality of professional performance and on production of knowledge.

The Humanistic Theory of Paterson and Zderad, based on a phenomenological dimension, reveals the need to rescue the human dimension of care, opposed to the biomedical model that still prevails nowadays in health area and that, in a way, restricts the way to experience the health-disease process.

According to the study, it is clear that nursing retains the essence of the profession, which is the care with concern for others and does so through the effective therapeutic communication. Thus, it is understood that this corresponds to the authenticity of human existence. It was apprehended in the speeches that nursing professionals, despite the inherent characteristics of the complex hospital environment, establish inter-personal relationships and consider the presence of human feelings in the care actions as important as the technical activities.

Thus, in a humanistic dimension, despite the constant living with the pain and suffering of others, professionals appeared committed to the act of caring, including the patients' families, in which they understand the importance of their actions and clearly define their limits of professional performance as human beings.

As limitation of the study, there is the need for more research to better understand the difficulties that nurses face on a day to day work and to develop strategies that minimize the daily stress and expand humanized care.

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