ORIGINAL RESEARCH

Intensive care unit nursing relationships in the view of Paterson and Zderad

Eliane Regina Pereira do Nascimento^I; Juliana El Hage Meyer de Barros Gulini^II; Ana Paula Minuzzi^III; Maíra AntonelloRasia^IV; Rutes de Fátima Terres Danczuk^V; Bruna Caroline de Souza^VI

^I Ph.D. in Nursing, Associate Professor, Department of Nursing of the Federal University of Santa Catarina, Florianópolis, Santa Catarina, Brazil. E-mail: pongopam@terra.com.br
^II Ph.D. in Nursing, Physiotherapist of the Intensive Care Unit in the Federal University Hospital of Santa Catarina, Florianópolis, Brazil. E-mail: julianagulini75@gmail.com
^III Master in Nursing Care Management, Nurse at the Child Development Center of the Federal University of Santa Catarina. Brazil. E-mail: annaminuzzi@yahoo.com.br
^IV Multidisciplinary Master in Health at the Federal University of Santa Catarina, Nurse Association of Parents and Friends of Exceptional Children. Brazil. E-mail: mairarasia@gmail.com
^V Nurse, Specialist in Gerontology by the Federal University of Santa Catarina. Brazil E-mail: rutes40@yahoo.com.br
^VI Nurse. Federal University of Santa Catarina. Brazil E-mail: bruniikaa@hotmail.com

DOI: http://dx.doi.org/10.12957/reuerj.2016.5817

ABSTRACT

Objective: to examine, in the light of Paterson and Zderad, how nurses relate to patients and relatives in an intensive care unit. Method: this qualitative, descriptive study, which collected data using semi-structured interviews of 26 nursing professionals at Florianópolis University Hospital, Santa Catarina State, from June to December 2002, was approved by the research ethics committee (Opinion No. 035/2002). Data was analyzed using the Collective Subject Discourse technique. Results: nurses establish power relationships with patients, and distance themselves from family members. Conclusion: in the view of Paterson and Zderad, intensive care nurses do not establish a dialogical relationship with patients and relatives that values subjectivity, encounter, call and response.

Keywords: Intensive care unit; nursing; nurse patient relationships; family-professional relationship.

INTRODUCTION

This article is the result of part of the thesis developed in an Intensive Care Unit (ICU) during the Doctorate in Nursing course at the Federal University of Santa Catarina. The ICU is a troubled multiple devices environment where patients live with impersonality, lack of privacy, dependence on technological equipment, social isolation, rigid routines, emergencies, little communication, the risk of death, among others. With these features, the ICU is totally different from other hospital units and especially the residential environment of the patient and their families^1,2.

However, it is also considered a place of hope and a survival chance by patients and families, due to the sophisticated equipment, the constant presence of a specialized team to care people in critical situations³.

Through this scenario, the distancing of relationships between professionals and patients and families makes hospitalization even more difficult to be faced. Providing quality of care and security, and give satisfaction to the nurse also satisfies patients by enabling effective care with attention and dedication. The working process of care reveals the essence of the nurses´ activities⁴.

It is believed that dialogue is an indispensable tool that helps. Not only dialogue as a conversation between two people, but as a relationship in which there is a true sharing, an inter-subjective transaction, that is, the relationship of a unique individual (me) with another individual also unique (you)⁵.

Thus, the research aimed to analyze the relationship of nurses with patients their family in an intensive care unit based on the conceptions of Paterson and Zderad⁵.

THEORETICAL REFERENCE

The concepts of dialogue

The Theoretical Model of Paterson and Zderad shows the dialogue as a central concept that enables the nursing to reconcile reason and sensibility, subjectivity and objectivity in the act of care⁵. The authors used the ideas of some philosophers to support the theoretical model, such as the philosopher of dialogue, Martin Buber. For this author, the relationship between people takes place in two different ways, but necessary: ​​the relationship Me/you and the relationship Me/that. The relationship Me/you is an attitude of genuine interest in the person with whom we are interacting, we value their uniqueness, it is an interrelationship. The ratio Me/that occurs when the other is an object for us, using him as a means to get something ⁶.

The dialogue can be achieved through the meeting, therelationship, the presence, a call and an answer⁵. Through the meeting, the other is not an impersonal individual, he or her, but becomes sensitive and you close the EU5. The relationship means being with the other. There are two ways of human beings to relate: as subject and object and as a subject with the subject, both are humanistic nursing members⁵.

In the genuine dialogue, the human being is related to the other as a presence. Being present means being accessible to others, be open to other, being available. The call and response in the nursing dialogue occur verbally and nonverbally, referring to the ability of nursing staff related to the subjective and objective aspects of the situation experienced. It occurs in both directions⁵.

Nursing is a caring response to a call for help through the understanding of the meaning of life and search for potential experiences. During the meeting, the inter-human relationship is intentionally focused on the well-being and being better. Therefore, nursing is a vivid dialogue between the nurse and another person, relating to being present. To answer it, it is necessary to consider it as a phenomenon that occurs in the real world of human experiences, varying according to the patients, their age, the clinical situation, their inability as well as the perception of nurses about the need and their attitudes to respond to it⁵.

METHODOLOGY

This is a descriptive study with a qualitative approach, carried out in the ICU of the University Hospital of the Federal University of Santa Catarina in Florianopolis, State of Santa Catarina, with nursing professionals.

The inclusion criteria of the participants were to work in the ICU for at least 3 months and be in professional practice in the data collection period. Of the total of 33 ICU nurses, 26 of them participated in this study; eight were nurses and 18 mid-level professionals, 18 were female. Participants were 3 to 23 years of experience in nursing and three months to 20 years of activity in the ICU. Data collection was carried out between June and December 2002 through semi-structured individual interviews after the signing of the Consent Term. The interview focused on the perception of professionals about the ICU nursing relationship with patients during hospitalization and with the family at the time of patient admission. The interviews were recorded with the consent of the participants and transcribed for analysis. Participants were identified by the letter N (nurse) and M (mid-level professionals), followed by the number representing the interview order (N1.... N8), (M1 ..... M18).

The interviews were organized and analyzed according to the methodological approach of the Collective Subject Discourse (CSD)⁷. This methodology organizes qualitative data obtained from interviews and consists of four methodological approaches: the central idea (CI), being the essential claims of discursive content explained by the subjects. Key expressions (KEX), being excerpts from the literal words of the subjects that represent the synthesis of the contents in the research objectives. Anchoring (AC), being the articulation of the speech to the theoretical reference on which it is founded. Collective Subject Discourse (CSD) is the speech synthesis composed of KEX that has the same CI; the sum of isolated pieces of speech that forms a whole coherent discourse; prepared in such a way as if it was a person speaking for a group of people⁷.

The study met the recommendations for research involving human beings, according to resolution 196/96 of the National Council for Health Research, which conducted after approval of the Hospital Board and the Ethics and Research Committee with Human Beings of the Federal University of Santa Catarina under Opinion Nº 035/2002.

RESULTS AND DISCUSSION

For submitting this article, two methodological figures of SCD: CI and SCD⁷. The statements were framed on two themes: Possession, about the relationship of nurses with patients and Distancing, showing the professional relationship with the family.

Theme 1 Possession

Central Idea - From the family warmth to the institution

This discourse shows what happens daily in the ICUs, especially when it comes to public health institutions, such as the one used in this study were most patients of low socioeconomic status, a fact that seems to take them to submit to the authority of professionals with nothing or little claim. The asymmetry of the worker-patient relationship seems to grow as it grows the social distance between them. The right to exercise their citizenship is blunted.

The ICU is an environment full of ethical and technical components that require attention. Taking humanized care is a difficult task, despite the health professional effort. This care requires individual and collective attitudes, respecting privacy, individuality, and dignity of the patients⁸.

When the human being who was until then managing his life and often evens his family is subjected to this speech, to a hospitalization, particularly in ICU, has not managed himself and no possibility to act autonomously.

The ICU hospitalization abruptly breaks with the way of life of the subject, including his relationships and his roles. His identity is greatly affected. Due to the severity of his condition, it is regarded as a subject unable to choose, decide and give an opinion without rights to expression and information¹.

The discourse shows the impersonal relationship; that is the relationship Me/that between the nurses and the patient. In this power relationship, there is no dialogue in the meeting between those involved in the relationship. The meeting will ensure an authentic intersubjectivity when care professionals no longer hide behind their professional role and exercise domination by imposing rules and routines. Instead, they show their presence as someone who is concerned about understanding their experience of being a patient in ICU and help him to live this experience. Establishing standards and rigid routines, the professionals hinder the effective response to the calls of patients. The answer will come only if the professionals are aware of the dialogue and may be through interventions for the care of the physical aspects of patient care or goals or serving their insecurity and fear with genuine presence as a professional caregiver.

The humanized care, achieved by personal care and empathic relationship, contributes positively to the individual´s adaptation to the ICU, which favors their physical and emotional balance⁹.

Despite the physical/body contact performed by the nurses, these professionals cannot always touch the soul of people cared and had difficulty in helping them to build sense among the disruptive situations of human existence¹⁰.

The nurse-patient relationship involves a variety of physical contact in the implementation of procedures, the interpretation of gestures, movements, and positions that patients on mechanical ventilation communicate their emotions, feelings, and perceptions, as they do not express through a spoken language. However, communication incorporation with the patient as part of routine care is influenced by several factors. Some of them are directly related to the knowledge that the nursing team has regarding the impact of this variable on the health status of patients. To the extent that this benefit is not known by the team, the communication will not be systematically integrated into daily practice, and nursing technicians and nurses will continue approaching these patients only to perform administrative or functional activities^11,12.

We are in the technological age where the patient monitoring occurs through a screen, without the need for direct contact with him, favoring the detachment of health professionals, especially doctors and nurses. Nevertheless, care is beyond the technicality. Even though the ICU is a completely different environment from other units, it does not relieve the humanization of care, which is expressed by the relational attitude of health professionals with patients and their families. If care is mechanized and little compromised, it results in the devaluation of human care. These placements are showing the need for human interaction during the care provided, reason considering the communication as an important interactive factor and humanization in ICU¹³.

It is noticed in the speech that workers are aware that they are not leading care ethically. The ethical care implies respect for others, recognizing the objectivity and subjectivity of the patient and family, the right to meet their real needs, the right to be entered in the space of care, to participate, where possible, of decisions about their care, especially in regard to their subjectivity, not wanting a careful and be respected if not result in damage to their health condition. Ethical care is a humanized care, it is changing, support, security, concern, reliable, understanding, to be present, to be supportive, answering the call, it is the dialogue.

Theme 2 Distancing

CI - The i ndifference to the family in the patient ´s hospitalization

The disease is already an anxiety situation, insecurity and often imbalance in the family organization. When hospitalization is required, the situation worsens and, in the case of intensive care, it enhances even more. The ICU is for many families, a place where the loss of identity, intimacy, autonomy, citizenship and especially the largest of them, the loss of life, occur with greater intensity, becoming a strong emotional aggression. The situation of the hospital is further aggravated by the unexpected way in which often it occurs, giving time to the family prepare themselves emotionally, and also the separation between them, imposed by the service¹⁴.

Family members suffer from separation, from anxiety regarding the disease and what might happen because of the little information due to the unavailability of staff providing such assistance, becoming a stressful event for both the patient and their families¹⁵.

It is worth highlighting several reasons that further contribute to the unpleasant sensations: The ICU is different from other hospital units and, above all, the patient´s home environment and their families. It is an environment with many machines, in which individuals live in emergencies, risk and death daily, with social isolation and lack of privacy¹⁶.

The relationship between nursing and family should aim their well-being. The relationship must provide the family to notice the possibilities of help and support in nursing. Nursing should be accessible, perceptive, available and ready to meet the needs reported by family members, related to experience with the hospital in a critical environment. It is expected that nursing realizes the family also focused on care and not as an appendix to their sick relative.

When it comes to family members of people admitted to ICU, it should consider comfort, but this has been only related to the infrastructure of the hospital, such as waiting rooms with comfortable chairs and televisions, access to food, drinks, and blankets. However, it is understood that the promotion of comfort goes beyond the environmental sphere, as results from the interaction between parents and health practices, the medical-scientific rationality that underlie and institutional objects, which may be a source of comfort or discomfort¹⁷.

At the time of hospitalization and permanent process in the ICU, the nursing should establish the meeting and dialogue to take place to perform the family hosting. Being present, relating, creating bonding between family/nursing are ways of establishing relationships of the host.

The relationship difficulty between nursing and family induces detachment. This occurs by several factors, the most obvious is the lack of preparation of the nursing for the family´s needs and work organization.

For some nurses, the difficulty in meeting the family is linked to the specifics of intensive therapy, to their personal limitations or health team and also to the families of the way to express their feelings.

Nursing care in intensive care goes beyond accepting or not the family´s visit, also including the establishment of a trust and assistance. The nursing team has the task of identifying the real needs of families. The more anticipated for the interaction nurse/family, the best for the family and the hospitalized patients¹⁸.

The lack of care of workers to the families shows that the relationship between them takes place in a not welcoming logic, that the area of intersection between them did not open for dialogue, for a process of tapping the problems, an exchange of information. At that time, the family needs that there is a meeting between them and the health workers of the ICU, the meeting Me/you, Me/we, the meeting that leads to communion, sharing, to help them better support this complication in their lives⁵.

Knowing what is happening to the patient, although negative, is less frightening than not knowing. The distrust and the feeling that the team is hiding information can be avoided by nursing staff when they spend a few minutes of their time transmitting to the family, a brief information of the patient¹⁹.

A study in an ICU in the southern Brazil found that the care given to family members, such as information about the patient´s condition and the equipment that surrounds the guide whether or not to touch the patient, flexibility in time and visit time, meet some needs felt by the families of ICU patients, which gives satisfaction to the family. The host is essential for dialogue, for the match between worker and patient¹⁹.

In the SCD, the time factor appears as a complicating element of relationships, dialogue, meeting between them and the family. However, there are those who recognize that this is not a reason that there is not attention to the family. It can be said that this contradiction shows that is still very limited and tenuous the capacity we have to relate to each other and often imagine in another´s shoes. Also, there is the fact that the workers do not see the family as customers, members of our practice as shown in the speech we understand that it is the patient who needs care and probably they have no availability to be with his family in crisis experiences and suffering. It is necessary a watchful eye to issues that permeate the experience of the family of ICU patients, to exercise the ability to empathize with others, cultivating dialogue and creating a family of inclusion strategies in the practice of nursing care²⁰.

Relatives seek professionals needing to be informed, to give them some knowledge, and welfare. They feel that the possibility of being informed, conveniently, is an important variable to consider in lived experience²¹.

The expression shown in the speech, it is a simple thing sometimes just a single word or only hears them shows that it is possible to do different work, which can include family as a nursing client meeting their needs. It is indeed possible involvement of the subject-subject relationship⁵.

CONCLUSION

It was found in both SCD that there is a fragility in the relationship of nurses with patients and families.

The SCD of the theme "possession" was as CI- The family warmth to establish property and portrayed the exercise of the power of nursing on the patient. The man who until then managed his life and often even to his family, when subjected to a hospital, particularly in ICU, has no management at all about himself and not able to act autonomously.

The theme Distancing expressed the CI- professional indifference to family, not attending to their calls for the meeting at the time of doubts, anxieties, and uncertainties. It was shown in the second SCD; there was an experience with the ICU, even more difficult.

The ICU nurses need to humanize care, providing opportunities for relationships, optimizing expressions, both objective and subjective of patient and family. The relationship with the patient and family entails authentic presence at the meeting in the call and response. However, for this to occur, the training of nursing staff is required.

It is pointed out as a weakness of this study of a joint analysis of information issued by nurses and mid-level professionals as they have training and differentiated responsibilities and the fact that the non-inclusion of other health professionals of a surveyed unit.

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