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Nursing process clinical and integrity of nursing care to the people with cancer: a pilot study


Iraci dos SantosI; Lindalva Roberta FrançaII; Araci Carmen ClosIII; Célia Caldeira Fonseca KastenbergIV; Alexandre Vicente da SilvaV
INurse, PhD in Nursing, Full Professor at the State University of Rio de Janeiro, Professor of the graduate Program in Nursing, School of Nursing/UERJ. Email: iraci.s@terra.com
IINurse, Master's in Nursing through the Graduate Program in Nursing at the School of Nursing at the State University of Rio de Janeiro, Nurse of the National Cancer Institute of Rio de janeiro.
IIINurse, Master of Philosophy through the Program Graduate at the Gama Filho University of the State of Rio de Janeiro. Assistant Professor in the Department of Fundamentals of Nursing, School of Nursing, State University of Rio de Janeiro
IVNurse, Psychologist, PhD in Psychology through the Graduate Program in Nursing at the State University of Rio de Janeiro, Associate Professor of the Department of Public Health Nursing, Faculty of Nursing, State University of Rio de Janeiro
VNurse, Master's in nursing through the Graduate Program in Nursing at the State University of Rio de Janeiro. Assistant Professor of the Department of Public Health Nursing, Faculty of Nursing, State University of Rio de Janeiro

ABSTRACT - This study aimed to test the Process Clinical Caritas (PCC) form, for the possibility of application in nursing staff that cares clients with oral cavity cancer. Descriptive method and self-report technique of developed in Rio de Janeiro, Brazil, in August 2012, applying a data production instrument based on the transpersonal caring theory for 10 nurses who work in oncology. The results showed the form’s consistency with the Watson’s PCC aspect of, showing clarity and homogeneity of the questions. In the examples, the nurses realized that in their care practices included: touch, gestures of love and kindness in customer communication, respect for spiritual practices, attention to human needs, guidance to the wellbeing of the client and promotion of the healing environment. It was concluded that there was no need for changes in the form, demonstrating its applicability to the definitive research on the PCC.

Descriptors: Nursing care. Head and neck cancer. Theory. Pilot test. 



In daily care to clients with oral cavity cancer (OCC) the sensitivity of nursing professionals in their caring practices is perceived. Among the challenges faced are various difficulties such as taking care of bodily, physical, mental and spiritual, dimensions without favoring the needs of the care regarding the aforementioned illness, following medical therapy.

This relates to tumor wound care, handling of the tracheostomy, because the profile of this clientele is characterized by disorders of speech, impaired self-image and consequent low self-esteem. In addition to the health professional, the person with OCC faces difficulties, mainly regarding the impaired verbal communication and self-care (SC).

Because there is a loss in promoting dialogical care among both it is believed in an aesthetic care perspective, which the therapeutic nursing use sensitive poetic myth listening1, unveiling the potential of giving love, essential to the exercise of this profession. Thus, the object of this study is the perception of the nursing care process for people with oral cavity cancer.

The proposal from the aesthetic perspective finds support in the proper and specific performance of the nursing staff related to different types of care, considering the concern, accountability and affective involvement with the individual phase of the illness2. Such care is called expressive, because it allows a holistic practice to meet the moral, physical, spiritual, psychological and social dimensions of the client3.

The concern with the OCC is justified by the fact of it being among the eight most frequently diagnosed malignancies in Brazil, as it is considered the most common cancer of the head and neck region. Furthermore, it was estimated for 2012 the total 14,170 onsets of this disease, distributed in 9,990 men and 4,180 women4. Despite being an easily diagnosed pathology due to its well-defined and visible precursor lesions, many sick people begin their treatment in the advanced state, which requires medical treatment and adequate nursing for the client's bodily dimensions.

 Realize the living situation of the individual with cancer brings several meanings, changes in values, beliefs and attitudes that demand appropriate and individualized interventions to minimize the threat to their physical and mental integrity. This leads nursing professionals to confront their own vulnerability and finiteness5.

It is believed that, for the development of the clinical process of care for people with OCC, the need for a consistent and adequate when coping with difficulties encountered by clients and professionals in the care of nursing interventions focused perspective to the care of the physical body, mental and spiritual dimensions. Given the above, the problem was formulated - What is the perception of nurses on their professional performance with clients with oral cavity cancer?

This study had as objectives: to analyze aspects of caring for the whole of the client affected by oral cavity cancer, especially the perception of nurses about their care practices in daily work; Test the Form Process Clinical Caritas (PCC) aiming its possible application in nursing staff that cares for clients with oral cavity cancer.


The processes of transpersonal caring and PCC incorporate art, science and spirituality. This implies that the nurse constantly examine and explore the existing critical intersection between the personal and the professional, employing their talents, interests, and gifts in the provision of a humane and reconstitution care service of (caring - healing] for them self, of other people and the planet. They are conceptual elements of the theory proposed by Jean Watson: Process clinical caritas; relation of transpersonal caring; moment of care6.

Among the aspects of this emerging theory it describes: expansion of the vision on self and person (be as unit transpersonal mind, body spirit; spirit in a body [embodied spirit] ; awareness of care - reconstitution and intentionality to care and promote the reconstitution; awareness of care as energy within the environmental human field for a moment of caution; phenomenal field (what is uncommon)/ consciousness unitary, i.e. whole continues and connection between everything and everyone; forward in the modalities of care - reconstitution/ arts of nursing as the future model for advancing the practice of nursing as nursing, or consciously guided by a theoretical philosophical orientation of nursing6-9.

In the publication found online http://www2.uchsc.edu/son/caring/content/wct.asp ), in 2003, the theoretical concerns that, as part of the evolution of his ideas and the evolution of the theory itself it has replaced the caring factors by the process clinical caritas. Thus, the PCC is formed by 10 components6,10, which are appropriate and / or complement the issues raised by the authors of this pilot investigation, as described:

1. In your care practice together with the client it is possible to observe aspects of - Practice of love - kindness and equanimity within the context of awareness of care6,10?

2. In your care practice together with the client it is possible to observe aspects of- Being authentically present, strengthen and sustain the profound system of beliefs and subjectivity of your life world and the being cared for6,10 ?

3. While taking Care of the customer is it possible to cultivate - your own spiritual practices and of the transpersonal I, overtaking your own ego6,10?

4. Does developing and maintaining a relationship of aid establish the - confidence in authentic care6,10?

5. Does being present and supporting the expression of positive and negative feelings provide a deep connection with your own spirit and the person who is being cared for6,10?

6. Does the creative use of yourself and of all the ways to learn as part of the care process; engaging in artistic care practices, contribute to the client's reconstitution6,10?

7. Does engaging in authentic experience of teaching/learning that meets the integrality of being and of the meanings of living allows you keep within the client's framework6,10?

8. Do you create a reconstitution environment of in levels physical, mental, and spiritual environment, allowing a subtle energy and consciousness, by which, the totality, beauty, comfort, dignity and peace are maximized?

9. You meets the client considering their basic needs, with a conscious intentional care, administering what is essential to human care, aiming to enhance the alignment of the body/mind/spirit, totality and unity of the being in all aspects of care6,10?

10. While developing care, do you believe in openness and attention to the spiritual mysteries and existential dimensions of life - death; care of your own soul and the being which is being cared for6,10?


This is a pilot research, through the approach of quantitative research, applying the descriptive method and self-report technique that11, characterizes a survey of information, i.e. the variables selected for the study. The research was developed considering the existence of an objective reality that can be quantified and described. To develop it priority has been the perception of nurses on their care practice with clients admitted to the healthcare institution.

The choice of method and technique of research because is justified it is a study, aiming to investigate the possibilities of adopting an aesthetic/humanist perspective of caring for clients with OCC using both a referential adequacy of the transpersonal caring, with focus on the proposal of process clinical caritas7,10, here considered as the Clinical Process of Nursing Care (CPNC).

Field and research subjects

The production of data occurred in a Federal Health Institution, located in Rio de Janeiro - Brazil -, specialized in the area of oncology and possessing an OCC treatment sector. In this field, there is a division of activities for client care, considering the training of nursing team members, meeting the nurse’s needs:

-Receive the day and / or night shift, recording in the order and occurrences book for the members of their team, as well as all tests and procedures to be performed such as; performing dressings, making guidelines for the client and accompanying in caring for the tracheostomy and enteral tube. Making the admissions of clients to be admitted in their work unit; prepare the client and family to hospital discharge, directing regarding the care at home: with the surgical dressing and/or the wound tumor, handling of the tracheostomy and enteral tube. Providing care in the clinical complications.

Strategy for the pilot test

The Data Production Instrument (DPI) was drawn up, aiming at the reach of a design objective of the grant Research Productivity - PQ- CNPq, by Iraci. dos Santos, approved by the Ethics Committee of the UERJ - Protocol no. 005.3.2012, referring to the construction of instruments in nursing research, compatible with the Brazilian reality of the professional practice. This research project was approved by the Research Ethics Committees of the UERJ and the National Cancer Institute (NCI) -Protocol no. 52723. Its construction is based on the adequacy of the 10 aspects of PCC 10, considering the possibility of moving closer to the aspects of aesthetics/humanist perspective of nursing care2.

The DPI was composed of 10 questions considering the following organization and instruction: Fill out the form by means of scores ranging from 0 to 3 by Likert Scale11, in each item or answer option corresponding to the 10 aspects of the PCC; marking an X in one of the columns blank, relating to the answers never (0), rarely (1), often (2) and always (3); Description of the example of the care practice corresponding to the marked response.

The pilot test was conducted, in April 2012, with 10 nurses, active in the area of oncology, who were invited and agreed to participate in this research, after knowing your objectives, advantages and disadvantages, as well as the dissemination of their responses, respecting their anonymity. It is recalled that the test was aimed at, also, assess the DPI, whereas their consistency with the aspects of PCC, clarity and uniformity of questions.

The data were treated according to the quantitative absolute frequency of nurses who noted the Likert Scale, a common scale, to make a quantitative discrimination, expressing a point of view on a given subject11.

The data for examples of nurses about their practice of care related to the PCC were submitted to content analysis12, in the form of thematic categorization. Such analysis is composed of three phases: pre analysis, exploitation of material, and processing of the data, whereas the quantitative record units. Considering, even the predominance of these units for the delimitation of thematic categories, composed by subcategories.


Regarding the possibility of applying the 10 aspects of the PCC in the practice of nursing care, it was found that the total of 10 predominated seven and six nurses always marking the option corresponding to questions 1, 4 and 9. However, the option was never marked by two people, in items 3 and 10. The points 6 and 7 of the PCC were marked in the option often, by four people. While the option was rarely marked by three nurses in aspect 5. It should be stressed, that the aspect 2 had the options marked: often, always and rarely, respectively, for five, three and two subjects.

The fact that the aspects 6 and 7 of the PCC have been little marked, in option often, suggests a lack of confidence of nursing professionals in its potential to use their body senses, emotions, feelings and creativity, aiming to restore the balance of body dimensions of the OCC client. With 6 being the aspect related to the use of the body emphasizing creativity to get to know as part of the care and contributor for the client reconstitution process. Remember that several creations from the art of nursing are considered as improvisations. Regarding the aspect 2, it was expected that most subjects the marks, since relating to the constant and steady presence of the nurse, as well as their respect for the client's individuality. Therefore, the health team is notorious that nursing care is provided incessantly.

On the other hand, the PCC 7, concerning the experience of teaching/learning to meet the integrality of the being2, and the meanings/sense of living, aiming to keep it within the framework of the customer, suggests that the subjects of this pilot study little recognize their educator role. As if while developing care practice, was impossible to teach and learn with the client.

It is noteworthy that the subjects of the pilot study were oriented to exemplify each response marked referring to 10 aspects of the PCC. Therefore, according to their perception, they described their care practices, corresponding to the aspects described on the research form. In relation to the examples relating to aspects 1 to 4, there is a total of 28 examples of practices of individual care, and 16 subjects without examples, as presented in Figure 1. With such examples, the categories were defined thematic human-Being in care is to respect the human condition of the client; Therapeutic environment as a promoter of care in full the client; transpersonal caring as the effect on body balance restoration of the client.

Being humane in care is respecting the client's human condition

By analyzing the individual topics it was noted the predominance of respect the individuality of the user of health services, who often need the contact of other human beings to feel accepted in the community, the environment in which coexists with these. Thus, as reported by nurses,

contact with the other exceeds the humanistic; touch the patient... watching your speech, gestures and expressions is treating them individually. The relationship of kindness and respect their beliefs, spirituality, the comments about their family...... without trials......

This seems to us to be in addition to the well-done wound dressing, although, the professional needs to demonstrate

 Competence... develop a relationship with the customer to help,
 attention, interest...... for which the customer accepted its
 attitudes and behaviors.... Show yourself as present
 by providing the customer with information necessary for their

 It seems to us that are such behaviors that establish trust and mutual security among professionals and clients.

Analyzing the examples of care related to the PCCs 1, 2, 3 and 4, ratifies that care if conjugates in expressions of interest, consideration, respect and sensitivity, which are demonstrated by words, tone of voice, gestures and touch. This is reflected in the art of care at the junction of knowledge, manual skills, experience and sensitivity 16-18, in accordance with the descriptions of Figure 1.


The transpersonal caring as an effect on body balance restoration of the client

 As for examples of care related to aspects of PCCs 5-7, the application of the following nursing practices was realized:

 touch, gestures of love and kindness during the care together with the customer; communication, so to speak, the respect for the religious and spiritual practices; put yourself in the place of another; orientation of nursing; be attentive to customer needs; promote environment of comfort and enhance the comprehensiveness of the being.

Regarding the environment, subtle energy is reflected on the conscience of those who provide the care, because the larger, more shall deliver its energy which, being positive, will generate an environment of well-being6,7,10. Then, the affective touch is essential when transformed into an attitude. Because touch represents the care itself, the sensitivity and professional solidarity, making it into a human attitude that strengthens the bond between the nurse and being cared for14.

In the practice of caring exemplified by nurses, are conducting healing, guidance on diet, exchange of tube and maintenance of healthy environment. While these examples reflect the predominance of the daily work practices, if corroborated, that clients experience the technical and human care, as these are important for the restoration of these. Therefore, the technical care rehabilitates the physical body of the subject, returning it to its functionality, while the human care/expressive values their humanity, transcending the technicality19.

These types of care transcend possibilities that go beyond a certain point of care, and contribute to the success of the client in the treatment of the disease. Thus, also, the technology of caring for diagnosing the importance of a careful expressive, aiming at the promotion of well-being, restoring the balance of physical body, mental and spiritual dimensions2. Towards the maintenance of health, the study also reinforced the idea that holistic health is concerned with the wellbeing of the whole person not limited to treatment and symptomatology manipulation.

Then, such care contribute to the quality of life of the person with OCC, because the challenge of nursing is precisely, in developing a practice of caring the dimensions mentioned above. In this regard, it is understood that for the nursing professional, what makes the difference in treatment is the way it is expressed, producing effects in restoring the full balance of the client.

Advocating the application of transpersonal perspective on nursing care, explains the importance of relationships, communication, establishing healthy bonds, as these are valued as a form of expression, learning and growth, seeking harmony7,9,14-18. It is important to reinforce that the development of a relationship of trust is required a proper communication, minimizing the conflicts, aiming to promote harmony in relations between professionals and customers, as shown in Figure 2.

The therapeutic environment as a promoter of the client's comprehensive care
In relation to the aspects of PCCs 8 to 10, it is observed that the overall total of individual themes corresponds to 18, highlighting a total of 11 subjects whose practices of care were not exemplified by the subjects of this research. In spite of this, the practices exemplified allowed delimiting the following category, predominantly, by individual themes/ practices of caring:

 maintenance of a clean and comfortable environment, with peace and joy manifest in smile, without noise, harmonic, where clients feel comfortable, respecting and to others; a family environment, in which the habits and personal objects are allowed.
With these characteristics answered it is possible the coexistence of clients and professionals in an environment of subtle energy and awareness6.10, conducive to humane care and transpersonal, as it managed to meet human needs, considering their spirituality regardless of religion of the client, as shown in Figure 3.

The nurses who work in units of client care with oral cavity cancer exemplified the development of their care highlighting the importance of being present supporting their feelings. This attitude is essential to the process of clinical care, visa allow the spiritual connection between the professional and the client. This result corroborates the reference to the values of love, kindness, empathy, as bases of the care process, as well as respect for the human being and their freedom of choice10,13,14.

It is believed, then, in essence this care where fall love, gestures of solidarity and respect for the equanimity between the people, characterizing an authentic helping relationship. These fundamental values are the practices of care with the client, as shown in Figure 3.


After completion of the pilot test, no changes occurred in the form of clinical nursing care process, thereby demonstrating its applicability to this research. However, it is necessary to apply statistical tests on the instrument in order to verify the internal consistency levels.

As construction of scientific knowledge, this work contributed in the area of ​​care practice, education, and nursing research, encouraging the exercise of social practice in the context of society. The interest to implement it, aimed to acquire greater understanding about the perception on the integrality of the human being among those involved (members of the nursing team) in caring for people with neoplasia in the oral cavity.

For the area of care practice, has helped understand what they idealize their interventions and to encourage them to nursing care focused on the integrality of the client, when providing direct care. The study also reinforced the idea that holistic health is concerned with the wellbeing of the whole person not limited to treatment and symptomatology manipulation. Therefore, it reinforced the idea that holistic health is concerned with the wellbeing of the whole person not limited to treatment and symptomatology manipulation.

For the field of teaching and research that has opened up opportunities for further discussions about the issues of nursing care among the sick, seen that the results obtained will help to underpin new studies in the area of oncology nursing, such as expansion of knowledge.

For society, in general it was alerted on the uniqueness of the person with the referenced disease, showing that they are part of it. Therefore, in their insertion in society, family, at work and in social circle the customer has the right to be considered as a citizen in special condition related to the performance of a new role.

Furthermore, it is expected a greater understanding of the society on the difficulty of the individual living with oral cavity cancer and subjected to certain types of treatment. They should be seen as a human being, a citizen having some limitations, but with desires, wishes and expectations, which are their right and should be included in the family and social circles.


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Direitos autorais 2014 Iraci dos Santos, Lindalva Roberta França, Araci Carmen Clos, Célia Caldeira Fonseca Kestenberg, Alexandre Vicente da Silva

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