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RESEARCH ARTICLES

 

Contribution of ethnomethodology for evaluation of nursing care in the operating room

 

Lina Márcia Miguéis BerardinelliI; Mariana Nepomuceno GironII; Fátima Helena do Espírito SantoIII

 

INurse, Associate Professor, Department of Medical-Surgical Nursing and the Graduate Program of the School of Nursing at the State University of Rio de Janeiro. Brazil. Email: l.m.b@uol.com.br
IINurse, State Secretariat of Health of Rio de Janeiro, Master from the Graduate Program in Nursing at the School of Nursing at the State University of Rio de Janeiro, Brazil. Email: marigiron20@yahoo.com.br
IIINurse, Associate Professor, Department of Medical-Surgical Nursing and the Graduate Program in Healthcare Sciences at the Aurora de Afonso Costa Nursing School of the Fluminense Federal University. Rio de Janeiro, Brazil, Email: fatahelen@terra.com.br
IVExcerpt from the Master's thesis: The reception of users at the surgical center and the humanization of daily nursing care practices. Approved by the Program of Graduate Studies in Nursing at the State University of Rio de Janeiro, 2013.

 DOI: http://dx.doi.org/10.12957/reuerj.2014.15666

 


ABSTRACT: Ethnomethodology seeks to understand the social realities of a given social group or institution. This exploratory ethnomethodological study aimed to characterize the discourse of operating room users and analyze the nursing care evidenced by that discourse. Data were collected from 18 users at a state hospital in Rio de Janeiro in 2013 by participant observation and semi-structured interview. Content analysis revealed the category: analysis of nursing care in the operating room. Fear of the unknown generated user unease, anxiety and nervousness, which reverberated in the statements, codes, symbols, imagery, which lead to a profusion of ideas. It was concluded that ethnomethodology contributes to investigating everyday emergent phenomena, allowing access to the necessary information about the meaning of the user experience, and leveraging human subjectivity and the dimensions of care towards more humane care practices.

Keywords: Care; surgical procedure; ethnomethodology; nursing care.


 

INTRODUCTION

In the early afternoon, around 1:00 pm in the internal corridor of a hospital sector, there was a person lying on the table waiting for their turn to be served. She wore a blue sweater and a white cap covering her hair. Her face without makeup revealed a few expression lines and, by her appearance, was a young person. The uneasy look was who was looking for something, frowning and the snapping of her fingers marked the State of apprehension and concern. The room was cold and many people circled the place, some walked quickly, others passed, looked and said nothing. Until a person walking by and said: - I'll be back to pick you up. And really came back, after 35 minutes.

For each reader this scene will have a meaning and a differentiated meaning. The described scene marks the features and the plurality of ethnomethodology, which values the meaning and significance of a particular action, defining itself as analytical methods and procedures used by individuals to make sense of everyday social practices1. In addition, fulfills the function of examining beliefs, common sense behaviors, interactions between the members of the group, adding to the social practice which takes also into account the fact that the entire social group be able to understand them self, as well as comment and analyze them self2. Whereas the reality is socially constructed and is present in the everyday experience of each one, and that at all times you can understand the social constructions that pervade the conversations, the gestures, the communication, that is, the practical activities.

The location described by the observer is a surgical Center (SC), space of care, teaching and research, complex, depending so much on the specifics for taking the human being in a surgical situation in search of a solution for their health problem in the environment, which differs from other areas of the hospital, either by restricting access, either by the presence of different technological apparatus, surgical, anesthetic drugs, medications and monitoring devices3.

In this environment nursing is responsible for receiving and accommodating patients needing special care due to the dependency of a surgical procedure, as is also responsible for the management and administration of the unit and nursing teams4.

In addition, the actions of care are constantly evaluating multi-professional teams as both users, since the surgical center consists of an environment susceptible to a variety of risks to the pros there entered and is seen as a highly stressful for the patient and the team work.

Adding to this, nursing professionals, along the historical trajectory, have been developing mechanized manner, repetitive and controlling based on rules, routines and protocols, mostly without reflection of their practice5 and without the reading of human subjectivity, so necessary for understanding of the individual, as a human being and as a being of sensitivity. Therefore, understanding the human being as a unique being, multidimensional, impregnated with history, deserves to be seen individually, helping them reflect on their conflicts, their relations with the world, with family, with work, as well as in interaction with each other, to bond formation, realization of care and the ability to drive their own destiny.

In this sense, contrary to the context described above, those who suffer from the repercussions are users of health institutions, which do not receive care, loving and worthy of their desires and needs. Thus, there are the discontent and criticism in relation to nursing care provided.

The experience of active listening and reports of users' expectations were sufficient to address the impacts of grievances, fears, anguish and desires in relation to SC, as well as the care provided by the teams. This dialog channel with the users has strengthened our cognitive, affective and emotional abilities in order to encourage attention and sensitivity to the demands of those people, being decisive to the development of this study.

Thus, it was observed that after discharge some users returned for consultation and talked about the care offered. The same fact was also observed in the SC: after discharge for medical ward and/or hospital discharge, users expressed their feelings regarding the nursing care received in that unit. During this professional experience with this type of clientele, we were able to better understand how hard it is for people to deal with situations, acute or emergency surgical because, in addition to the feelings of fear and insecurity, there is also change of self-esteem, anxiety and, often, frustration.

On the other hand, the nursing literature at the surgical center contextualizes the humanization of health care, passing through the history of the profession, the humanization of nursing, its multiple discourses to the National Policy on Humanization6-10. The different approaches to analyze humanization at the surgical center nursing care offered to users who need to solve their health problems.

From the above, the following question arises: How does the contribution of ethnomethodology on nursing care assessment by users of the surgical Center? To this end, the following objectives were established: characterize the speeches of the surgical center users and analyze nursing care evidenced in these speeches.

This study may help to subsidize the nurses who work in the SC, in their relationships with users in the pre, trans and post-surgery, both those working in care practice as well as the unit's management. Likewise, stimulating reflections, creating care strategies in conjunction with the team, so that people feel well served, winning the causative impacts reactions and negative feelings that lead to anxiety, fear and stress.

THEORETICAL-METHODOLOGICAL FRAMEWORK

The Ethnomethodology is a social current originated within the framework of American Sociology, from the studies of Harold Garfinkel, specifically in the work Studies in Ethnomethodology, in 196711.

It considers that reality is socially constructed by its members, from the practical knowledge of a particular group about their daily activities, through conversation, gestures and communication, which give meaning to their everyday actions.

The chain also has its origins linked to Ethnography, the symbolic interactionism, Existentialism, Marxism and the Phenomenology of Alfred Schütz. It is characterized as an inductive method and aims to document, describe, explain and interpret the worldview, meanings, symbols and life experience of the subject participants12.

The theoretical and epistemological significance of Ethnomethodology is due to the fact of affecting a radical break with traditional ways of thinking of sociology. While the positivist sociology of nature faced social phenomena as objective realities, ethnomethodology sought to understand them as the individual's own practice constructions.

In this way, the social fact is no longer stable object to be a product of continuous activity of the men, who are seen as actors. The new theoretical current then passes giving importance and analyzes everyday activities like methods that the members of the society use to make these rational activities. Since its inception, Garfinkel has used terms considered key concepts of ethnomethodology as: practice, indexicality, reflexivity and notion of member13.

Method

This is an exploratory, descriptive study based onthe ethnomethodology principles, which were developed in a State hospital from May/July 2013. It is considered an emergency hospital and emergence of media and high complexity, belonging to the network of State Health Secretary of Rio de Janeiro (RJ) and located in the municipality of São Gonçalo. The subjects consisted of 18 users in postoperative hospitalized in medical clinic and surgical units of the hospital clinic.

The criteria for inclusion were: adults aged 18 years or more, without distinction as to sex, race, color and religion; after being subjected to surgical procedures, regardless of the nature of the procedure, emergency or elective; be in clinical conditions favorable, lucid and oriented; interested in participating in all stages of research development on a voluntary basis.

This survey was conducted taking into account the provisions of Resolution nº. 466/2012 National Health Council, on research involving human beings, under Protocol nº. 276.54. The participation of the patients in the study was conditioned upon the signing of the informed consent, after reading and understanding of the ethical procedures on the anonymity, the goals, the advantages and disadvantages with regard to the implementation of the research.

The data was produced through participant observation, recorded in the field journal and the semi-structured interview, detached, specific issues to the study, recorded on an electronic MP3, device supported by a previously tested script. Therefore, we alternate the data from the field journal with the interviews. The interviewees were identified by letter E associated with, the sequential number of participation, for instance: P1, P2, P3 and so on.

After the interview, the data were transcribed, arranged chronologically distributed according to the answers, classified and categorized according to the content analysis method14, emerging three categories, only one of which will be addressed in this study: Evaluation of nursing care in the surgical center.

 

RESULTS AND DISCUSSION

The 18 participating users of the study submitted to surgical procedures were between 25 to 84 years of age, most with older than 55 years; prevailed the males and with white skin. The reported household income comprises between 2 and 3 minimum wages.

With regard to participant observation, was selected a field journal scene situation, as the following annotations:

Situation: On a Wednesday, at 1:30 pm a male, adult, hospitalized in the unit, waiting for a reoperation of elective orthopedic surgery. Admitted to the SC, on a stretcher and accompanied by a nursing technique. The patient was received by the nurse in the industry outside the SC that led inside. The professional was quiet the whole time, however, the patient apparently anxious, from the moment they entered the SC did not hesitate to speak in an attempt of a professional interaction, to explain that he was there for a surgical reoperation. During the user's speech, the nurse smiled as he led the stretcher. When the user stopped talking, the nurse asked about comorbidities and allergies, having negative answers to both. The professional retained the patient waiting for the procedure on the stretcher, standing in the hallway of the SC.

The described situation demonstrates evidence of construction of reality and social practices that take place at the SC. One can see that in a few moments, the interaction between professional and user is restricted, with little verbal communication. However, at another time, it was observed that the interaction between users and the professionals pervades the nonverbal communication present in human contact, to be next, pay attention to what the user is right now.

The communication, which can be verbal and non-verbal, is that promotes an involvement, a bond and, consequently, the establishment of a trust relationship between the user and the professional; It is characterized as a thinking person, active, willing, laden with subjectivities capable to overcome physical barriers that separate people, the internal environment of the SC and the external environment15.

It is identified that, on entering the SC, the patient is apprehensive and delivery to their health situation for someone who does not know that their problem is solved.

The nurse is the professional who produces a common in daily life and living territory of his practice and can provide flexibility in their tasks in order to respond to the demands of users. Therefore, to establish a verbal or non-verbal communication, whereas verbal communication involves dialog, listen to what the user has to say right now, which will lead to their practice of care regarding this individual.

Under this argument, the bug is a precise communication element that is present in the process of care, and it is at this point that the forms of care will be developed according to the relationships that lock during the meeting between two people, free of conscience and different cultural universes. And appreciation of this meeting place of knowledge between two people is that the friendship and professional relationships of trust are constituted. Favoring this space for dialogue is to humanize the care16. Sequentially, we present the results of the category.

Evaluation of nursing care in the surgical center

In this category, the social reality constructed in the SC is through language, not used grammar and linguistics, but of everyday life in SC, as can be seen in the following speeches:

The staff is very good. My frustration is because what moves me, is the motivation for these people to continue working. To be a nurse to work in healthcare, you have to have a DNA to it, you have to like what you do. (P12)

Nurses always treat me well, even at the time when the surgery ends they call me, change of bed, take me there [Post Anesthetic Care Unit - URPA], is always checking if I'm well, if I'm getting better, if I'm awake. But then, I have nothing to complain about. (P1)

It was great, all the time trying to reassure me [...] she [nurse] entered three times [in URPA] to talk to us. (P2)

I got there [in the SC], and it wasn't visiting day, my son was worried that he didn't know where I was. The nurse made a point of getting me out of there [URPA], took me out for my son to see me at the door of the SC; brought me back, treated me well, all the time watching what I needed. She arranged a ward for me and said that he would be there, if I had, here, Thursday, to see me. For me, that was the best (P3)

Look, I don't even know if it's right for me to say this, [...] they deserved to earn a little more for what they do there, you know. I think that their work should be more valued. (P4).

The indexicality expression, understood as the set of languages, has been transposed by ethnomethodology17 and is present between the lines of the statements. In a way evidenced in the judgment of the care actions. According to the perception of the deponents, nursing workers are good. They demonstrate why they chose that profession because, according to the understanding of some, even with the devaluation of the work, nursing, expressed commitment along the development of their activities. Notably the assessment of caution appears in all the symbolic forms as set out in statements, as well as the rules, the gestural, and behavior.

The focus of ethnomethodology has their lenses focused on the conceptual issues as fundamental topics of sociology, to the theory of action, for the nature of intersubjectivity and finally to the social constitution of knowledge18.

Noted equally among other authors, that the social actors seek to exploit the properties of practical reasoning and practical actions, analyze their circumstances and influences, share a subjective understanding of those same circumstances, pointing to the common understandings and evaluation of complex and detailed ways in which contexts provide subsidies for their interpretation17.

In this sense, it is possible to understand, if nursing care implies actions for accomplishments life, based on meeting the needs of both users and the professional services that promote the care, which needs to involve interaction, autonomy and efficaciousness of the subjects involved.

Participants continued to report what could be improved in nursing care in the SC:

Talk more with us, know how to calm others. There are times that they gets so nervous, [...] there are patients who go out of here with great pressure and come back saying it operated because the pressure is on, understand? So I think it's cool, because we get in there, in a scary environment. (P1)

I think it is [...] to wait, have to stay there [URPA]. Because I was nervous, sometimes a person came by and I kept calling, understand? [...] other times I couldn't hear. I thought I had to be a person there, people are on IV. Thus, a person to meet there at least to give more attention [...] I stayed in this room there a couple or three hours before I went into surgery, standing by. I was having multiple surgeries. (P2)

Most lack affection by patients. I don't know you, but you also welcome me, I'm at a difficult time. I don't you know, I never saw you, I'm here, let's go, playing, relaxed, but the affection: Calm down, it's going to be OK, don't worry, this enthusiasm. Help, another: Hi, how are you? You’re going to operate now. A conversation, you know? They joked, it was good, distracted him enough, but an affection that we need our parents at that time, they could be there, in my point of view. I was not mistreated at any time, but to make the patient more comfortable. Despite having gone through it for the first time, the first impression is the one that stays. I was treated well and such, but it is only on more affection [...]. (P14)

In the statements, there is the concept of reflexivity, an ethnomethod designating the practice at the same time describe and constitute the social framework governed by the codes and behaviors of the group18. As noted by users, to mention the need for the presence of a professional nursing care to the bedside of someone who is near. You need to understand to be next, giving support and comfort to the user, is also nursing care and this aspect is very underrated and often seen as a minor action. Although they consider the work offered by nursing professionals as very good, still, some users reported that lack interaction, communication, more conversation between nursing professionals and the user, which demonstrates that the formation of bond and presence are fundamental in that moment in which the individual finds himself weakened, in a physical space generally unusual to him and with a range of feelings and expectations for the surgery. It also adds that these actions are describable, intelligible and analyzable reportable as also developed in the papers presented by the authors19-23. And thus the ethnomethodology is concerned to elucidate how the accounts or descriptions of an event are produced in interaction, in order to achieve a clear and objective methodological status.

 

CONCLUSION

In this study, it was possible to characterize the speeches of the surgical center users and analyze nursing care evidenced from these pronouncements. Analyzing the nursing care in SC and focus depends on the viewing angle you want to achieve, in view of the technological advances of the equipment used, the type of surgery, whose size determines the complexity or not of the care. The surgical patient vulnerability requires the nurse, in this area, activities based on specific knowledge of pre, post and trans-op, to the achievement of the goals, therapeutic success and safety of surgery and care.

It sought to focus ethnomethodology to the description and expansion of the studied phenomenon, as a contribution to the analysis of nursing care, from the speeches of users who have had surgical procedures and this was only possible by the availability and exchange of experiences of users which used the services of the surgical center.

Nursing care in the SC, as noted in depositions, fell to subjectivity, i.e. the user missed what is essential in human care, of listening, of precise warmth, attention, solidarity on arrival at the surgical Center and be welcomed into their health demands.

The SC as a peculiar and complex unit within the hospital context, whose specificities often go unnoticed for those not familiar and turns into a place feared by all, especially for those who never needed a surgical intervention. The fear of the unknown generates discomfort, anxiety and nervousness on the part of users, reflected in the lines, verbal and non-verbal codes, symbols, in the imagination, which lead to a profusion of ideas. Similarly, observed in gestures of professionals and health teams, which unwittingly, to develop their activities, send signals and information that are frightening for those awaiting a procedure. Above all, before the daily routine of a SC, whose activities have become banal and commonplace for certain professionals, who failed to consider the minimum attention and careful with has frail health.

Even so, it is common that patients be surprised when they are well treated, depending on previous experiences of careless or neglect of public institutions, professionals and health services, when in fact the human being is the focus of assistance of any health professional committed to his practice.

It is concluded that the ethnomethodology contributes to the research of the emerging phenomena of everyday life, allowing necessary information and knowledge to maximize human subjectivity and the dimensions of care, for the exercise of a more humane practice.

 

REFERENCES

1.Coulon A. La etnometodología. Madrid (Es): Ediciones Cátedra; 2005.

2.Coulon A. Etnometodologia. Petrópolis (RJ), Vozes; 1995.

3.Giron MN. O acolhimento de usuários no centro cirúrgico e a humanização das práticas cotidianas do cuidado de enfermagem [dissertação de mestrado]. Rio de Janeiro: Universidade do Estado do Rio de Janeiro; 2013.

4.Silvia DC, Alvim NAT. Ambiente do centro cirúrgico e os elementos que o integram: implicações para os cuidados de enfermagem. Rev bras enferm. 2010; 63: 427-34.

5.Regis LFLV, Porto IS. Necessidades humanas básicas dos profissionais de enfermagem: situações de (in)satisfação no trabalho. Rev esc enferm USP. 2011;45:334-41.

6.Oliveira BRG, Collet N, Viera CS. A humanização na assistência à saúde. Rev Latino-Am Enfermagem. 2006; 14: 277-84.

7.Ministério da Saúde (Br). Política nacional de humanização: humaniza SUS: Brasília (DF): Editora MS; 2004.

8.Ministério da Saúde (Br). Cadernos humanizaSUS: atenção hospitalar. Brasília (DF): Editora MS; 2011.
9.Macedo CA, Teixeira ER, Daher DV. Possibilidades e limites do acolhimento na percepção de usuários. Rev enferm UERJ. 2011; 20: 457-62.

10.Giron, MN, Berardinelli LMM, Santo FHE. O acolhimento no centro cirúrgico na perspectiva do usuário e a política nacional de humanização. Rev enferm UERJ. 2013; 21: 766-71.

11.Rawls AW. Harold Garfinkel, ethnomethodology and workplace studies. Bentley College (USA): Organization Studies; 2008.

12.Maciel LHR, Lima Junior PO, Capelle MAC. Etnometodologia: uma revisão sistemática sobre o tema em bases de dados da Web. Revista FSA. (Teresina) 2014; 11:70-83.

13.Berardinelli LMM. A (im) posição silenciosa no cotidiano da enfermeira preceptora. [dissertação de mestrado]. Rio de Janeiro: Universidade Federal do Rio de Janeiro, 1998.

14.Bardin L. Análise de conteúdo. Lisboa (Pt): Edições 70; 2009.

15.Waldol VR. Cuidar: expressão humanizadora da enfermagem. Petrópolis (RJ): Vozes; 2006.

16.Waldol VR, Fensterseifer M. Saberes da enfermagem: a solidariedade como uma categoria essencial do cuidado. Esc Anna Nery. 2011; 15: 629-32.

17.Oliveira AS, Montenegro LM. Etnometodologia: desvelando a alquimia da vivência cotidiana. Cadernos EBAPE.BR.2012; 10 (1):129-45.

18.Guidens A, Turner J. Teoria social hoje. Tradução de Gilson C. de Souza. São Paulo: UNESP; 1999.

19.Vargha Z. Organization, interaction and practice: studies of ethnomethodology and conversation analysis. Organization Studies. 2011; 32:1745-9.

20.Coelho MJ. Cuidar/cuidados em enfermagem de emergência: especificidade, aspectos distintivos no cotidiano assistencial [tese de doutorado]. Universidade Federal do Rio de Janeiro; Rio de Janeiro: 1997.

21.Santo FHE. As interações entre profissionais e estudantes na trama da construção da identidade profissional da enfermeira [dissertação de mestrado]. Universidade Federal do Rio de Janeiro; Rio de Janeiro: 1997.

22.Santo FHE. Saberes e fazeres de enfermeiras (os) novatas (os) e veteranas (os) sobre o cuidado de enfermagem no cenário hospitalar [tese de doutorado]. Universidade Federal do Rio de Janeiro; Rio de Janeiro: 2003.

23.Berardinelli LMM Gestos de Cuidado: Estudo Interdisciplinar através de Imagens. [tese de doutorado]. Universidade Federal do Rio de Janeiro; Rio de Janeiro: 2003.