id 20787

ORIGINAL RESEARCH

 

Being an intensive care nurse: identity elements present in the field of social representations

 

Rafael Celestino da SilvaI, Márcia de Assunção FerreiraII, Thémis ApostolidisIII

I Doctor's degree in Nursing. Assistant Professor, Department of Fundamental Nursing, Federal University of Rio de Janeiro. Brazil. Email: rafaenfer@yahoo.com.br
II Doctor's degree in Nursing. Full Professor, Department of Fundamental Nursing, Federal University of Rio de Janeiro. Brazil. Email: marcia.eean@gmail.com
III Doctor's degree in Psychology. Director, Social Psychology Laboratory, Aix-Marseille Université. France. E-mail: themistoklis.apostolidis@univ-amu.fr

DOI: http://dx.doi.org/10.12957/reuerj.2018.20787

 

 


ABSTRACT

Objective: to recognize the identity aspects present in the social representation of nurses about the care practices for the client hospitalized in intensive therapy. Method: field study, qualitative, descriptive and explanatory, based on the theory of social representations and on the social identity concept. After approval by the Research Ethics Committee, interviews were carried out with 21 nurses working in the assistance of an intensive care unit in a federal hospital, using a semi-structured guide. Data were submitted to the content analysis. Results: social identification and enhancement of the group itself, and social comparison and stereotyping of the outside group are evidenced, which are: the ways of using the technologies, the delineation of the typical patient figure, as well as the attributes of the ideal nurse, the sense of work, the intra and intercompany relationship. Conclusion: it is recommended the reorganization of the field of social representation from interventions under identity elements.

Descriptors: Nurse care; intensive therapy unit; social identity; social psychology.


 

 

INTRODUCTION

Considering the theory of social representations, the development of human thought is based on the various group insertions of actors in social, historical, political, and cultural fields, among others1. This insertion of individual members into a social space produces a sense of belonging, from which identity is defined. Therefore, social representations (SRs), through practices, raise the issue of social identity, which expresses a stand and a way of being in the world 2, being part of the context of knowledge.

Discussions on this identity theme involve different disciplines. In the field of education, for example, the methods for building the professional identity of basic education teachers have attracted some interest, considering the social representations of this profession. Such methods are related to historically determined cultural and social structures from which teachers have reconstructed their identity3.

In collective health, this concern is related to the professional performance and identity of the "new sanitarian," in view of the creation of undergraduate courses in public health. When investigating the perceptions of undergraduates and graduates of these courses, even though most of them did not initially have an interest in this area, the experiences acquired during the program allowed them to build a sense of belonging, which is related to the identification with political and social elements and values of practice in this field4.

In nursing, the focus of this study, the production of knowledge about this theme is based on the analysis of professional identity development. A study conducted a philosophical analysis of this identity and reported that it emerged from the Nightingalean model in 1860, when definitions were proposed regarding what nursing was or was not5. This professional identity has been developed throughout the socio-historical construction of this profession, as reported in a study with graduates of a nursing undergraduate course in the 1970s about the purpose and meaning of being a nurse at the moment of professional choice. The identity of these professionals covered: nursing as a second option; care as synonymous with doing; the social stigma of the profession; the possibility of insertion in the labor market and social ascension6.

Some areas of nursing practice, such as the specialized fields, also hold discussions about a professional identity of nurses to understand and explain their behavior and actions in these scenarios of care provision, for instance, in intensive care units (ICUs).

Some authors argue that a clear professional identity is observed in this environment, of unique character, which includes all health agents related to such environment. When choosing to work in an ICU, a specific identity that is common to several professional categories is defined in contrast to other hospital sectors: the intensive care worker's identity7, a profile that demands specific competence, sharing of common values, and control over those who act there. Nurses are united by a sense of belonging that helps them ensure meaning to the world, deal with daily life issues, and establish communicative relationships.

Poor understanding of this social identity encourages the creation of stereotypes about nursing care in ICUs, which is the focus of this study. These stereotypes are organized based on questionnaires found in the literature about the behavior of intensive care nurses, marked by moments when the patient is seen as an object, depersonalizing care relationships and worrying about high complexity technical actions8,9 as well as implications of such actions for safety10-12.

In this sense, this study was conducted considering the need to learn more about the elements that influence professional actions for the adoption of intervention strategies on these elements to improve the quality of care. A previous study about SRs of ICU nurses on their practices observed these representations are organized around the ICU technology and patients, creating styles of care that are suitable for this scenario13.

Given the above, the question is: What identity aspects are observed in social representations of caring practices towards ICU patients by nurses working in this environment? The objective of this study was to identify the identity aspects present in SRs of ICU care practices of nurses working in this environment.

 

THEORETICAL FRAMEWORK

The study was based on the theory of social representations and the concept of social identity. In the perspective of social psychology developed by Deschamps & Moliner, identity is a subjective, dynamic phenomenon that results from a two-pronged observation of similarities and differences among oneself, other people and certain groups14. SRs compete for such identity that is common to individuals, which, in turn, fosters social identifications and differentiation based on affiliation and belonging to a social group. Thus, the social categorization between who we are and who we are not helps to understand and organize reality, determining identity15.

In this perspective, the study frameworks are justified, as they will be applied in an attempt to understand how the processes of categorization and social comparison occur, from which the identity and practices of ICU nurses are defined, establishing interfaces with SRs developed by these nurses regarding their practice.

 

METHODOLOGY

This is a field study with a qualitative descriptive-explanatory approach and application of the procedural dimension of the theory of social representations. The field was a federal hospital in the municipality of Rio de Janeiro, and the ICU section of this institution. Of all 24 nurses working in this ICU, 21 were directly involved in patient care and present during the study period. The other three nurses were excluded because they were on vacation or leave.

Data were produced through individual interviews. The interviews were conducted in the ICU, in the afternoon, lasting on average 1 hour and 30 minutes. A script was used to collect sociodemographic data to characterize the participants and a semi-structured questionnaire was used to explore the theme, with questions addressing the daily practice of nurses in the ICU, patient care style, use of technologies, among others.

Data from the interviews were analyzed by thematic content, after conducting the following stages: identification of the most frequent and significant themes, organization of the groups of meaning, and categorization, allowing the definition of two axes of analysis. This study was approved by the research ethics committee of the studied institution, under protocol 35/10. The participants' anonymity was respected as nurses were identified using the word Nurse followed by an Arabic number, according to the order of their interview. Data production occurred from January to June 2011.

 

RESULTS AND DISCUSSION

We: element of belonging of ICU nurses

Social identities are shared by those who hold the same social positions, who have a sense of belonging in common and similarities. This social identification was present in data of 17 registry units (RU) and was identified when interviewees referred to their care practice, characterizing an intensive care nurse, that is: a professional who seeks strategies to provide quality care to patients, incorporating the use of technologies and constant improvement of knowledge that explains such use.

They have this idea of being practical because of technology, because of care, we know how to perform several procedures in a patient. It's not a very different view from mine, while an ICU nurse is more or less like that, the question of an ICU nurse of trying to solve, there's that patient in serious condition, constant monitoring of the machine. (Nurse 4)

One of the elements that supports intragroup similarity and encourages a sense of belonging is the use of technologies in patient care, observed in 14 thematic RUs. In this sense, nurses give great importance to this component of their identity, in which using technologies and giving them appropriate value mean acting in line with the expected practice of ICU nurses.

We, who work in the ICU, if there's no monitor here, there's no need to place patients here, no need to call the ICU [...] it's an infirmary, a clinic, and I'll be checking the vital signs every two hours [...] it's part of our life in the ICU, it's part of the team, it's involvement actually, there's no way out [...]. (Nurse 4)

The emotional component of this sense of belonging directed to the group itself emerges when ICU patients' recovery is achieved. They show positive appreciation of being part of this group and acting in such a scenario, demonstrating satisfaction with the work developed and a high level of commitment. This theme was present in 9 RUs.

You deal with these situations of pain, suffering, and it's good to see the patient leaving after that, see the patient thanking us [...] it's rewarding to see that all your effort, that whole night you spent there, the boy got better and, survived. But that's the daily life in the ICU. (Nurse 20)

This positive feeling explains nurses' preference for patients classified by them as presenting a more serious condition, to protect the in-group and strengthen the affiliation of its members. With this choice, nurse participation in patient recovery is more visible, when compared to a patient in a less serious condition.

Anyone who works with intensive care likes to see the patient in a serious condition because we like to work, so the satisfaction is huge when you see this patient getting better and better [...] I like to take this patient and see him wake up, be extubated and leave this place talking. (Nurse 18)

They: between differences and stereotypes

Similarities bring important consequences to the perception of the groups. This happens because the more an individual identifies with a group, the more this person can differentiate this group from the others. Thus, the effect of contrast is seen as a result of intensified differences between the categories, where the in-group is appreciated and the out-group is depreciated, assigning common features or stereotypes to such contrast. Appreciation is perceived when they address the recognition of ICU nurses, ensuring them the status of professional of greater knowledge in 12 RUs, and designing requirements considered as essential for ICU nursing care in 14 RUs.

But the intensive care nurse is always seen as the nurse who has more knowledge. (Nurse 13)

Technical-scientific knowledge because you are dealing with a patient of greater complexity than that of another sector and with technology. (Nurse 2)

As a consequence, a negative evaluation emerges for nurses working in clinical sectors, as they are stereotyped as professionals of less knowledge, inferior to that of intensive care nurses.

They find it complex. They think it's a whole different world, I can tell you that because I was relocated to the clinic. Then I stayed in the clinic for 3 days. [....] People really don't know anything. I think everyone should have a period in the ICU because the ICU is a school. (Nurse 1)

The definition of spaces inside and outside the ICU is another example that illustrates the depreciation of the out-group. It becomes clear when the comparison is made in relation to the other members of the multidisciplinary team that do not work exclusively in this sector and constitute the structure outside the ICU.

In general, the relationship is good, most of them are people who are there most of the time, physical therapists, physicians, and nurses. Regarding people from outside, for example, people from the nutritional therapy, we don't have much contact, we only talk about essential things, they often say things we don't agree with. (Nurse 17)

The dialog between the in-group and the out-group, we versus they, ends up being portrayed in the discussion about the image of the intensive care nurse, which was observed in 16 RUs. A positive self-image is observed among the ICU nurses (in-group), whereas among the other nurses there was a trend of negative evaluation of the ICU nurses (out-group).

They think we're arrogant, snobbish [...] What happens is that we have more technology skills than the others [...] in an emergency situation, the people who are better prepared to deal with these situations are those who have more technology skills [...] in some cases, it can be for admiration, you see the person can handle a certain situation [...]. (Nurse 7)

This identity issue has been considered by experts in SRs as a central element of this theory, especially in the organization of the field of SRs, since the individual projects the social identity into the object it represents16. A classic study in which the discussion of identity is evident is that of cross-cultural representations of AIDS 17.

In this study, the author shows that a sense of defense supports the creation of SRs of AIDS, based on the following logic: Not me, not my group; that is, the subjects seek to divert attention from the threat of AIDS to "I" (internal group), changing their view to other people, those who receive the responsibility due to their origin and development (external group – the one who is threatened and who threatens)17.

More recently, other groups have received attention from researchers regarding these intergroup relations, for example, gypsies and rural people. In this case, they attempted to analyze the intergroup relations between gypsy and rural women and learn more about the representations and practices built in in-group and out-group relations15.

The representation of the gypsy out-group is based on fear and perception of the gypsies as cursed people. The representation of the rural out-group among the gypsies is unclear, but reinforces a tendency to create a positive self-image for the appreciation of their group of belonging in comparison to others. Regarding the in-group representations, positive elements are observed when building the social identity of each of these women15.

This example illustrates the role of identity in everyday life and how it interferes in social relationships with others. These relationships are guided by the processes of identification and differentiation which, in turn, mediate the meanings attributed to oneself and the others, attesting the connection between SRs and identity18.

Regarding this study theme, results from other studies support data reported in this study. One of them was produced from an ethnographic study conducted in the ICU of a public university hospital7. Among the axes of analysis, ICU workers appear as a professional identity, in which a group of elements supports the construction of such identity.

At the highest level of the hospital is one of these elements, that is, the participants reported great satisfaction with working in a sector considered as an excellence service, in a hierarchical position superior to other hospital services, with high-level professionals, greater organization of service dynamics and multidisciplinary team. In addition, they reported a self-image of heroism, a savior, which increased their sense of gratification when patient recovery was achieved7.

Being an ICU nurse/top-level professional is another element of the identity of ICU nurses. Superlatives are used to describe this professional, always above the peers, who are seen as less skilled, or even ignorant. Their self-image is superior to that of their colleagues, due to the knowledge they have and skills to handle technology7. Although they disagree with the elite/ top-level image their colleagues have of them, which increases the distance between them and their peers, they feel proud of their role7.

The ICU workers' sense of belonging to a group is reinforced by other experts, who show that the creation of an identity with the ICU by nurses is related to the elements that produce the feeling of pleasure in these professionals, which are: helping patient recovery, handling ICU equipment, continuously seeking to improve, and being recognized for the work developed19. This aspect of satisfaction and pleasure at work is reinforced in a study that was conducted to understand the perspective of physicians about health and work in the neonatal ICU of a public hospital. In the interviews conducted for the study, the participants highlighted their satisfaction with working in the ICU, mainly because of the idea of having more control over complications in the condition of ICU children due to the use of equipment20.

Regarding the superlative knowledge of ICU nurses, seen as one of their identity pillars, it was considered the essence of the representation structure of intensive care for mobile ICU health professionals21. The technological dimension of nursing care practices in the ICU has been the focus of a number of national and international studies, which value the need for ICU nurses to pay attention to these technologies in their daily activities22-24 to help maintain the life of patients and express their knowledge, reinforcing their professional identity and the importance of technologies in intensive care units.

One example of the need to pay attention to technologies is seen in a study that analyzed equipment faults while nurses were handling them, reporting operational problems of infusion pumps and batteries of artificial ventilators, besides errors of the professionals linked with equipment design. These results highlight the importance of nurses performing technovigilance – proper management of ICU equipment – to prevent incidents and risks to patient safety24.

Considering the data and the understanding of the concept of social identity, these representations are influenced by aspects of identity, on the one hand: social identification and appreciation of the in-group, such as the vigilant and interventionist attitude of intensive care nurses, the use of technologies/machines in patient care, the positive feeling of recovering a patient in serious condition chosen to receive care, the professional recognition based on knowledge; and on the other hand: social comparison, which stereotypes and depreciates the group of nurses who do not work in the intensive care unit, and vice versa.

In this case, the established profile of an intensive care nurse based on knowledge leads to a negative evaluation of other professionals, considered from the outside, which is the starting point for conflicts between teams. Consequently, it also generates the opposite movement of depreciation of the ICU nurses, who are seen as mechanical, technological, inhuman.

Care humanization in intensive care units is also a major concern in the literature of this field, and the focus of different studies 9,25,26. One of these studies is about the relationships of nursing professionals with patients and their relatives in an ICU based on the concepts proposed by Paterson and Zderad25.

The authors report a relationship of power of nursing professionals to the patients and distance from relatives, without a dialogical relation that values encounter and subjectivity. Therefore, they conclude that care humanization is required, allowing patients and their families to express objective and subjective dimensions25. Such appreciation of the subjective dimension, which strengthens commitment and accountability, is also highlighted in another study as one of the elements that can promote nursing care humanization in the ICU26.

Therefore, images of professional classification are constructed based on this identity, establishing intensity metrics that classify professionals as: more/less capable, clearly marking the position of each group and respective practices, which influences the relationship between them.

 

CONCLUSION

The identity components obtained in this study relate, in the field of social representations, to other normative, affective and symbolic elements and contribute to the meanings attributed by these professionals to their care practice in ICUs. These SRs are wrapped in the social identity of intensive care nurses that includes guiding elements of technology use, definition of a typical ICU patient and the attributes of an ideal nurse, the meaning of work, and intra- and inter-team relationships. This group of factors is linked in order to configure care practices of nurses, ensuring a particular meaning to the social category of being an ICU nurse.

Theoretical limitations of this study have been identified because its results are associated with the study context, showing possibilities for studies on identity in new scenarios, with more subjects, increasing the power of generalization. In view of the above, the category Being an ICU nurse reveals aspects that may be the focus of interventions that promote the practical application of the study results.

In this perspective, by understanding the SR field as a structured group of meanings, knowledge and information, and considering identity as part of such group, it can be reorganized using reflective groups that allow the interference of some elements of the identity that gain relevance after data analysis: in technologies, when overvalued in distance customer care management; in ICU patient typification, which consequently underestimates patients in less severe conditions, more alert and their subjective complaints; and in the superlative of ICU nurses, which underestimates the knowledge of other professionals and are a cause of conflicts.

 

REFERENCES

1.Rocha LF. Teoria das representações sociais: a ruptura de paradigmas das correntes clássicas das teorias psicológicas. Psicol. cienc. prof. 2014 [cited 10 jan 2018] ; 34(1): 46-65. DOI: http://dx.doi.org/10.1590/S1414-98932014000100005

2.Jodelet D. A representação: noção transversal, ferramenta da transdisciplinaridade. Cad. Pesqui. 2016 [ cited 2018 Jan 10 ]; 46(162): 1258-71. DOI: http://dx.doi.org/10.1590/198053143845

3.Gebran RA, Trevizan Z. Social representations in the construction of professional identity and teachers' activity. Acta Sci. Educ. 2018 [cited 2018 Jan 10]; 40(2): e34534. DOI: http://dx.doi.org/10.4025/actascieduc.v40i2.34534

4.Silva VO, Pinto ICM. Identidade do sanitarista no Brasil: percepções de estudantes e egressos de Cursos de Graduação em Saúde Pública/Coletiva. Interface (Botucatu). 2018 [citado em 10 jan 2018]; 22(65): 539-50. DOI: http://dx.doi.org/10.1590/1807-57622016.0825

5.Carvalho V. Sobre a identidade profissional na Enfermagem: reconsiderações pontuais em visão filosófica. Rev. bras. enferm. (Online). 2013 [citado em 10 jan 2018]; 66(esp): 24-32. DOI: http://dx.doi.org/10.1590/S0034-71672013000700003

6.Teodosio SS, Padilha, MI. To be a nurse: a professional choice and the construction of identity processes in the 1970s. Rev. bras. enferm. (Online). 2016 [cited 2018 Jan 18]; 69(3): 401-7. DOI: http://dx.doi.org/10.1590/0034-7167.2016690303i

7.Menezes RA. Difíceis decisões: etnografia de um centro de tratamento intensivo. Rio de Janeiro: Editora Fiocruz; 2006.

8.Reis CCA, Sena ELS, Fernandes MH. Humanization care in intensive care units: integrative review. Rev. pesqui. cuid. fundam. (Online). 2016 [cited 2018 Jan 10]; 8(2): 4212-22. DOI: http://dx.doi.org/10.9789/2175-5361.2016.v8i2.4212-4222

9.Nascimento ERP, Gulini JEHMB, Minuzzi AP, Rasia MA, Danczuk RFT, Souza BC. As relações da enfermagem na unidade de terapia intensiva no olhar de Paterson e Zderad. Rev. enferm. UERJ. 2016 [ citado em 10 jan 2018 ]; 24(2): e5817. DOI: http://dx.doi.org/10.12957/reuerj.2016.5817

10.Abraham J, Kannampallil T, Brenner C, Lopez KD, Almoosa KF, Patel B, et al. Characterizing the structure and content of nurse handoffs: a sequential conversational analysis approach. J. Biomed. Inform. 2016 [cited 2018 Jan 10 ]; 59: 76-88. DOI: http://dx.doi.org/10.1016/j.jbi.2015.11.009

11.Oliveira JGAD, Almeida LF, Hirabae LFA, Andrade KBS, Sá CMS, Paula VG. Interruptions in intensive care nursing shift handovers: patient safety implications. Rev. enferm. UERJ. 2018 [cited 2018 Dec 10]; 26: e33877. DOI: https://dx.doi.org/10.12957/reuerj.2018.33877

12.Mendes RNC, Carmo AFS, Haddad MCL, Rossaneis MA. Percepções de enfermeiros sobre o uso de equipamentos na Unidade de Terapia Intensiva. Rev. enferm. UFPE on line. 2014 [citado em 10 Jan 2018]; 8(7): 1904-11. DOI: https://dx.doi.org/10.5205/reuol.5963-51246-1-RV.0807201411

13.Silva RC, Ferreira MA, Apostolidis T. Estilos de cuidar de enfermeiras na Terapia Intensiva mediados pela tecnologia. Rev. bras. enferm. (Online). 2014 [citado em 12 jan 2018]; 67(2): 252-60. DOI: http://dx.doi.org/10.5935/0034-7167.20140034

14.Deschamps JC, Moliner P. L'identité en psychologie sociale: des processus identitaires aux représentations sociales. Paris (Fr): Armand Colin; 2011.

15.Bonomo M, Trindade ZA, Souza L, Coutinho SMS. Representações sociais e identidade em grupos de mulheres ciganas e rurais. Psicologia [Internet]. 2008 [citado em 29 mai 2017]; 22(1): 153-81. Disponível em: www.scielo.mec.pt/pdf/psi/v22n1/v22n1a07.pdf

16.Seidmann S. Identidad personal y subjetividad social: educación y constitución subjetiva. Cad. Pesqui. 2015 [ cited 10 jan 2018 ]; 45(156): 344-57. DOI: http://dx.doi.org/10.1590/198053143204

17.Joffe H. "Eu não, "o meu grupo não": Representações transculturais da AIDS. In: Jovchelovitch S, Guareschi P, organizadores. Textos em representações sociais. Petrópolis (RJ): Vozes; 2007. p.297-322.

18.Spezani RS, Oliveira DC. O perfil da produção científica sobre identidade no campo da teoria das representações sociais. Psicol. teor. prat. [Internet]. 2013 [citado em 29 maio 2017]; 15(2): 104-18. Disponível em: http://editorarevistas.mackenzie.br/index.php/ptp/article/view/4149/4454

19.Cruz EJER, Souza NVDO, Correa RA, Pires AS. Dialectic feelings of the intensive care nurse about the work in Intensive Care. Esc. Anna Nery Rev. Enferm. 2014 [cited 2018 Jan 10]; 18(3): 479-85. DOI: http://dx.doi.org/10.5935/1414-8145.20140068

20.Rocha APF, Souza KR, Teixeira LR. A saúde e o trabalho de médicos de UTI neonatal: um estudo em hospital público no Rio de Janeiro. Physis. 2015 [citado em 10 jan 2018]; 25(3): 843-62. DOI: http://dx.doi.org/10.1590/S0103-73312015000300009

21.Nascimento KC, Tosoli AM, Erdmann AL. Representational structure of intensive care for professionals working in mobile intensive care units. Rev. Esc. Enferm. USP. 2013 [cited 2018 Jan 10]; 47(1):176-84. DOI: http://dx.doi.org/10.1590/S0080-62342013000100022

22.Ribeiro GSR, Silva RC, Ferreira MA. Technologies in intensive care: causes of adverse events and implications to nursing. Rev. bras. enferm. (Online). 2016 [cited 2018 Jan 10]; 69(5): 972-80. DOI: http://dx.doi.org/10.1590/0034-7167.2016690505

23.Bourgain JL, Coisel Y, Kern D, Nouette-Gaulain K, PanczerM. What are the main "machine dysfunctions" to know? Ann. Fr. Anesth. Reanim. 2014 [ cited 2018 Jan 10]; 33(7-8): 466-71. DOI: http://dx.doi.org/10.1016/j.annfar.2014.07.744

24.Ribeiro GSR, Silva RC, Ferreira MA, Silva GR, Campos JF, Andrade BRP. Equipment failure:

conducts of nurses and implications for patient safety. Rev. bras. enferm. (Online). 2018 [cited 2018 Sep 10]; 71(4): 1832-40. DOI: http://dx.doi.org/10.1590/0034-7167-2016-0547

25.Medeiros AC, Siqueira HCH, Zamberlan C, Cecagno D, Nunes SS, Thurow MRB. Comprehensiveness and humanization of nursing care management in the Intensive Care Unit. Esc. Enferm. USP. 2016 [ cited 2018 Jan 10]; 50(5): 816-22. DOI: http://dx.doi.org/10.1590/S0080-623420160000600015

26.Michelan VCA, Spiri WC. Perception of nursing workers humanization under intensive therapy. Rev. bras. enferm. (Online). 2018 [cited 2018 Jn 11] ; 71(2): 372-8. DOI: http://dx.doi.org/10.1590/0034-7167-2016-0485