Interaction between the nursing technician and the family of the hospitalized patient

Abstract

Objective

Analyze the interactions observed between the nursing technician and the family of the hospitalized patient, in the light of the premises of Patient and Family-Centered Care and the Ethics Code of Nursing Professionals.

Methods

Qualitative study with the premises of Patient and Family-Centered Care and the Ethics Code of Nursing Professionals as the theoretical frameworks. The participants were nine nursing technicians from the medical clinical wards of two public hospitals in the State of São Paulo. The data were collected using participant observation and analyzed using Conventional Qualitative Content Analysis.

Results

The interactions between the nursing technician and the relatives were limited in terms of using the premises of Patient and Family-Centered Care and in complying with the recommendations of the Ethics Code of Nursing Professionals, as the following categories revealed: Not treating the family members with respect and dignity; Not sharing information with the family members; Not negotiating on how to participate and collaborate in the care provision.

Conclusion

It is fundamental to incorporate the premises of Patient and Family-Centered Care and the ethical aspects related to the family recommended in the Ethics Code of Nursing Professionals and in the professional experience of the nursing technician, contributing to high-quality, ethical and solidary care.

Family; Nursing; Nursing care; Medical chaperones; Education, professional

Resumo

Objetivo

Analisar as interações observadas entre o técnico em enfermagem e a família do paciente hospitalizado, à luz dos pressupostos do Cuidado Centrado no Paciente e na Família e do Código de Ética dos Profissionais de Enfermagem.

Métodos

Estudo qualitativo, cujos referenciais teóricos foram os pressupostos do Cuidado Centrado no Paciente e na Família e o Código de Ética dos Profissionais de Enfermagem. Participaram nove técnicos em enfermagem das unidades de clínica médica de dois hospitais públicos do Estado de São Paulo. Os dados foram coletados por observação participante e analisados pela Análise Qualitativa de Conteúdo Convencional.

Resultados

As interações entre o técnico em enfermagem e os familiares foram limitadas no que se referiu à utilização dos pressupostos do Cuidado Centrado no Paciente e na Família e no cumprimento do que era preconizado pelo o Código de Ética dos Profissionais de Enfermagem, conforme revelaram as categorias: Não tratando os familiares com respeito e dignidade; Não compartilhando informação com os familiares; Não negociando a forma de participação e colaboração na prestação do cuidado.

Conclusão

É imprescindível a incorporação dos pressupostos do Cuidado Centrado no Paciente e na Família e de aspectos éticos relacionados à família preconizados pelo Código de Ética dos Profissionais de Enfermagem na formação e na vivência profissional do técnico em enfermagem, contribuindo para um cuidado de qualidade, ético e solidário.

Família; Enfermagem; Cuidados de enfermagem; Acompanhantes formais em exames físicos; Educação profissionalizante

Resumen

Objetivo

Analizar las interacciones observadas entre el técnico en enfermería y la familia del paciente hospitalizado siguiendo los criterios de los objetivos de la Atención centrada en el Paciente y en la Familia, así como del Código de Ética de los Profesionales de Enfermería.

Métodos

Estudio cualitativo, cuyas referencias teóricas fueron los propósitos de la Atención centrada en el Paciente y en la Familia, así como del Código de Ética de los Profesionales de Enfermería. Participaron nueve técnicos en enfermería de las unidades de clínica médica de dos hospitales públicos del Estado de São Paulo. Los datos fueron recolectados por la observación participante y analizados por el Análisis Cualitativo de Contenido Convencional.

Resultados

Las interacciones entre el técnico en enfermería y los familiares estaban limitados en lo que se refiere a la utilización de los objetivos de la Atención Centrada en el Paciente y en la Familia y en el cumplimiento de lo recomendado por el Código de Ética de los Profesionales de Enfermería, según las categorías reveladas: no tratando a los familiares con respeto y dignidad; No compartiendo información con los familiares; No negociando la forma de participación y colaboración en la prestación de atención.

Conclusión

Se torna imprescindible la incorporación de los principios de la Atención Centrada en el paciente y la familia y de los aspectos éticos relacionados a la familia recomendado por el Código de Ética de los Profesionales de Enfermería en la formación y la experiencia profesional del técnico de enfermería, lo que contribuye a una atención de calidad, ética y solidaria.

Familia; Enfermería; Atención de enfermería; Chaperones médicos; Educación profesional

Introduction

The Ethics Code of Nursing Professionals presents more than the rights and duties of professionals, as it considers their responsibility to promote the recovery of health, prevent diseases and illnesses, and alleviate suffering in the care for the person, family and community. It also recognizes the principle of respect for the person’s right to life, liberty, equality, security, freedom of choice, dignity and treatment without any distinction.⁽¹⁾

Nursing workers should understand that the participation of family members is fundamental for quality patient care. Otherwise, all aspects of care, including policy, program development and evaluation, do not respond to their true needs.⁽²⁾ Professionals need to develop specific scientific and technical knowledge, within the social, ethical and political practices, which is accomplished through education, research and care, materializing during the care.⁽¹⁾

With regard to care for the family, as recommended by the Code of Ethics, the philosophy of Patient and Family-Centered Care stands out. It is a process of planning, providing and evaluating care, which seeks to transform the relationships established during care into health benefits, highlighting the collaboration among patients, family and professionals, in all care.⁽²⁾ Besides proposing that the professionals recognize the family as a unit of care, its premises are directed at the promotion of the health and well-being of individuals and family members, ensuring that they are treated with dignity and respect; sharing information; encouraging their participation in care and decision making; and integrating their collaboration into the development, implementation and evaluation of policies, health programs, professional education and care provision.⁽²⁾

In our reality, with regard to nursing care, these recommendations should extend to the nursing technicians, who represent the majority of professionals and are responsible for direct care provision, spending more time with the patients and their families.

Although the literature presents evidence on the importance of the family’s role in care, especially in the pediatric area, there are few publications about the experience of the nursing technician with families of adult hospitalized patients. It is known that countless difficulties mark the meaning the nursing technician attributed to the interaction with the adult hospitalized patient’s family.⁽³⁾

Thus, the following questions arise: How does the nursing technician interact with the patient’s family during the practice of care? Does (s)he use the assumptions of Patient and Family-Centered Care and the Ethics Code of Nursing Professionals?

This study aimed to analyze and discuss the interactions observed between the nursing technician and the family of the hospitalized patient, in the light of the assumptions of Family-Centered Care and the Ethics Code of Nursing Professionals.

Methods

Qualitative research, whose theoretical reference frameworks were the premises of Patient and Family-Centered Care and the Ethics Code of Nursing Professionals.^(1,2) The methodological framework was Conventional Qualitative Content Analysis, recommended when studies on a theme are still scarce.⁽⁴⁾

The study was carried out in the medical clinical wards of two general public hospitals in the State of São Paulo. One of them had 48 beds, without a humanization program; the other, with 41 beds, had an established humanization program.

Nine nursing technicians participated, seven of whom were women, who had graduated between five and 16 years ago, possessed four to 12 years of professional experience and had worked at the institution between two and 12 years of age, complying with the following selection criteria: working in medical wards and having more than two years of professional experience. This number of participants was defined by the saturation criterion, reached when the information was sufficient to reproduce the study, new additional information was obtained, and additional coding was no longer possible,⁽⁵⁾ in which the certainty of the researcher as to having found the internal logic of the research object should prevail.⁽⁶⁾

Data were collected between February 2013 and April 2014. The strategy used was participant observation, commonly used in qualitative studies and fundamental in field research, because it permits understanding the reality, in which the researcher interacts directly with the subjects in their social environment, aiming to collect data and understand the research scenario.⁽⁷⁾

The observations were carried out by one of the researchers and they looked at how the nursing technicians behaved when interacting with the family members, what dialogues they maintained with them, during the care provision; and with their colleagues in this respect, thus approaching the reality. These observations were immediately recorded in a field diary.⁽⁷⁾

Data were analyzed after transcribing, reading and re-reading the observations, following the steps recommended by the method: coding, categorization, integration and description of categories.⁽⁴⁾ The observations described in the text were identified by the initials ON, for “observation note”, and a numerical sequence (NO1, NO2, ...), aiming to maintain the participants’ anonymity.

The research project received approval from the Ethics and Research Committee of the Federal University of São Paulo, Protocol 517.749/14, and the participants signed the Informed Consent Form. At the end of the data collection, the results were returned to the chief nursing officers of the institutions.

Results

The interactions of the nursing technicians with the relatives of the hospitalized patients were limited regarding the use of the premises of Patient and Family-Centered Care and the compliance with the recommendations of the Ethics Code of Nursing Professionals, as described in the categories, named in accordance with the theoretical frameworks.

Not treating family members with respect and dignity

The nursing technicians showed disrespect by not valuing the requests of the accompanying family members, including those related to the patient’s comfort, focusing their priority on the preparation of the medication, in addition to complaining that the companions complained too much, which was very tiring.

While preparing the medication, two nursing technicians talk about the companion, that he complains too much: bathroom that is dirty, snack that did not come, lack of water to drink. One of them says, “This is very tiring, so much medication to prepare, and I have to stop to listen to complaints” (NO1).

An elderly bedridden patient’s companion goes to the nursing station and asks for a diaper change. Two nursing techniques exchange glances with indignation, go to the room, find the patient and verify that the sheet is all wet. They look at the companion and say that the priority is the medication, because there are few employees and cannot change the patient all the time. One of them looks at the companion and says: this time I’ll change her, but you’ll have to give me a “hand”; the other leaves the room. [...] The technician removes the entire sheet, leaving the patient exposed and the companion helps to change the diaper (NO3).

The disrespect was also observed when the professionals interrupted the visiting hours to perform the patient’s bath, asking the companion to leave the room, while the relatives who arrived were forbidden to enter. They also blamed the relatives for not bringing a towel to dry the patient, even though the latter informed that they did not know about this need. Furthermore, they left the patient’s body partially exposed in the hallway after bathing, causing an expression of dislike in the family.

During visiting hours, two nursing technicians enter the room to bathe a patient, asking their companion to wait in the hallway; relatives who are arriving for the visit are forbidden to enter. [...] After some time, a technician appears in the hallway, telling the other that he needs a sheet to dry the patient and, looking at the family, says that this is happening because no one brought him a towel. Relatives say they did not know. Some time later, the technician appears in the hallway with the patient in a bath chair, covered by a sheet, but his gluteus is exposed, and the relatives look at each other with displeasure. [...] The family is waiting in the hallway, complaining about the delay and saying that they will have the right to stay longer than visiting hours (NO8).

Other observations also denoted the nursing technicians’ lack of dignity and respect for family members, who did not seem to perceive the presence of the patient and his or her companions during the procedures; during the patient’s admission to the unit, they acted as if the family member were invisible; informed, incisive and disrespectfully, that the companion could not stay on the bed; and set rules for the family member, determining that he could not leave the room, blaming him for problems with the patient.

Nursing technician enters the room to perform bed bath. She takes off all the patient’s clothes, exposing her, starts throwing water with a plastic bottle and soaping her entire body. [...] The patient beside her, a young woman, and her accompanying grandmother, look with indignation and turn their faces. After a while, they look again, the first covers her face with the sheet and the other turns her face to the wall (NO7).

Two nursing techniques receive an elder elderly patient from the intensive care unit, accompanied by her granddaughter. She is not speaking at all, but her expression is frightened and she is paying attention to every movement. The technicians put the patient in bed and leave (NO4).

Patient and her two children talk, sitting on the bed. Two nursing technicians pass through the corridor, they look into the room, they exchange glances with indignation and one says to the other: “- Handle this!” She replies: “Leave it to me”. She enters the room and says in an incisive and sharp voice: “They can get off the bed, they are bringing ‘bugs’ to the patient and taking ‘bugs’ to the street.” The other technician is in the corridor watching her colleague communicate with the relatives, laughing (NO5).

Nursing technician enters the room to perform a procedure. The companion informs that the patient is calm. The technician answers: “At night he was agitated and had to be restricted; all this happened because you were not here”. The companion changes her facial expression, seemingly not understanding what happened and says she has been in the hospital all the time. The technician looks at her and says sharply, “You cannot leave here, do you understand?” She ends the procedure and leaves the room (NO2).

Despite the countless observations that showed disrespect for family members, a situation was observed in which a nursing technician demonstrated respect for the patient’s privacy, explaining to the family member how the procedure would be performed.

Nursing technician enters the room to give a bedridden patient a bed bath. She greets the patient and the companion, explains how the procedure will be performed, the importance of her privacy and asks him to wait in the hallway. Afterwards, she raises a paper towel to close off the door glass [...] and asks the patient for permission when washing her private parts (NO9).

Not sharing information with family members

The nursing technician communicated little or shared little information with the family. Communication merely served to ask about the patient’s condition. When asked by the companions about the performance of procedures the patient would be submitted to, he restricted himself to answering only what was necessary or answered nothing.

Nursing technician enters the room, looks at the newly admitted patient and asks his granddaughter: “were both of her legs amputated”? Granddaughter answers yes. Technician nods, says “hum!” and leaves the room (NO4).

Nursing technician enters the room, bringing a vacuum cleaner, without saying a word. The companion follows her with her head, and when she is leaving the room, she asks if this is for her patient. The technician says yes and starts closing the door. The companion again asks if it is in the lung, the answer is yes and then the technician goes away. [...] Technician returns bringing material for puncture. Companion gets up, mentioning a question, but the professional does not look at her, leaves the material and leaves (NO3).

Not negotiating on how to participate and collaborate in the care provision

The nursing technician did not negotiate on the care provision with the family members, assigning them responsibilities, even when they did not have the skills to perform the procedure that was determined.

In the bathroom of the ward, the nursing technician asks the daughter of a patient if she knows how to bathe and she answers negatively. The technician tells the daughter to bathe the patient in the shower in a bath chair and returns to the bedroom, leaving them in the bathroom while she arranges another patient’s bed. The daughter, with difficulty, manages to put on the gloves, tries to bathe her mother and, after drying her, takes her to the bedroom. The technician looks at the floor, sees a little stool, looks displeased, picks up the towel and says to the daughter in an imposing tone: “-Clean her!” (Referring to the patient). The daughter tries but is unable to clean her properly. The technician takes the diaper, asks the daughter to hold the mother, who does not stand without help, and puts on the diaper without completing the hygiene; puts the patient in bed, dresses her and covers her with the sheet [...]. Before leaving, the technician asks the daughter for the patient’s name. She responds and the technician leaves (NO6).

Discussion

This research was limited to studying a specific scenario. Thus, it is recommended that further studies be undertaken to broaden the understanding of the teaching and knowledge of the nursing technician on Patient and Family-Centered Care and the Ethics Code of Nursing Professionals in different care settings.

The analysis of the observations revealed that the nursing technicians value the performance of procedures, especially medication, higher than listening to the requests of family members as, often, the professional does not even perceive their presence, as if they were invisible. The absence of communication and the non-sharing of information between the technician and the relatives were also observed. Even when family members asked, the professional often did not respond or did so laconically.

Professionals should change their practices and take positions to care for their family members with dignity and respect, listening and respecting their choices and perspectives, so that their knowledge, values, beliefs and culture are incorporated into caregiving.^(1,2,8) Nurses have the skills to develop, together with their team, awareness and training on the subject. To do so, they need to find themselves prepared to deal with the family member’s insertion in the care and, if this does not happen, one should seek training on family care and professional ethics.

With regard to the lack of communication and information sharing with family members, the professionals presented difficulties, possibly out of fear of sentimal relations or out of lack of preparation to face certain situations.⁽⁹⁾

During the hospitalization process, family members have many doubts and turn to the caregiver to obtain information, in order to get clarity about the actual situation and find comfort. How this information is transmitted, whether in a hurry or tactlessly, depends on the sensitivity of the professional.⁽¹⁰⁾ This situation shows a worrisome care scenario, as the professionals need to establish more respectful, sincere and loving communication, improving the interactions between the technician and the family.

Professionals are responsible for transmitting information in an objective and accessible manner, clode to the family members’ reality,⁽¹¹⁾ informing about their rights, risks, benefits and problems related to the care practice, with the purpose of having them participate in the care.^(1,2)

To do so, it is necessary for the nursing technicians to develop the ability to communicate with the patients and their families, which takes place during the care because, at this moment, the professionals should be encouraged to reflect on their own actions, behaviors, values and beliefs.⁽¹²⁾ In this sense, communication plays a fundamental role in the interactions between people as it is how we demonstrate our thoughts, will and attitudes.⁽¹³⁾

Regarding the negotiation about the participation and collaboration of family members in care provision, this situation was not observed, as the nursing technician assigned them responsibilities to take care of the patient, regardless of their desire or the ability to do so. According to the assumptions of Family-Centered Care, families should be encouraged and supported to participate in care and in free and informed decision making, choosing their level of action and collaborating in the development, implementation and evaluation of policies and programs, in facilitating health care, in vocational education and care provision.⁽²⁾

The family needs to be seen as an important partner in the care, fundamental in relieving the patient’s suffering and anguish, being able to perform technical procedures of low complexity, after training, which is important for the continuity of care after hospital discharge. Reflection is due on the use of family members as substitutes for the nursing workforce though,⁽¹⁴⁾ emphasizing that, according to the Ethics Code of Nursing Professionals, it is prohibited to delegate the tasks of nursing professionals to family members.⁽¹⁾

On the other hand, the large number of bedridden patients and the lack of professional can be the reason for the transfer of care to the family members and for the impossibility to offer proper care to the patients and their relatives.⁽³⁾ The professional, who often were not trained for this approach during their vocational courses and along their professional trajectory, cannot be held responsible for the scenario that was observed.

The professionals need to broaden their view on the family members’ tasks in care, as their inclusion in care depends exclusively on contact and communication and should be pleasant for all stakeholders.⁽¹⁴⁾ In short, the patient should not be considered as the sole focus of care, also including the family, aiming for the best way to welcome family members and include them in nursing care as a care unit.^(15,16)

Conclusion

The interactions observed between the nursing technicians and the family members were limited with respect to care for the family and the ethical conducts. The teaching and health institutions need to adopt a distinguished perspective when educating and training these professionals on the theme “family” and the ethical-professional conduct, contributing to high-quality, ethical and solidary care.

Referências

• ¹
  Conselho Federal de Enfermagem (COFEN). Resolução COFEN nº 0564/2017. Aprova novo Código de Ética dos Profissionais de Enfermagem [Internet]. Brasília (DF): Diário Oficial da União; 2017[citado 2018 Mai 30]. Disponível em: http://www.cofen.gov.br/resolucao-cofen-no-5642017_59145.html
  » http://www.cofen.gov.br/resolucao-cofen-no-5642017_59145.html
• ²
  Institute for Patient- and Family-Centered Care. Advancing the practice of patient- and family-centered care in hospitals: how to get started… [Internet]. Bethesda, MD: Institute for Patient and Family - Centered Care; 2017 [cited 2018 May 30]. Available from: http://www.ipfcc.org/resources/getting_started.pdf
  » http://www.ipfcc.org/resources/getting_started.pdf
• ³
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Publication Dates

• Publication in this collection
  Jul-Aug 2018

History

• Received
  6 Apr 2018
• Accepted
  30 July 2018