Dialectic feelings of the intensive care nurse about the work in Intensive Care

Abstracts

Objective:

To identify the perception of intensive care nurses about the work on the scene of Intensive Care and discuss motivating factors of intensive care nurses stay in their work in Intensive Care.

Methods:

This research of qualitative and descriptive character, its object is the perception of the intensive care nurses about the work in the Intensive Care Unit (ICU). The research was developed in a private Intensive Care Unit from Rio de Janeiro with ten nurses. The technique of data collection was the semi-structured interview, which took place from June to August 2008. We used content analysis to process the data.

Results:

The results showed that intensive nurse has affinity with technologies and likes direct patient care. It was found that there are aspects that result in pleasure and pain in that work, which reveals a dialectical perception of this productive activity.

Conclusion:

It was concluded that this work is predominantly pleasure factor for nurses due to the status that the sector occupies in the hospital environment.

Occupational Health; Work; Nursing; Intensive Care

Objetivo:

Identificar a percepção dos enfermeiros intensivistas sobre o trabalho no cenário da Terapia Intensiva e discutir fatores motivadores da permanência no trabalho em Terapia Intensiva.

Métodos:

A presente pesquisa, de caráter qualitativo-descritivo, tem como objeto a percepção do enfermeiro intensivista sobre o trabalho numa Unidade de Terapia Intensiva (UTI). A pesquisa desenvolveu-se numa UTI particular do Rio de Janeiro com dez enfermeiros. A técnica de coleta foi a entrevista semiestruturada, ocorrida de junho a agosto de 2008. Utilizou-se da análise de conteúdo para tratar os dados.

Resultados:

Os resultados revelaram que o enfermeiro intensivista tem afinidade com tecnologia dura e gosta do cuidado direto ao paciente. Verificou-se que há aspectos que resultam em prazer e sofrimento, o que revela uma percepção dialética sobre o trabalho.

Conclusão:

Concluiu-se que este trabalho é, predominantemente, fator de prazer para os enfermeiros devido ao status que o setor ocupa no ambiente hospitalar.

Saúde do Trabalhador; Trabalho; Enfermagem; Terapia Intensiva

Objetivo:

Identificar la percepción de los enfermeros intensivistas sobre el trabajo en una unidad de cuidados intensivos y discutir los factores motivadores de la permanencia del trabajo en Terapia Intensiva.

Métodos:

Investigación cualitativa y descriptiva, que tiene con objeto la percepción del enfermero intensivista sobre el trabajo en una Unidad de Cuidados Intensivos (UCI). La investigación se desarrolla en un hospital privado de Rio de Janeiro, con 10 enfermeros. La técnica de recolección de datos fue la entrevista semiestructurada, realizada entre junio y agosto de 2008.

Resultados:

Los enfermeros intensivistas tienen afinidad con la tecnología dura y les gusta la atención directa al paciente. Se constató que hay aspectos que resultan en el placer y en el dolor, lo que revela una percepción dialéctica del trabajo.

Conclusión:

Este trabajo es, predominantemente, factor de placer para los enfermeros debido a la condición de que el sector ocupa en el medio hospitalario.

Salud Ocupacional; Trabajo; Enfermería; Cuidados Intensivos

INTRODUCTION

The objective of this study is the perception of intensive care nurses about working in Intensive Care Units (ICU). This objective appears as an excerpt of the dissertation defended at the Faculty of Nursing at the University of Rio de Janeiro State, in the year 2009¹.

This work can be defined as "activity resulting from expenditure of physical and mental energy, directly or indirectly towards the production of goods and services thereby contributing to the reproduction of the human individual and collective life"^2:341. Despite of this definition be relevant, it is believed that the category labeled "work" also encompasses the inventiveness, the ability to review and judgment of subjective mobilizations to perform the task, combining cognitive, motor and psychological potential in a continuous and dynamic process³.

In this perspective, the work interferes with various dimensions of social life. Such human activity affects the social, economic, political, cultural sphere, occupying centrality in the life of contemporary society. The work, occupying central role in contemporary society, also changes the health/disease process of others, resulting in promoting health or disease.

In the current context, the work is shaping up as a painful activity and causing mental suffering to a multitude of workers and/or professional groups. From the advent of neoliberalism and globalization, it appears that the worker should be multipurpose and multifunctional. With this, the work pace has become increasingly intense; subtracting the worker's labor breaks; working conditions, especially in the context of public service, they are increasingly precarious, noting a lack of resources, human and material, and forms of employment of the worker or guarantee their rights or ensure job stability⁴.

Moreover, the new technology in the work have required increasingly psycho-cognitive ability of workers; quick judgment and decision making and resilience to unanticipated and variability of the labor process. Moreover, technology awakens the workers fascination, fear, stimulus to learn and similar sensations to the beginner or novice faced with new and unusual situations⁵. These factors also combine to raise the painfulness at work.

Thus, occupational stress is a reality observed in several areas and sectors of work, not exclusive of professionals active senior positions in large institution; occupational stress is then indifferent to the hierarchical level where they are, since it is directly related to responsibilities, collections, work pressure, competitiveness, and day of hard work, among other features of globalization and neoliberal capitalism⁶.

In the hospital sector, especially in intensive care units with the centralization of material and human resources with high quality standards (which allows for prompt and effective care), the stress affects the nurse to find in performing their activities a constant expectation regarding emergencies and emergency calls. Besides often experience, work situations are characterized by variability, uncertainties and contingencies⁷. Through this, for the goal of the work being achieved, it is necessary to make adjustments in the execution of tasks, adapting to the real working conditions and such situation is characterized as stressful for many of these professionals⁸.

It is undeniable that among the prescribed work (task) and real work (work activity), there's a gap caused by unforeseen or unanticipated by the organization of work. This distance is defined as 'variability', ie, a set of variations that may occur, normal or incidentally, randomly or not, both in production and in service delivery or between workers^8,9.

The work process is made by the appropriate activity to an end (the work itself), the object of work (a matter on which the job applies) and the means of labor (tools used)¹⁰.

Extending this composition, it was found that the organization of work goes through the division of labor as well as the division of men. That is because, with the division of labor, prescribing the cadences, the offices of activities and actions, in short, the experimental procedure, yielding hierarchies, controls, power relationships, responsibilities, then featuring the men's division¹⁰.

Work situations are usually marked by unforeseen variability of uncertainties, making a simple non-existent man-task, in which the restricted to the rules of organization of work prescribed obedience does not ensure the desired reliability of the service performed. Thus, in order to reach the main goal, it is often necessary to adjust the prescribed task, making the implementation of the most dynamic and efficient work. These adaptations are identified as the real work¹⁰. For a better understanding of the human-task interface and its impact on employee health and productivity, ergonomics drafted the aforementioned concept of 'variability'.

Situations of variability in the intensive care nurses work are many and are related to the following situations: (i) the interdependence of nursing work with the medical treatment; (ii) the worsening of the clinical condition of customers; (iii) the need to provide and operate diagnostic tests to customers who change their health situation; (iv) lack of effectiveness in the way it establishes communication between the professionals who make up the multidisciplinary team, (v) the constant introduction of new technologies in the ICU; and (vi) the mediating task Nurse between doctors, clients and staff of nursing staff⁷, among physicians, customers and team nursing technicians⁷.

The variability negatively alter the health and illness of nurses working in intensive care process, generating various negative consequences, as irritability, high blood pressure, fatigue, pain, muscle tension, stress and premature aging. However, despite the negative effects on their health, many critical care nurses remains active in the work environment⁷.

Thus, it was considered important to investigate the perception that the intensive care nurse has about their working reality within the context of Intensive Care, which is evident in a complex, dynamic and changing character, resulting in the constant need for nurses to readjust and overcome many adversities.

From the scored problematic, are presented as objectives: a) to identify the perception of intensive care nurses about the work in the setting of Intensive Care; b) discuss motivating factors of nurses stay on the job in Intensive Care.

METHODOLOGY

This research is qualitative and descriptive approach, developed in the Intensive Care Unit of a Hospital of private health network, located in the municipality of Rio de Janeiro.

The criteria for choosing this scenario was due to the fact of the need to collect information in a location that was recommended by the Ministry of Health (MOH) standards. Thus, it is reported that the ICU chosen is nationally recognized for excellence in service to its clients and by conducting innovative research of great interest to the scientific community. Thus, the choice for this ICU was deliberate because it was important to collect the information in a place where there was good working with a number of staff and adequate equipment to perform the task, and that the situations were indeed variability arising from how they do not establish the organization and work process and infrastructure issues.

The subjects were ten intensive care nurses, three men and seven women in the full exercise of professional activities, acting in this ICU for at least a year. The criteria of choice over the operating time of nurses was on the concern that these nurses had already seized the labor reality, having a consistent view of the organization and work process. The operating time of the professionals interviewed was at least three years and maximum of 19 years. It was also a criterion for inclusion of subjects in the aspect of volunteering their own free acceptance and availability of time to provide the information.

The technique of data collection was the semi-structured interview consisting of the following questions: 1) How long have you act in Intensive Care?; 2) How was your entrance in the context of Intensive Care; 3) What is significance of this work for you?; 4) Do you feel motivated to start your workday?; 5) What factors motivate your stay in the Intensive Care; 6) Have you ever needed medical leave during the time working in Intensive Care?; 7) To what factors do you attribute to maintaining your health on the dynamics of working in Intensive Care?.

The interview was applied in the period of June to August 2008. To maintain the anonymity of the subjects, we used an encoding for each interview, aiming to prevent any connection between the content of the interviews and the subjects in the descriptions of the reports contained in the results. Therefore, as the interviews were transcribed, they were given the code of I1, I2, I3 and so on, following a chronological order in which the transcripts of the interviews were recorded. The interviews were recorded in microcassette tape. During the interview, notes were made in the field diary relating to facial expression, posture, gestures, silent periods, rhythm, tone, emphasis and intonations in speech, as well as apparent emotions and feelings.

Finally, the scale of resilience with the subjects themselves reading and noting the questions was applied. The scale developed by resilience is one of the few instruments used to measure levels of positive psychosocial adjustment in view of major life events. It contains 25 items described positively with Likert type response ranging from 1 (strongly disagree) to 7 (strongly agree). Scale scores ranging 25-175 points, with higher values indicating high resilience¹¹.

The data were analyzed and interpreted according to the content analysis, which is characterized by the organization of information through phases or stages, leading to a structured and organized results of the content. After transcribing and reading the responses, with identification of the meanings, it was proceeded to the codification of the reporting units to identify and discuss the issues contained in the records for the construction of the logical framework of thought of the subject, resulting in the construction of the following categories of analysis:

- Profile of nurses to work in the Intensive Care;

- Pain and pleasure: the dialectical feelings of the intensive care nurse.

The project was submitted to the Ethics Committee in Research (CEP) of the hospital where the research was carried out, obtaining assent to the development of the research protocol number 255.

RESULTS AND DATA DISCUSSION

Category 1 - Profile of nurses to work in the Intensive Care

In this category, we discuss the aspects inherent to the intensive care nurse´s profile, on the requirements from their labor dynamics, fraught with situations of variability, that require the professional´s constant mobilization of their psycho-cognitive capabilities to execute their activities for seriously ill patients and in risk of death.

A major challenge of human resource management is the allocation of individuals in sectors whose psycho-cognitive demand service is compatible with the characteristics of the worker and professional and personal aspirations. This action is important because of the need to maintain a healthy work environment, which encourages the development of creativity, talent, motivation and job satisfaction. This action also enables the improvement of productivity and quality of the care provided and the promotion of workers' health. In this perspective, we seized the subjects' discourse a personal and professional profile of the intensive care nurse, as shown below:

There are different profiles, right? I think there are a lot profiles. Some people have no profile for it! [...] You do what you like, really, because you like, especially here in Intensive Care [...] (I8).

From this report, it became clear that in order to keep the work environment of the ICU, it is important for nurses to have affinity with hard technology and who likes to perform complex procedures and nursing care of critically ill patients, in addition to skill for judgments and taken quick and effective decisions.

To perform this work context of high complexity, it is also necessary that nurses wish to be constantly empowering and sometimes adapting their theoretical-scientific and practical knowledge to be inserted and stay in the reality of the assistance to be given¹², as the following statement:

We have a lot of knowledge, we have to study a lot, we have to understand some needs of that one who does not speak, but they transmit signals or sounds when he can, if not only signals: a modified frequency, a sweating... see what all this means. (I6).

In intensive care, technological change is constant and requires training and continuous professional development, specialized and familiar with existing technological devices in these units. Moreover, it requires thorough knowledge about the diseases most commonly associated with assisted customers to be possible full and intensive care of the patients¹³.

The ideal of these professionals to work closely with patients providing direct assistance in coping with complex, variable and unpredictable situations, dealing with the limits between life and death, is reaffirmed when they have the opportunity to work in an institution where there are working conditions and favorable infrastructural incentives for the development of working activities with quality.

I learned everything I learned here. My school was here. [...] I fell in love. I fell in love because it is hard not to fall in love with this hospital, which gives all of us growing conditions: quality training, material and human resources. (I2).

Given the inherent characteristics of the ICU, teamwork becomes crucial. Thus, besides the function of labor dynamics of the Unit, the nurse assumes the role of a link between the patient and the multidisciplinary team, a mediator of interpersonal relationships in the workplace. And, with this, it is important they carry, beyond the essential theoretical background, leadership skills, insight, initiative, teaching ability, maturity and emotional stability¹⁴.

Even being a nurse on duty, we led a team. So we have some responsibilities with the team, with the technical, the issue of authority. We need to do this to keep the organization, to maintain order. (I3).

The technical and scientific instrumentation is essential for the development of care initiatives in the intensive care environment. Thus, a structure of education and in-service training is also essential for professional development factor, ensuring the quality of care provided to critically ill patients¹².

In this sense, associated with the aspect of leadership, the profile for teaching is also present in this set and appears in the statements such as the following excerpt from the speech of one of the subjects of this study:

In the second year I came here, I've been invited to also compose the staff of Continuing Education, because I already had leadership profile for teaching, innate in me. I´ve been in this path of teaching within the practice that made me study hard, it makes me even study harder! It has a research yet, of course with less intensity than when you're younger. What is natural. (I9).

With regard to training and upgrading, the intensive care nurse must have the ongoing commitment to their own professional development as well as being able to perform in educational remaining team of healthcare processes favoring mutual benefit among professionals. Added to this, they should be responsible for the process of education in the health of individuals and families in their care, contributing to the qualification of professional practice, building new habits and inadequate demystifying concepts assigned to ICU¹⁴.

We have to keep working and working from home, studying, because the commitment is great with patients, family members and with help to the professional growth of other coworkers. (I5).

When we report to all the activities developed by intensive care nurses, we can see that there are job requirements involving care, education and administrative activities. On the one hand, it refers to the thought that these characteristics of labor dynamics, fraught with complex situations and variability, could result in damage to the health of the worker. The need for continuous raising psycho-cognitive and their motor skills would be high workload and thus psychophysical wear factor. However, it was possible to understand that these same situations are considered stressful for these nurses identifying as characteristics that favor their professional achievement, to be compatible with their personal and professional identity, ie, are factors that give pleasure and satisfaction.

This dialectic situation involving characteristics of the work context in the ICU, with risk factors for psychophysical suffering of workers and personal and professional profile of nurses who can derive pleasure from an activity that has a high potential for suffering, will be addressed in the category below.

Category 2 - Pain and pleasure: the dialectical feelings of the intensive care nurse in the Intensive Care work

This category of analysis discusses the relationship between nurses and their working reality in ICU, emphasizing a dialectical perception of this work, in which feelings of pleasure and pain emerge, merging as two sides of a sheet of paper in order to characterize and understand what they think about the process and work organization in intensive care.

The pleasure-pain results from subjective relations between workers and their work, as well as inter-subjectivity experienced in interpersonal relationships and organizational values responsible for defining specific types of workers experience their work and share their social, emotional and professional relationships in the organizational context¹⁵.

In Intensive Care, nursing work is permeated with complex situations arising from the inherent characteristics of this scenario. AUTI, being a dynamic work space for working in it, has great movement of personnel, use of technology, high level of current knowledge, intense pace of work and constant ability to deal with emergencies and death. The labor organization puts nurses in situations of variability which demand continuous mobilization psycho-cognitive and motor potential for regulating the activity toward the concreteness of the task. So such scenario is configured as an environment that focuses a high psychic load¹².

This particular complexity of intensive care nurses appear in reports as generating psychophysical stress and wear.

The Intensive Care stressed people, the staff, the demand. Ah, it is very demanding! The degree of responsibility we assume. You assume and when you see, you took a number of things and then your health is going, going, going, going. Here there are many tasks, many things! Each day increases a point, I mean, the degree of responsibility! We see almost everything at the same time! (I9).

The nurses in the ICU is responsible for patient care in both emergency cases as in cases of life support. For this, these professionals must be able to care for all patients, independent of their diagnosis and clinical context, broadly, integrated and continuous with members of the healthcare team, using critical thinking, analyzing problems and finding solutions to them. This approach ensures a practice within the ethical and bioethical principles of their profession. Thus, the nurse must evaluate, organize and decide the appropriate use of human, physical, material and information resources in the care of critically ill patients, aiming teamwork, effectiveness and cost-effectiveness¹⁴.

This responsibility carries with distress and suffering at work, as it appears in the passage of one of the statements given below, in which the subject of the study reveals the emotional distress they feel in carrying out their work.

People are getting older, sicker, the treatment is prolonged. [...] We never know what we are doing. If we are making a futility, prolonging the suffering of the person. If we are doing things, working like crazy during the day to the end of the day the patient died and all that was in vain. Or, if it really has to be done, whether it is worth, even if it has to invest, you understand? It has these two sides. This is my challenge and that I participate in my daily life. Nowadays, I think so. [...] We see that by age, by comorbidities, that everything we're doing here is... unnecessary! This is really a trouble. (I2).

The ICU was created and developed to assist patients in critical condition and offer them an immediate, intensive and comprehensive care, which would enable the restoration of health of these patients, saving their lives¹⁶. However, while technological resources related to advanced life support in the ICU are available, it is not always possible to achieve this greatest objective, saving lives. Death can be delayed, but it is inevitable and therefore occur.

Some professionals may deceive with the technological advancement of care, missing the critical sense, which results in prolonging the suffering of the patient, the family and even the professional himself, who is frustrated due to the high level of expectation arising, perhaps, from his omnipotence. When the result of a prolonged treatment is positive for the patient's recovery to continue this care is commendable, but if its result is weak, the decision for its continuation is questionable¹⁷.

The work is an expression of freedom, humanity, and therefore the origin of many accomplishments. To be understood only as a sample of productivity and benefit to the organization, the worker is degraded for not satisfying, going to have a continuous wear with the possibility of having more pain than pleasure in their activities¹⁷.

Some days you arrive and physical fatigue joint with all these factors, you get very tired! And you're wondering why you chose to be a nurse, the nurse pays for everything, everything is the nurse... but it is normal from human being! (I8).

Suffering and pleasure at work shows a plan that creation involves the collective experience with the self and the other. This is taking the work as a human activity, especially it is a continuous process of renormalization, invention of new rules, new problems¹⁸.

Dialectically to feelings of distress, there are situations that generate pleasure in nurses, as the possibility of intervention and promoting patient recovery, constant learning, professional development and institutional recognition.

This work has great meaning! Because you deal with a critical patient and see that patients go out so lucid. One patient was all complicated, in a coma, and this patient start talking to you... it's a very big return that you have! [...] A large part of them goes out thanking us! This is very rewarding! (I1).

Critical care nurses feel more valued than other nurses because of the opportunity to exercise direct care to patients and can manipulate this specific technology scenario¹². These professionals dominate the technological devices, have different training and further training, provide direct patient care and work in a location that provides adequate material resources, besides feeling that dominate the "divine forces". All this translates into a high self-esteem; so this is a context that enables the emergence of pleasure. In the following report it is possible to show this analysis:

In intensive care is where I feel most nurse. I think care is closer to the patient. I think we better do our tasks, we play our role better. I like to stay close to the patient. I love to severe ill. And the things of intensive care, these respirators, the thousands of medications, the instability, the severity of the patient and his recovery. Here is where I feel fulfilled professionally. It is here that I feel real nurse. I feel close to God and working for Him (I3).

Although the work causes wear, if considerable efforts are recognized and valued, the employee understands that his effort was not in vain and believes in his contribution to the organization as well as for himself.

No entanto, caso isso não seja percebido pelos outros, pode então ser desencadeado o sentimento de sofrimento ao invés de sentimento de prazer¹⁷.

However, if the others do not perceive that, may then be triggered feelings of distress rather than feeling of pleasure¹⁷.

CONCLUSION

Thinking on the meaning of the professional practice for nurses in Intensive Care, it is concluded that they present contradictory perceptions. The same characteristics identified as precursors factors of distress were also cited as justification for the extent of the pleasure. Thus, pleasure and suffering, frustration and joy, motivation and demotivation, satisfaction and dissatisfaction are joined as two sides of the same coin, so that one does not exist without the other, and these contradictions important for maintaining both mental health nurses as the professional identity with their work activities.

In this perspective, it is important to remember that the work always brings some degree of pain for the worker, because it is conceived and executed by some other, conflicting with personal desires and longing of the workers. Thus, the work also is never neutral in relation to the subjectivity of the people and not in relation to the health-disease process.

Thus, the subjects showed dialectical perceptions about working in the ICU. Then, on one hand the feeling of pleasure is bound (i) helping in the recovery of a critically ill patient, (ii) to manipulate hard technologies, (iii) the ability to think quickly on the variability of work in the ICU (iv) the need to continue training and (v) the acknowledgment by the patients and families in the work developed.

However, on the other hand there are also negative perceptions regarding work in this scenario, which bring out suffering feelings. The feeling of suffering arises, among other reasons, lack of recognition of the organization labor in relation to efforts made to put an end of the task by the great responsibility placed on nurses and the psycho-cognitive disengaged to care for critically ill patients.

It appeared that the work in this ICU is proud and elevated self-esteem of nurses factor because there is a culture established in the profession and in the hospital setting that reinforces the deuterium workers are professionals with a distinctive and sophisticated profile. There is the perception they dominate the hard technology, deal with variability, make decisions quickly and have a high capacity to instrumentalize them to care for critically ill patients.

Such situations are characterized as motivating factors for nurses stay in employment scenario; Another factor for nurses to remain in that environment is operfil personal and professional subjects, which is under immediate compliance with labor demands in that ICU.

Finishing this article, it is worth noting that these results are relevant to that scenario, in that time of collection and the group of professionals who were the subjects of the study. However, it is important to note that, depending on the characteristics of work organization-which can change according to economic and political interests of the moment, the identity of professionals with work in relation to productive activity performed, the predominantly positive perception, perceived in this study, may change, resulting in more pain than pleasure. Thus, it should emphasizes, once again, the dynamics of the working world and the variability that are vulnerable, so as the "natural" contradictions that pervade this universe.

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Publication Dates

• Publication in this collection
  Jul-Sep 2014

History

• Received
  17 July 2013
• Reviewed
  04 Apr 2014
• Accepted
  23 Apr 2014