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Print version ISSN 0080-6234
Rev. esc. enferm. USP vol.42 no.4 São Paulo Dec. 2008
The meaning of the nursing process for nurses at intensive therapy units: an interactionist approach*
Significado del proceso de enfermería para enfermeros de una unidad de cuidados intensivos: un enfoque interactivo
Albertisa Rodrigues AlvesI; Consuelo Helena Aires de Freitas LopesII; Maria Salete Bessa JorgeIII
Master. ICU nurse of Hospital Geral de Fortaleza (HGF). Professor at Faculdade
Católica Rainha do Sertão. Fortaleza, CE, Brazil. firstname.lastname@example.org
IINurse. PhD. Professor at State University of Ceará (UECE). Coordinator of the Master's Degree Course on Clinical Healthcare and the Nursing Concentration area at State University of Ceará (UECE). Fortaleza, CE, Brazil. email@example.com
IIINurse, PhD. Professor at State University of Ceará (UECE). Leader of Grupo de Pesquisa Saúde Mental, Família, Práticas de Saúde e Enfermagem (Research Group on Mental Health, Family, Health Practices and Nursing) . CNPq researcher. Fortaleza, CE, Brazil. firstname.lastname@example.org
The study aimed at comprehending the meaning of the Nursing Process practice for nurses in an intensive care unit. Symbolic interactionism and thematic analysis were used as the theoretical-methodological reference. Seven nurses from an intensive care unit who experience this practice in a public hospital in the city of Fortaleza, Ceará were part of the study. Data collection was performed from May 1st to August 30th, 2006, using participative observation and semi-structured interviews. The results show the social interaction of the nurses with other professionals, the meanings of the nursing process and opinions for improving the ICU. The comprehension of the nurses' experiences allowed for the recognition that their experiences are contradictory and the meanings are manifested and expressed through self-interaction and interaction with other people.
Key Words: Nursing process. Intensive Care Units. Interpersonal relations.
El estudio tuvo como objetivo comprender el significado de la práctica del Proceso de Enfermería según enfermeros de una unidad de cuidados intensivos. Utilizamos la interacción simbólica y el análisis temático como referencial teórico metodológico. Fueron parte del estudio siete enfermeros de la unidad de cuidados intensivos, quienes son parte de esta práctica en un hospital público de la ciudad de Fortaleza, Ceará. La recolección fue realizada durante el 01 de mayo al 30 de agosto del 2006, a través de la observación participativa y la entrevista semiestructurada. Los resultados mostraron la interacción social de los enfermeros con los demás profesionales, los significados del proceso de enfermería y las opiniones para mejorar la atención en la UCI. Comprender la experiencia de los enfermeros permitió reconocer que las vivencias son contradictorias y los significados son manifestados y expresados a través de la auto-interacción e interacción con otras personas.
Descriptores: Procesosde enfermería. Unidades de Terapia Intensiva. Relaciones interpersonales.
The Nursing Process is worth noting among nursing technologies since, as a work methodology, it offers directives for developing nursing healthcare based on the scientific method, whose purpose is to identify the human necessities of the client and implement the adequate nursing therapy(1-2).
In practice, we have observed difficulties for the application of the Nursing Process, and even its non-applicability, since actions are centered uniquely on common sense, without any type of planning and, consequently, making it difficult to use logical reasoning associated to scientific foundations to develop actions that can be studied, discussed and proven in the nursing science. This is one of the aspects that have hindered the growth of nursing scientificity.
Nowadays, the Nursing Process is named systematization of nursing care, nursing care methodology or process of caring(3), and it is constituted of five inter-related stages (investigation, diagnosis, planning, implementation and evaluation) in a systematic and dynamic way so as to promote humanized, directed and result-oriented care, added to its low cost(4).
In the development of nursing theories, the focus of nursing care is the person, considered a bio-psycho-socio-spiritual being in some, beyond the biomedical model which focuses its action on the disease(5). However, in clinical practice, we observe that actions are still fragmented, based on signs and symptoms of a disease whose cure permeates the responses to the service demands, and are not always centered on satisfying the necessities of the person who is there to receive care.
Therefore, we understand that the application of the Nursing Process has been hampered by other difficulties, with a task-centered care being prevalent in clinical practice. This results in automated and bureaucratic actions, whose priority is the accomplishment of tasks instead of patient-centered care. Besides, the Nursing Process is a strategy and work instrument of the nurse, and not an end in and of itself. Without this comprehension, the nurse will only execute another task.
For almost 20 years, we have developed the Nursing Process in healthcare at a public hospital ICU, which was based on the basic human necessities according to Maslow's theory of human motivations and João Mohana's classification, contemplated in Wanda de Aguiar Horta's Theory of Basic Human Necessities.
Since this theoretical proposal is constituted by a holistic and comprehensive view of the human being, we have perceived that, in practice, our actions are still fragmented, based on signs and symptoms of the disease, whose resolution permeates the responses to the service demands and are not always centered on patient satisfaction, even though they may be biological. We observe that the Nursing Process has become another bureaucratic task to be executed and, as such, we understand the importance of permanently evaluating its practice.
Thus, by seeking to comprehend what the development of the Nursing Process means for the nurses, how it works based on this meaning and how the nurse relates with other people regarding this practice in the daily routine of intensive care, we developed the study, using Symbolic Interactionism as a reference framework. Therefore, the present study aimed to understand the meaning of the Nursing Process practice for nurses in intensive therapy units.
Symbolic Interactionism, successfully used in Nursing, was chosen as a theoretical reference framework because it is a theory in which the meaning is the core concept, where the theoretical propositions happen based on the interaction of people within the social structure, with the human actions defining and participating in the world(6).
Furthermore, there is the belief that the Symbolic Interactionism respects the nature of life and actions of the human group, with the essential condition for consciousness, world of objects and construction of attitudes lying in group life(7).
Symbolic Interactionism is a perspective of Social Psychology, the only social science that depicts the actions of the human beings in their relation with the world, focusing on the nature of interaction and the social dynamics among people. It had its start in the late 19th century, with George Herbert Mead as one of its most important figures. As a man of science, he was influenced by philosophical pragmatism and behaviorism(6). There are studies by important American figures like George Herbert Mead, John Dewey, W. I. Thomas, Robert E. Park, William James, Charles Horton Cooley, Florian Znaniecki, James Mark Baldwin, Robert Redfield, and Louis Wirth(7).
Mead taught at the Chicago School from 1893 to 1931. His theory is based on the description of human behavior, whose main data are the social actions, conceived as observable external behaviors and also as an undercover activity. He opposed John B. Watson's theory, follower of the Iowa School, which reduces human behavior to infra-human mechanisms, whose social dimension is seen simply as influencing the individual(8). Mead wrote several articles, but his influence was strengthened by the publications of lectures and notes by his students, as well as the interpretation of his works by several sociologists, especially Herbert Blumer(7). His works were compiled and published after his death in 1931, with the best-known Mind, Self and Society being published in 1934(9).
In spite of all Mead's writings and notes, he did not intend to publish them in life. It was up to Blumer to systematize and present them clearly and faithfully, with his main work being published in 1969, Symbolic Interactionism, Perspective and Method, where the three basic premises of symbolic interactionism were described(7):
1. The human being acts towards things based on the senses that they have for him. These things include all physical objects, other human beings, human being categories (friends or foes), institutions, well-regarded ideas (honesty), activities of others and other situations the individuals may find in their daily life.
2. The meaning of these things is derived, or arises from, the social interaction that someone establishes with their partners.
3. These senses are manipulated and modified through the interpretative process used for the person to deal with the things that are found.
Important topics of the author's thinking, which, along with the view of meaning are essential for the comprehension of the Symbolic Interactionism theory, are defined by: root images, group living, social interactions, the nature of objects, people as actors, the nature of human actions, interconnections of individual actions in society, the mind, the self, things, symbols, language, society, self-interaction, human action and group activity, among others.
This is a qualitative study. The theoretical axis is centered on the Symbolic Interactionism, seeking to understand the meaning of the Nursing Process practice for nurses in intensive care units.
The qualitative research approach requires that the world be examined with the idea that nothing is trivial, but that everything has the potential to build a course that may lead us to a better comprehension of the study object(10-11).
The research was performed with seven healthcare nurses in three intensive care units of a large public general hospital in Fortaleza, considered a tertiary care reference in the Single Health System Sistema Único de Saúde (SUS) for the state of Ceará and the Northeastern region.
As inclusion criteria, eight nurses were investigated, with graduation time between 2 and 20 years, employed at the institution between eight months and 23 years, and at least two years of experience in the Nursing Process. The latter was required since it was considered time enough for the nurse to have experienced all stages of the Nursing Process and be able to perform a critical evaluation of the whole nursing activity.
The number of interviewees followed the theoretical saturation criterion, which is based in the repetition of ideas. Saturation is the finishing criterion, with different representations being investigated until the inclusion of new strata does not add anything else to the study(12).
The research project was approved to the Review Board of Universidade Estadual do Ceará and filed under the number 06174148-5. Data collection complied with the specific recommendations for research with human beings.
Data were collected from May 1st to August 30th, 2006, through participative observation and semi-structured interview, in the morning, afternoon and night shifts.
The study started with participative observations, in order to approach the reality under study. Research should be performed with prior participative knowledge of the research phenomena. Participative observation is a rigorous process of discovery of the empiric world under study, consisting of two stages: exploration and inspection. Exploration is the preliminary stage where the investigator carefully probes the phenomenon to determine its general nature. The second stage is the inspection, different from exploration since it is more focused(7).
Questioning was centered on the following phrases: What does it mean to develop the Nursing Process during the nurses' day-to-day routine at the ICU? How does the nurse act, interpreting the Nursing Process practice in his/her day-to-day routine at the ICU? What is the meaning of the Nursing Process for the nurse, and how does the nurse relate with others regarding this practice within the day-to-day routine at the ICU?
We sought to develop the research according to the notion that research must be performed with prior participative knowledge, in order to approach the research phenomena(7).
Therefore, data were analyzed according to the theoretical perspective of Symbolic Interactionism, based on its basic premises and core concepts. Thematic category analysis was chosen for the methodological procedures (13).
As for the ethical and legal issues, the Regulatory Guidelines and Norms for Research involving human beings were followed, according to National Health Council Resolution 196 of October 10th, 1996(14). In order to preserve the participants' identities, they were named E1, E2, E3, E4, E5, E6 and E7.
Nurses aged 26-58 participated in the study, being three single, two married, one widowed and one divorced.
From the study results, the themes presented herein are The social interaction of nurses at the ICU: meanings and beliefs; and the categories, Perceiving the nursing team, Perceiving the Nursing Process in relation to the other professionals, Self-interaction, Rethinking the Nursing Process, which arose from the nurses' testimonies when they manifested their opinions about the social interaction with other people at the ICU regarding the Nursing Process, either their nurse co-workers, nursing auxiliaries or other professionals. And, by self-interacting, the nurses manifested how they perceive themselves developing the Nursing Process, the meanings that it has to them. By re-thinking the Nursing Process, the nurses also pointed out forms of improving the ICU.
Perceiving the nursing team
This category arose from the nurses' perception of their own nurse co-workers at the ICU, the experiences shared in developing the nursing process and the performance of the nursing auxiliaries in this practice. Looking at the testimonies, we observed their spontaneity when accusing each other, which was very clearly observed in E3's, E5's and E6's statements when they mentioned how this practice occurred in their daily routine.
[...] there are many nurses who do it, but there are also many nurses who don't [ ] many colleagues want it to happen, but there are many who hamper it [ ] there is still [ ] a reluctance in using the process [ ] (E3, E5 and E6).
Human errors in nursing activities can be considered ethical, exposing the patient to risk or damaging situations, where all actions are directly and intrinsically linked to the professional's actions, when some damage to the patient results from them, in which several factors can contribute to the occurrence of risk and damages in the care process(15).
In E1's discourse, we could observe that the depreciation of the Nursing Process is evident in nurses' everyday practice, when they act according to the meaning that it has for their working process. The ethical occurrences are conflicts experienced by people or groups of people who base their actions on personal and group values considered socially(15).
[...] she does not write what the nursing diagnosis is related to [ ] she wrote nothing and still had the nerve to write her name, to sign it [ ] (E1).
Another important aspect to be observed was the social division of the nursing activities. At this moment, we had in mind that the nurses would dominate the Nursing Process, just like the capitalists do with their workers, with the nursing auxiliaries doing the necessary tasks and procedures, without any knowledge whatsoever about the science of the work process, since the responsibility of planning the Nursing Process belongs to the nurse.
The process is not really present in our relation of nurse and auxiliary [ ] we do not really work with the process, no [ ] although they know about the Nursing Process, they do not work with it, it's a very distant reality for them [ ] sometimes I think that the auxiliary did not read, sometimes I think they do not give it enough attention [ ] they only have the matter of the mechanical work [ ] (E2, E6 e E7).
Since the nurses are responsible for the conception and management of the Nursing Process, they should seek strategies for the participation and involvement of the whole team, nurses and auxiliaries, so that the process can flow in an integrated and interconnected network of actions, not with each performing activities independent from one another.
I believe it's still not being respected, no way [ ] it doesn't work having me to prescribe if there is no systematization, where the whole team understand what that is, the value of that prescription, of that care (E5).
E5's interpretation of the other professionals not acknowledging the Nursing Process stems from the social construct with the other ICU professionals. The explanation is that each person builds his/her course of action influenced by the activities of the other, directs the social process of the institutions, the class systems, the division of activities and the social organizations. Opposite to what is usually thought, the norms, rules and values do not direct the social process of men, but what they do is what dictates and maintains group life(7).
Therefore, the elaboration of the meanings the Nursing Process has for the ICU nurses emerged from the social interaction process. People are actors when they engage in action, being capable of abandoning, verifying, reviewing and elaborating their world of objects.
Perceiving the Nursing Process in relation to the other professionals
The life of the human group consists and exists in the combination of courses of action with each member of the group. Such articulation of courses of action creates joint actions (8). From this interaction with each other, people form objects that constitute their world and act based on the meaning these objects have for them. To understand joint actions, it is necessary to enter the world of objects, understand how they see and act, based on the meanings these objects have for them. It requires putting oneself in the place of the other, see the situation as it is seen by the actor, observing what the actor takes into consideration, observe how he interprets what he takes into consideration, observe the types of alternatives for acts that are mapped by the actor and attempt to follow the interpretation that led him to that course of action.
The nurses show that the idea of shared and interactive work among the many professional categories does not exist in their day-to-day, because each professional performs the activity for which he/she was qualified for, with the complementarity of actions being inexistent.
As I see it, for the other professionals, not from the team, it's still imperceptible. [ ] there's no significant impact [ ] it's not really acknowledged, you know [ ] it's as if our evolution were something insignificant [ ] (E2, E3 e E5).
The Nursing Process is still unknown by other healthcare professionals, and this allows for the fragmentation of the actions among them and the reduction of care as a procedure, since what could have been shown as a nursing intervention by the nurse also exists as a notion, held by other professionals, that the nurse has total autonomy to develop this work process.
Regarding the educational model of the healthcare professionals, it has been based on the curative care for the disease and the fragmentation of the human being into isolated parts, seeking the objectivity of the actions so that the knowledge of several courses is rarely shared in the search for the subjectivity of the caregiver as well as the care receiver. The concern among the professionals working side by side evidences the all-encompassing fear of losing autonomy and space, making the workplaces into environments favorable to impersonality and high competition.
[ ] I never talk about the process with other professionals, only with those of the nursing team (E5).
The division of work in the hospital is the reproduction of the evolution and division of tasks in the capitalist production mode, preserving some religious charitable-assistential characteristics of the 18th century, at the same time as general market rules are added, typical of current capitalist societies(13).
Within this context of role dissociation, fragmentation of the functions and knowledge, it is not surprising to empirically identify the shared and divided reality, delimited by several disciplines, where each exerts its function independently of the whole.
When nurses take over the care for the ICU patient by means of the Nursing Process, it brings along the whole experience practiced in their day-to-day and, according to their experience, they start to face the care situations, interacting with themselves and assuming care, planning the courses of action, defining priorities based on the evaluation of the patient's health status and taking several attitudes necessary for care. In the face of this self-interaction process, the Nursing Process is evaluated for professional practice, as well as its importance and meanings, building ways of thinking and acting from there.
When asked about the meaning of the Nursing Process in their everyday routine, the nurses expressed several meanings through feelings and opinions:
[ ] Well, I think it's really important professionally, because it makes our profession grow [ ] it can be acknowledged [ ] as a valuable professional [ ] who sees the patient as a whole [ ] (E1).
It means a quality of nursing excellence for my patient (E2).
Opposed to them, E3 reinforced the fragmentation of tasks in practice and the reduction of the human being to parts, feeling embarrassed for not being able to deliver adequate care, since it reiterates the functionalist view of nursing work.
I feel like I can't execute the plan, execute the plan and care for the patient [ ] I feel embarrassed [ ] (E3).
Involved in the mechanics of the daily chores and the pressure for positive results, the nurses seem to not incorporate the Nursing Process as a work instrument that should be adequate to the needs of the clientele and the objectives that aim at decent human care.
For me, it is very important that I'd be able to do it like that. But I cannot do it like that, I abhor it a little, because I can't do it as it must be done (E3).
Even though they share similar problems, the meaning each person shows in relation to the same object depends on individual experiences, interpreting and directing his/her actions in the complex social world. We could perceive that E4 directs her daily actions based on the Nursing Process, assuming this work methodology as inherent to her profession. By planning and executing the nursing interventions, she directs her activities in the ICU daily routine, aiming at recovering the patient's health.
The process means to me the profession, what I AM, what I do in the ICU. Without the process, it's like the process were what I have to follow, what I have to do for my patients (E4).
The expression of pride mentioned by E5, constructed in the process of social interaction, is part of the experience of this nurse who experiences the daily routine at the ICU. Personal and professional accomplishments are highlighted, since she particularly directs her care actions based on the Nursing Process. She understands that the developed actions will be validated and proved through this working instrument.
It's very important for me, for all of us nurses [ ] it validates our work, our care, that what really proves what I did, how I do it, how I plan, how I execute it, so it won't be just an idea [ ] For me it's a really important personal, professional accomplishment. My God, what term could I use? I could even use the word pride [ ] (E5).
For symbolic interactionists, meaning plays a central role in the process of social interaction. Through interacting with oneself and with others, the interpretative process leads to a new meaning for what was experienced, where individual and collective values interfere in the meanings things have for the person(6, 16-17). Therefore, when the nurses have to face and cope with situations where they have to act, they actively build their courses of action, observing, maintaining and checking meanings resulting from the individual and collective self-interaction.
Symbolic Interactionism conceives social life, establishing a conscious inter-relation through the sense attributed to the actions, being manipulated, redefined and modified through the interpretative process(7).
Rethinking the Nursing Process
In the present investigation we observed contents that manifested forms of rethinking the Nursing Process, in a perspective of better performing the practice, aiming to occupy the social space and considering the other healthcare professionals and the institution itself.
[ ] I wonder, if the systematization were computerized, would I have more time to care for my patients? [ ] we are reformulating our systematization, because we're going to have computers! (E2).
Studies(1,18-19) show that the computerization of the Nursing Process optimizes the nurse's time for care actions, essential to provide dignified and human care, as well as performing the management duties that are part of the nurse's world. As such, the political willingness and the goals of the institution should be the same, i.e. the hospital managers' work philosophy, just like nursing activity managers have to work in harmony. Can we consider it a utopia to be pursued? This is a question that belongs to all of us, which shouldt therefore be answered by everyone.
In the current reality, where health has become a product and nursing workers service providers, the answer will surely be affirmative. However, if we rethink our teaching, viewing the critical dimension of this reality and our actions, aiming to change the status quo through permanent education of the workers, we can reflect about our healthcare practice instead of discussing exclusively administrative and bureaucratic problems.
In Nursing research, we observed that the application of the interactionist theory, both in teaching and practice, seeks to broaden knowledge in order to build actions and strategies focused on interactive and humanized relationships between people(20). The experience of basing this research on Symbolic Interactionism, based on the everyday experience of the ICU nurse who develops the Nursing Process, showed that it was possible to produce knowledge about this theme, in the scope of practice and research, based on the comprehension of the meaning of this practice for the nurse.
Reflecting on the Nursing Process in view of how one delivers care, how one evaluates the patient and the meaning of the Nursing Process for its practice, it can be seen that caregivers are in conflict with the belief in the Nursing Process. Sometimes they feel anger, dissatisfaction, frustration; sometimes they feel proud, considering this form of professional recognition and the occupation of the professional social space, with the achievement of authenticity and freedom of action.
From the social interaction with others, in the interpretative process, the nurses build attitudes as they experience the Nursing Process when delivering care to ICU patients. We know that most professionals were educated in the traditional healthcare model, with their way of thinking and acting focused on the disease and not on the person, becoming a part of this concept. Thus, the nurse may or may not consider the Nursing Process in a positive way, showing feelings, opinions and values when planning and executing the nursing actions.
Rethinking new strategies that respond to the necessities of people who should also play an active role in the health-disease process, adapting theoretical concepts to the socio-economic-cultural reality we work in, as well as the active involvement of all nursing team members, constitutes the possibility of heading in another direction.
We can see that the current reality is still far from an ideal situation, since the healthcare required by procedures, norms, routines and focused on the disease, not on the sick person, is still predominant. We understand that, by using a work methodology, the Nursing Process in this case, and not simply directing our actions according to common sense, we will be able to view a new future.
This study revealed, through participative observations, that the overworked nurse, with tasks and daily chores, relegates the planning of Nursing Process activities to a less important position and to the nursing team, rarely meeting to discuss healthcare, which can favor the depreciation and the idea of bureaucratic tasks even more.
We believe in the Nursing Process as a means and an instrument that makes it possible to perform tasks directed by feasible scientific actions, instead of an end in and of itself, or a synonym that its mere application will promote the quality of care. If this happens, it will remain as a form of control, discredited even by nursing itself.
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Received: 08/23/2007 *
Extracted from the thesis "O significado do processo de enfermagem para
enfermeiros: uma abordagem interacionista", State University of Ceará,
* Extracted from the thesis "O significado do processo de enfermagem para enfermeiros: uma abordagem interacionista", State University of Ceará, 2007.