NURSING TEAM AND COMMUNICATION WITH TRACHEOSTOMIZED PATIENTS A equipe de enfermagem e a comunicação com o paciente traqueostomizado

(1) Universidade Tuiuti do Paraná, Curitiba-PR, Brasil. (2) Universidade Federal do Paraná, Curitiba-PR, Brasil. Conflict of interest: non-existent Although health humanization is the key word for daily living in the hospital where the research study was held, nursing professionals face different kinds of difficulties, mainly the practice of co-responsibility regarding communication with tracheostomized patients. Among such deterrents, it should be pointed out information provision on the part of patients to nursing professionals, crucial to their treatment, and the effective communication between them. Communication between the tracheostomized and the nursing team objectifies to assess not only the cause for the need of a tracheostomy, but also the observation of factors, such as alertness, cognitive aspects, understandable and expressive language, regarding individualized care delivery3. From the communication carried on with patients, nursing may identify their needs, inform and elucidate procedures and situations that they wish to know about, promote relationship between patients, the multiprofessional team or family members, develop health education, exchange experiences  INTRODUCTION

over two years in the eligible settings to carry on the study.Exclusion criterion was any participants' wish to leave the study.The sample was determined by the sampling period.
Data collection was held between June, 2012 and March, 2013 by means of an open and close questionnaire (Figure 1).That was personally applied by the researcher to the 51 participants in the nursing stations of the studied settings.Participants were identified by Arabic numerals from 1 to 51 in order to keep their anonymity.Questions addressed the understanding of the nursing team's members on the communication with tracheostomized patients.
Quantitative data were submitted to statistical analysis and presented in tables and figures in order to facilitate visualization of the results.Quantitative variables were expressed by frequencies and percentiles.Chi-square test was considered to assess the association among quantitative variables.P values < .05evidenced statistical significance.
Analytical procedure of the qualitative data was carried out according to Minayo's content analysis 6 , which comprised three steps: organization, classification and final analysis.Analytical categories emerged from the answers to the open questions in the questionnaire (Figure 1).Content analysis consists of finding meaning cores which take up communication, whose presence or frequency mean something to the researched analytical object.The main goals of data organization and analysis steps are to establish the understanding of the collected data in order to meet the research objective.and change behaviors, among others.These are some communicative roles that the nursing team may be involved in, which do not prevent patients from being active subjects in these actions as well 4 .
Thus, the importance of intercommunicative practices and activities can be understood.The interaction between the nursing team and patients shows communication as a basic activity in nursing team's actions, and how significant interpersonal relations are in the nursing team's actions towards its patients, which means improvement in the quality of care and its humanization 5 .
Therefore, the present study aims to identify the nursing team's perceptions on the importance of communication to care for tracheostomized patients in order to help them in their recovery.Table 1 shows the variable distribution: professional category versus qualification and guidance regarding communication with hospitalized patients, their feeling while rendering nursing care, and understanding on the incapability of oral communication.

Participants' profile and qualification to communicate with hospitalized/ tracheostomized patients
As for the profile of the research sample, it can be pointed out that most participants range 31 and 50 years old (29%), with significant working time Figure 2 shows the frequency distribution of professionals who participate in the daily care of traqueostomized patients, in the perception of study participants.The highest percentage was attributed to nursing assistants and technicians.It is pointed that this issue enabled the choice of many alternatives, as that kind of caring is multiprofessional.
Table 2 shows variable distribution: professional category versus participants' qualification to guide tracheostomized patients and their recovery, and the importance of strategies to facilitate communication with tracheostomized patients.It can be observed in the justifications that the participants consider important to keep communication with patients during care delivery, especially to improve interaction between them, inform them, calm patients down, thus humanizing care.

Category 2 -Care participation for tracheostomized patients
"After all, we often assess this kind of patients between shifts, and communicate the other professionals whenever it's deemed necessary."(N.1) "Nursing team spends longer with the patient."(N 1; 2) "The nurse performs tube exchange, nursing team does the cleaning and aspiration whenever necessary."(N.2; 4) "The nursing team delivers all daily care to patients."(N.4) "The nursing team is present round the clock."(N.4; 5) Accounts show that the nursing team is daily present, rendering the necessary care to tracheostomized patients.They are the communication link with the other health professionals.It is observed that the nursing team is the communication bridge to the other health professionals, besides rendering ongoing care.Three categories emerged from the analytical process of qualitative data:  their education process, it can be observed that 93.1% (n=27) of nursing assistants, 83.3% (n=10) of nursing technicians and 57.1% (n=4) of nurses pointed that they had such guidance (p = 0.053).As for communication practices to hospitalized patients during nursing exercise, assistants accounted for 60% (n=18), technicians, 61.5% (n=8), while nurses accounted for 28.6% (n=2).Answers to questions on education to care performance show that 73.3% (n=22) of assistants feel well prepared, 75% (n=9) of technicians, and 57.1% (n=4) of nurses feel well prepared (Table 1).
According to authors 7 , contributions from communication learning in professionals' education enable them to deal with several limitations in the communicative process, being able to understand information provided by patients, advise people on their health status, elucidate care interventions, and meet patients' needs in an individualized, humanized way.
Researchers 8 carried out an investigation at a teaching hospital with the multiprofessional health team aiming to analyze caring actions performed in a SDU in the light of care humanization and presence of comfort measures and communication to carry out such actions.Results showed that comfort measures were present in 45% of the developed caring actions, and communication establishment in 40% of them.
Asked if the incapability of oral communication by patients interferes in their relationship to the nursing team, 19 (63.3%) nursing assistants, 6 (50%) nursing technicians and 4 (57.1%)nurses answered affirmatively (Table 2).Participants' answer points out the importance of communication in caring for tracheostomized.
During health and nursing professionals' education, it is necessary to develop students' sensitiveness and get to know clients' reality, to listen to their complaints and find possibilities to facilitate their acceptance, communication and understanding of their disease 9 because communication depends on the other.If a person finds it difficult to be objective, he/she will not be able to put himself/herself in the other's place in order to understand what he/she could apprehend 10 .
Assistants, technicians and nurses' role is not limited to carry out techniques and/or procedures; more than that, by developing the communicative skill, they try to meet patients' needs.Although tracheostomy brings major benefits, literature points out that it is necessary to perform proper techniques and specific procedures in each case because complications may lead to death in spite of not being frequent 11 .The need of intervention caused by lack of communication with patients was evidenced by the research participants.They refer to events of anxiety from both sides due to lack of effective communication, besides possible problems related to misunderstood interpretation of patients' needs and hindered communication.

DISCUSSION
Participants' answers evidence the importance that they attributed to guidance during their education on hospitalized/tracheostomized patients' care, especially communication.From the participants that claimed having such guidance, during the importance and the kinds of communication carried out by 10 nurses at a hospital in Vale do Paraíba Paulista/Brazil, it was concluded that they considered communication an invaluable tool for their professional performance, objectifying quality and excellence of care 13 .
The accounts on the necessary procedures to communicate unveil different kinds of guidance; it is perceived that participants own the necessary knowledge on how to lead tracheostomized patients in the communication process.The participants in this study consider guidance to tracheotomized patients on ways to communicate a major factor to help them recover.It is pointed out that all participants in this research work directly with tracheostomized patients.
Study developed which aimed to identify communicative ways and instruments used by the nursing team in order to understand adult patients in ventilation, evidenced that the nursing team highlights writing, eye blinking and hand pressing to communicate with patients.It was concluded that the team is concerned to set up effective communication with patients, praising care and struggling for their dignified recovery 14 .
Communication is a broader process than just speaking; it involves other resources such as body language, gestures and signals 10 .Thus, it is observed that some interviewees guide patients to communicate especially by means of gestures, signals.It is also possible to occlude the external orifice of the tracheostomy tube.This way, they can carry on communication with those patients.Researchers 15 claim that need of communication means essential care for tracheostomized patients as the incapability of oral communication boosts patients' stress.In order to minimize this situation, it is deemed necessary to offer options for communication, providing them with paper, pencil or, if that is possible, a magic writing pad.
Concern about the different non-verbal forms of communication is present in a study developed at Hospital Regional de Brasília (Regional Hospital of Brasília) which comprised eight nurses and five patients.It objectified to assess the main needs of patients unable to communicate orally due to the use of tracheostomy tube during hospitalization in an Intensive Care Unit as well as to optimize and validate the method of visual communication by means of illustration cards.Mentioned needs included: pain, heat, cold, aspiration, position change, raising of head-end of bed, thirst, communication with family members, lighting and hygiene.Researchers concluded that the method used was adequate; however, illustration cards with pain and Knowledge on communication underpins care, enabling the interaction between nursing team and patients, contributing to its quality.
Thus, caregivers are able to cope with several shortcomings in the communicative process, being able to understand the information provided by the cared being, and guiding people on their health status, elucidating therapeutic interventions, aiming at the implementation of nursing care 7 .
Regarding guidance on communication to tracheostomized patients, it was found statistical significance that nursing Assistants and Technicians carry out more guidance than nurses (Table 2).The lowest percentage presented by the category of nursing can be related to their performed tasks in care management rather than in patients' straight care.However, literature claims to be nurses' task to watch out for tracheostomized patients' care peculiarities as they are weakened, anxious due to the emergency situation they are experiencing, afraid of the pain, the unknown, of their recovery, the new lifestyle, and also afraid of dying 12 .
It was found that all participants consider that guiding tracheostomized patients on their ways to communicate helps their recovery (Table 2).Disregarding whether they are nursing assistants, technicians or nurses, they understand the relevance in developing strategies in order to promote the communication with people making use of tracheostomy tube.Intervention for lack of communication was reported as a major need because it may bring about anxiety and communication problems on the part of nurses as well as patients.Such a situation demands more efforts, communication and attention to patients.In the perspective of the study participants, whenever verbal communication is not possible, it deems necessary to search for alternative solutions so that some kind of communication be developed with patients.They understand that there are other kinds of communication besides the verbal one.
According to participants' accounts in this research, patients guided on communication keep calmer and more secure, which facilitates care and humanizes it.Guidance on the ways to communicate contributes indirectly to tracheostomized patients' recovery.It is observed the relevance it takes to research participants the maintenance of communication throughout care delivery in order to promote patient-nurse bonding; in order to improve their interaction, in order to inform, calm patients down and promote humanized care.
Literature points out that humanization is as important as nursing professional care delivered to patients, and health professionals must be aware of that.In a study developed to investigate knowledge, because studies evidence a high number of people with communicative disorders searching for care in health institutions 20 .Therefore, considering the need of integrated care for tracheostomized patients, it is relevant the participation of a multiprofessional team, especially the inclusion of a speech therapist to patients' recovery, which brings more security to the involved professionals.

CONCLUSION
Research results evidenced that participants have varied experiences in their professional area, and observe the need and importance of interacting with tracheostomized patients in their daily work.
Considering that communication is a basic tool in nursing care, that is, the process enables the relationship between nursing team and patients, nursing actions are unthinkable without mentioning the importance of communication for patients' wellbeing and recovery.
It was verified in this study that when oral communication with patients is not possible, members of the nursing team try to guide and foster different ways of communication, such as gestures, signs and written communication they understand that communication improves the interaction between the parts, lessens anxiety, and facilitates understanding with patients, family and multiprofessional team.
In the perception of the research participants, it can be observed that the development of communication strategies with hospitalized patients by the nursing team is fundamental for better care delivery as well as to contribute to patients' better and faster recovery.
heat themes required changes, thematic expansion and improvement in the visual system 16 .
Nursing team has basic knowledge on the ways to favor and implement the communicative process with tracheostomized patients.The communicative ways mentioned in this study were also addressed in a case study which followed up a patient after undergoing the process of tracheostomy.The study pointed to the importance of the nursing team, the use of mechanisms to improve their relation to patients by means of non-verbal communication through gestures, writing, facial expressions, among others 17 .Even though data and bibliography show the importance of knowing non-verbal communication for humanized care, authors stress that different undergraduates and health professionals do not own suitable knowledge on this form of communication 18 .
Regarding the professionals who participate in daily care for tracheostomized patients, data in this research evidenced that the majority belongs to the nursing team (98%), physical therapists (86%), nurses (70%), doctors (65%), speech therapists (39% -Figure 2).The highest percentage of nursing team members (nursing assistants and technicians) is justified as they render 24-hour care to patients 19 .However, the small percentage of speech therapists involved in caring process calls attention.This fact demands careful look from the researched institution as speech therapists' presence is deemed necessary in hospital settings for care planning and implementation to patients, mainly the ones presenting communication impairment.
That concern is shared by authors, who claim that measures must be taken in order to supply the high demand of speech therapists in public health

Figure 2 -
Figure 2 -Display of professionals who participate in tracheostomized patients' daily care (n=51)

Table 1 -Professional category versus education, guidance, feeling and understanding on the incapability of oral communication with hospitalized/tracheostomized patients (n=51) Variables Professional Category
Chi-Square Test -significance level p < 0,05 NOTE: 1 participant didn't answer questions 1 and 2, and 2 participants didn't answer questions 3 and 4.

Table 2 -Professional category versus ways of communicating, guidance, recovery and the importance of strategies that facilitate communication with tracheostomized patients (n=51) Variables Profissional Category
*It was not possible to determine p value for questions 5 and 7 because frequencies are null in NO category Note: 1 participant didn't answer question 5, and 2 participants didn't answer question 7

Category 1 -The importance of guidance on patients' communication during education
"This way we can identify many needs of theirs, thus rendering effective, quality care."(N. 5) "I've learned we should always communicate what will be done and its purpose."(N.6) "That's the best way to know their main needs, facilitating the best care delivery."(N.7) "To me, communication is a bonding, the core point."(N.12) "I got guidance during the nursing assistant course and humanization lectures."(N.13) " (N.32) "Multiprofessional work, cooperating with the need of each client's individual care."(N.37) "Communication is the way individuals and society has to interact."(N.49) Note: Percentage total is over 100% because there was more than one answer to the question.