Nurses’ recommendations to the psychoaffective dimensions of patients hospitalized in nephrology

Objectives: to analyze nurses’ recommendations on the psycho-affective dimensions of patients hospitalized in nephrology. Methods: a qualitative, exploratory and descriptive study, carried out by applying a sociodemographic and training questionnaire, reading a clinical case and conducting a semi-structured interview. Fourteen nurses from a reference hospital in nephrology in the Southeast participated. In the technical input of data treatment, thematic content analysis was used. Results: the recommendations included the exercise of empathy; monitoring of emotions from the implementation of the nursing consultation; continuous sharing of tensions, anxieties and desires; knowledge of one’s emotion; increased availability to listen; effectiveness of the approach in teams and social groups. Conclusions: recognizing patients’ psycho-affective dimensions, in the context of nurses’ performance, favors the expansion of therapeutic listening spaces, welcoming and interpersonal coexistence in nephrology, essential in the production of comprehensive health care. Descriptors: Nursing Care; Affect; Patients; Hospitalization; Nephrology. RESUMO analisar enfermeiros qualitativo,


INTRODUCTION
Nursing care in nephrology focuses on a complex universe of meanings implicit in their daily actions and actions, whether in the therapeutic bond established with patients, in the care provided, in the interaction with the team and family, or even in the development and use of educational health strategies (1) . In this scenario, among the different people involved in this process, nursing, patient and family, emotions, sensations and affections intermingled with each other, sometimes in a triad in which external elements linked to specific behaviors and demands permeate. caution (2) .
Chronic kidney disease (CKD) is known to significantly alter the life context of patients and their families, considering the effects and behavioral responses generated by diagnosis and treatment (3)(4) . During hospitalization, challenges such as forming a bond with the team and patient, the mechanisms of acceptance experienced, the relationship between family, cycle of friends and the community, among others, together, signal the breadth and scope of nursing practice in nephrology (5) .
Thinking about the psycho-affective dimensions of hospitalized patients in this context requires nurses to use tools such as communication, interaction, dialogue, listening and availability, as it is an essential dialogue mechanism for nursing care capable of strengthening the adherence, adaptation and recovery process amid the limitations imposed by the disease (2,6) . It is understood that caring for nurses encompasses a complex arsenal of techniques and technologies integrated in thinking, doing and assisting the human being developed by professionals, with a view to improving patients' and family's quality of life (1) . In this process, it is essential to develop tools and skills related to technical and humanistic capacity in dealing with emotional and intersubjective aspects in nephrology, favoring therapeutic listening in the context of nursing care (5)(6) .
In hospital environments such as nephrology, nurses come to live with the duality of patients' perceptions and feelings, which may, in some cases, reveal problems of low self-esteem, anxiety, emotional instability, loss or decrease in daily activities, suffering and fear of death (1,4,7) . Such aspects may be associated with not understanding the health-disease process, environmental factors and insecurity for not knowing how to behave and adapt in the face of adverse situations (2) .
In this context, there are still obstacles in the practice of nurses focused on biological or technical aspects of patients, which significantly contributes to the increase in stress and fear commonly identified in CKD treatment (7) . In some cases, dealing with emotions and affections ends up being neglected by professionals, making it difficult to establish a bond, dialogue, in addition to adherence to treatment (5) .
The attention to the psycho-affective dimensions of patients hospitalized in nephrology by nurses favors the creation of a welcoming space, empathy and trust to understand others and themselves, as well as, at times, strengthens spiritual and emotional support during hospitalization (2,6) . That said, the following guiding question was outlined for this study: what recommendations are made by nurses to meet the psycho-affective dimensions of patients hospitalized in nephrology?
It is recognized that attention to psycho-affective dimensions in nephrology enhances the intersubjective production of comprehensive nursing care, expanding the therapeutic bases of interaction, respect, and ethics (2)(3) .

OBJECTIVES
To analyze nurses' recommendations on the psycho-affective dimensions of patients hospitalized in nephrology.

Ethical aspects
This study was attentive to national and international standards of ethics in research involving human beings, being approved by a Research Ethics Committee. Participants' anonymity was ensured and their testimonies were identified with the initial letter N for the word "Nurse", followed by an alphanumeric order (1, 2, 3, up to 14) according to the final code presented (N1, N2, N3, up to N14).

Type of study
This is a qualitative, exploratory and descriptive study.

Methodological procedures
Initially, there was a visit to the service and contact with the Head of Nursing, at which point it was clarified that the conduct of the research would keep the assistance to patients assured and uninterrupted. With that being said, the researcher was inserted and familiarized with the service by meeting nurses to clarify the study, clarify any doubts and schedule the collection. Contact with these professionals took place privately, and the interviews took place according to the established schedule, in a rotation system, usually between the hours of 3:00 pm to 5:00 pm and from 7:00 pm to 9:00 pm.
Fourteen nurses participated in the study, aged between 30 and 55 years, being nurses responsible for patient care on day and night shifts and with at least six months of experience in the nephrology sector. Nurses who did not participate in any data collection and being on sick leave were excluded. For data saturation, it was considered the repetition of the responses in the time spent by each nurse during the production stages resulting from the reading of the clinical case, the individual responses in the printed questionnaire to identify the diagnoses and the information and recommendations suggested in the semi-structured interview.

Study setting
It was an anteroom of a large university hospital, a reference in nephrology, located in the metropolitan region of the state of Rio de Janeiro, Brazil. The choice was made because this is a possible space to be occupied for research and because it is familiar to nurses, who commonly use it to hold meetings, conversations, debates, lectures, training, qualification and updates with other nursing professionals.

Data collection and organization
Data production took place from November 2017 to April 2018. Initially, nurses were invited to participate in the research, followed by reading the Informed Consent Term (ICF). Upon acceptance, the instrument containing text typed and printed on A4 sheet on the clinical case was delivered, made from the scientific and diagnostic evidence identified in the clinical specialty. After reading the case, participants listed the main nursing diagnoses and the recommendations for each one.
In the second step, the questionnaire was applied, covering socio-demographic data and training of professionals; then, a semi-structured interview was conducted, recorded on a digital device (MP3 format), with the central guiding question: what are your recommendations for meeting the psycho-affective dimensions of patients hospitalized in nephrology? After transcribing the testimonies, reading and rereading the material produced made it possible to know the emotional and affective responses perceived by professionals about patients with CKD.
It is noteworthy that each nurse shared his impressions about the relevant elements from the instrument, describing recommendations according to the care of the psycho-affective dimensions of patients in hospitalization in nephrology through reflection and criticism about the care provided. To maintain the data organization process rigor, the criteria established in the COnsolidated criteria for REporting Qualitative research (COREQ) (8) was used.

Data analysis
Thematic content analysis was used as a technical contribution, since its use presupposes the following of different stages, namely: pre-analysis; material exploration or coding; treatment of results; inference; interpretation (9) . Transcripts of the testimonies recorded in full, text skimming and an exhaustive rereading of the material produced were carried out.
Thematic analysis of the corpus considered the most frequent records (9) . At the end, a large category was identified, entitled "Recommendations for the psycho-affective dimensions of patients hospitalized in nephrology" from their registration units.
Considering the technical support adopted and the testimony analysis process, the main nurses' recommendations on patients' psycho-affective dimensions and their respective definitions were identified. Chart 1 was elaborated, systematizing the main thematic category, covering the seven registration units and the respective testimonies illustrating each one.
The recommendations included the exercise of empathy, the professionals' ability to look beyond the disease, respecting patients' individuality; monitoring of emotions, from the implementation of the nursing consultation and its main stages; the need for continuous sharing of tensions, anxieties and desires; have a look beyond the machine; pay attention to the recognition of one's emotion and to the psycho-affective aspects of taking care properly; increased availability to listen; strengthening the bond; effective team approach, especially integrating nursing; effecting the creation of coexistence groups in the service.

DISCUSSION
Nephrology nursing deals daily with several patients and with the respective treatment modalities. Of these, a look focused on the psycho-affective dimensions is required, that is, that goes beyond the physiological aspects of CKD, sometimes intermingled in a therapeutic relationship and with the recognition of self-esteem, emotions and affections (2)(3) .
Study participants consider that the role of nurses in the nephrology scenario implies, above all, the exercise of empathy, which reflects in professionals' ethical behavior and the ability to put oneself in the other's place or vice versa (10) . The exercise of empathy requires attitudes that transform relationships between people, strengthening the bond between those who care and those who are being cared for, making them beneficial and positive.
In this scenario, situations such as patients' physiological and clinical changes may require nurses to adapt their approach in order to keep it therapeutic. Hostility and aggression behaviors can be caused by elevated urea and creatinine, indicating possible neuropsychiatric manifestations such as anxiety and depression, resulting, sometimes, from decreased immunity, insecurity, losses, anguish and fear of the unknown (7) .
Nurses emphasize that sensitive and empathic nursing care improves therapeutic adherence, especially during hospitalization, considering aspects related to the entry, stay and departure of patients in the hospital (1)(2)(3) . Generally, the routine of care involves the regular use of medications, monitoring vital signs, performing diagnostic tests, after dietary and exercise protocols, abstinence from substance abuse and regular monitoring by experts (11) .
It is understood that the way patients experience treatment is personal, that is, each one develops their own mechanisms, which can be of tolerance, frustrations, maintaining relationships, or even future projects. Some cope better with the disease, seeking information and motivation, others have greater difficulties and seek alternatives to adapt to the new lifestyle (12)(13) .
The initiative is to instruct them every day about this process, so that they learn to deal with their own behaviors and also with their emotions (12) . Maintaining an attentive and qualified listening, an effective dialogue and a broader view are actions that can favor self-care, improve adherence to treatment and also strengthen the bond between those who care and are cared for, making it, in addition to being instrumental-technical, therapeutic (3,13) .
In this experience, nurses realized that behaviors are producers of health care. All recognized that they need to perceive patients more during their stay in the hospital, look at it in full, knowing how to welcome and encourage them to self-care (11,14) . Those who help, who perceive the psycho-affective dimensions in others, naturally exercise empathy. It is empathy that gives time and voice to the various nuances of human care, making it safe, comprehensive, sensitive and welcoming (3,15) .
They also recognized that they need to adopt a more open posture when interacting with patients, develop self-perception, making the habit of sensitive listening and enlarged gaze (3,15) . As they are actions of a therapeutic nature, they are aimed at rethinking the approach, providing guidance and clarifying doubts, and technical care, how to handle the machine, puncture the arteriovenous fistula, make the dressing, even perform a nursing consultation (1,16) .

Records Unit Statements
Increased availability to listen There were countless managerial issues raised by nurses, which, if not considered fundamental, can significantly change the pattern of patients' daily self-care (4,6) . Among them is the nursing consultation, a health tool that requires a shared and aligned approach from the team. Putting it into practice in nephrology demands availability to listen, in addition to the understanding that this is a tool that cannot, in any way, be discredited or have its content emptied (16) . It is through it that nurses establish healthy habits, monitor emotions, teaching self-care (2) .
Managing requires, therefore, the mastery of this plurality, the continuous sharing of tensions, anxieties and desires, emotional selfrecognition -since the fundamental principles of care, in collective spaces, tend to achieve success only from the effective articulation between the spheres administrative, assistance, educational and research. Both must happen in an active, critical and purposeful way (17) .
Although the machine is considered by participants the protagonist and fundamental element to the health of patients who are there, it is also the major generator of changes in emotional patterns. For those who depend on a machine to obtain a better quality of life, it is expected to develop strategies such as social groups that allow them to improve their relationship with the process itself, coping (14) . In other words, to develop behavioral and cognitive skills that allow to control the demands of the internal and external environment, the management of the stressful event, the control, the reduction or even the elimination of emotional responses, since this process does not always happen harmoniously (17)(18) .
Understanding this range of feelings and sensations, reflecting the dependence on a machine, requires nurses to have an attitude that arouses patients to look at themselves during the entire treatment, i.e., that in addition to giving time and a voice, instruct them to self-care. That is, to awaken self-perception, making them see themselves as the main protagonist of their health and treatment (18)(19) .
Awakening self-perception requires nurses to dive into the most intimate of themselves, in order to know themselves and get to know the other, and also find ways to guarantee the recovery of autonomy (3) . Understanding care in these perspectives means associating it with a greater appreciation of life, extrapolating, through elements such as welcoming, attachment and accountability, the focus of attention to signs and symptoms, from the disease to the person, comprehensively (19) .
Comprehensive care is, therefore, aimed at the person, who needs multiple perspectives, multidisciplinarity, which is sometimes linked to a health system that is almost always transversal, in a network (20) . To perceive being intertwined in this process is a path towards the achievement of patients' autonomy and, also, making comprehensive care possible.
When considering these questions about comprehensive care, permanent health education, a set of actions that guarantee welcoming and guidance of patients and their families presents itself as an opportunity to improve treatment (21) . To make this therapeutic process, psychologists or even nurses must be present, directing their approach towards living with the process itself.
In the practice of nephrology service, thinking about comprehensive care is still a challenge, especially for nurses, considering the amount of 35 calls per work shift established by the Ministry of Health Ordinance 389 of 2014, not counting technical assistance, generating, in addition to gaps in the guarantee of welcoming and guidance, daily exhaustion on the health team (22) . Despite this limitation, on June 7, 2018, Ordinance 1,675 was instituted, which increases the number of nurses' attendance to 50 patients in each dialysis shift (23) .
It is up to these professionals, who work with patients with CKD, not only perform administrative and care functions, but also educational and research functions, mainly to try to make up for the shortcomings arising from primary care regarding early diagnosis and treatment (24) . Comprehensive care, therefore, must be preceded by the logic of intentionality, co-responsibility, collaboration and co-participation of those involved with assistance (20) .

Study limitations
The participation of nurses working in the studied practical field can be considered to be of little significance, seeing the process of effective changes in the professional approach to patients with CKD, in addition to the need to identify the intervening factors, the care demands and the elements of intersubjectivity that involves the perception of oneself and the other and interpersonal relationships. In this way, it is suggested its replication, with a wide range of participants, and in other realities, in order to verify the compatibility of the data with other services.

Contributions to nursing
The experience allowed nurses to reflect, in depth and content, on the care provided to patients with CKD, paying attention to psycho-affective aspects, reflected in the scenarios of tensions, anxieties, desires, needs and limitations common in the nephrology work environment. In some situations, these elements are present in the process of cognizable and cognizable communication that directly affects the interaction between nurse-patient-environment-treatment.

FINAL CONSIDERATIONS
The recommendations proposed by nurses focused on the exercise of empathy; monitoring patients' emotions from the implementation of the nursing consultation; continuous sharing of tensions, anxieties and desires; recognition of the emotion itself and the psycho-affective aspects of caring itself; increased availability to listen; the effectiveness of the team approach, as well as the creation of coexistence groups in the service. It is observed that such recommendations are powerful tools in the production of self-knowledge and self-perception by professionals, essential in learning and developing intellectual, psychological, affective, interactive and emotional skills for comprehensive health care.
The recognition and appreciation of the psycho-affective dimension by nurses reflects on the psychological and emotional context of patients in nephrology, requiring them to have greater scientific knowledge and technical skills to guarantee individual and group therapeutic support that encourages creativity, autonomy, solidarity and awareness. It also reinforces the importance of re-signifying spaces for coexistence in the service, favoring the process of welcoming patients' emotions and affections, whether through extended listening, dedication or even respect for the subjective experience with the disease.