Coping strategies for oncology nurses in high complexity

Objective: to identify the coping strategies of oncology services of nurses in highly complex hospital care before the person with cancer. Method: it is a qualitative research, with 18 nurses in inpatient oncology units and/or outpatient chemotherapy in two cities in southern Brazil, sampled by a snowball and carrying out semi-structured interviews. Data were submitted to thematic analysis. Results: three categories emerged that show strategies such as denial and resignation in care, for support in the health team and the plurality and multiplicity of perspectives on the care, including the patient and his family and the search for personal and professional improvement. Conclusion: coping strategies are expressed in the cultural understanding of what it means to have cancer or not and management of health institutions for nurses to work with satisfaction. The service in education is a major factor in the development of ethical competence.


INTRODUCTION
Cancer is a public health problem at the global level, with large epidemiological relevance to the incidence and mortality.It is a chronic disease and in the minds of the people, it is the symbol of impossible healing, referring to the human confrontation with the finitude of life (1) .
The care of people with cancer has advanced over the years.New screening methods, tracking of carcinogens and types of malignancies are examples of evolution.However, the term cancer is prevented by health professionals and loaded by the stigma of imminent death (2) .
The constant application of science and technology in the care process in health, especially nursing, has significantly influenced the practice of these professionals due to the emergence of ethical dilemmas in the profession, therefore, inferring the importance of bioethics for nurses in their decision-making across the moral problems (3) .
In the hospital context, the nursing staff takes great responsibilities ahead for these patients, with the expertise to assist in the diagnostic evaluation, treatment, rehabilitation and care to family members.Also, they must constantly deal with situations of suffering and death, which are exacerbated by the characteristics of demand and the working environment.This context requires nurses´ assistance with primacy in the full assessment of the patient and his family, going beyond the limits of the disease (4)(5) .
The nursing work routine does not consider the problems that professionals face in their daily lives, both on and off the job.It is expected that nurses never express their difficulties to the patient and can give just tranquility (5) .
In the difficulty of caring for people with cancer, there is a need to develop coping strategies, considering the ethical aspects involved in the different situations and relationships in the context of care, coping this, being defined as a set of behavioral responses that the individual issues before a stressful situation, to modify the environment in an attempt to adapt in the best way possible to the stressor event to reduce or minimize their aversive character (4)(5) .
In this perspective, this study is justified by the need to recognize the strategies that nurses develop on the face of conflicts and problems in the daily work, thus identifying their weaknesses, difficulties, and limitations.The objective of this study was to identify the coping strategies of oncology services of nurses in highly complex hospital care before the person with cancer.

METHOD
Exploratory and descriptive study with a qualitative approach carried out by18 nurses who worked in inpatient units and hospital outpatient chemotherapy in two cities in the south of the country.For the selection of the subjects, the "Snowball" sampling technique was used, consisting of elected initial participants in each of the two capitals, asking if, at the end of their interviews, other subjects with the features were indicated for the next data collection.Data collection took place simultaneously in the two capitals, in March 2013, after approval by the Ethics Committee on Local Research.The study followed the ethical principles related to the research and care of human beings.
A semi-structured interview was the data collection instrument, based on three guiding questions: 1) What are the difficulties you find in living with family members and patients and other professionals?; 2) What coping strategies do you use in the oncology care routine?, and 3) What strategies do you suggest to be adopted by the teams, to facilitate the confrontation of cancer care?
The interviews were audio-recorded and occurred in a participant´s preferred place, and later transcribed in full.Regarding the inclusion criteria of the participants, it was considered the professional developing care activity with adults with cancer and who had a year or more of experience in oncology.The methodology used to analyze the data was the thematic analysis, according to Minayo (6) , which included: a transcription of the interviews and the prior reading with delimitation of the key elements; in-depth reading and grouping of the key elements of categories and, finally, the descriptive and interpretive analytical process, promoting dialogue with current and relevant literature to the subject.To ensure the anonymity of the participants, they were identified in the study by adopting Greek names.

RESULTS
By analyzing the data, there were three main categories: a) denial and resignation in the care of people with cancer; b) searching for support in the health team and the plurality and multiplicity of perspectives on the care, including the patient and family, and c) the pursuit of personal and professional development.

Denial and resignation in the care of people with cancer
This category reflects individual actions culminating in strategies that apparently do not become beneficial to cancer patients, even if the momentary result of these strategies will enable the continuity of the actions of nursing professionals.The process of denial, which is a common defense mechanism, appears as a constant coping strategy: I think the stages of denial of a disease pass through the patient, the family, and especially by professionals who care.You also deny, even a lot of care for that patient.(Kera) de lo que significa tener cáncer y del manejo o no de las instituciones de salud para el enfermero trabajar con satisfacción.La educación en servicio es factor preponderante en el desarrollo de la competencia ética.Palabras clave: Enfermería Oncológica; Vínculos Emocionales; Ética; Relaciones Interprofesionales; Muerte.Another common situation to individuals facing cancer context individually was the attempts to quit, which although they have focused on maintaining a level of distance between the nurse and the subjects involved, it ends up strongly reflecting the care actions, disqualifying them and limiting them.
As soon as I entered I get involved but when the patient was poorly talking to the family and after that I was missing, was a lock.(Perséfone) For me to do my job with sanity and fortified emotionally, I have to set some limits.(Bia) Finally, it is presented in this category the actions of disease acceptance and their consequences, seeking to demonstrate that the resignation and naturalness are strategies used by nurses in oncological context: At first I was suffering a lot, but then we will have to face reality.(Eucleia) I try to work on the issue of resignation, accepting the disease naturally.(Têmis) Searching for support in the health team and the plurality and multiplicity of perspectives on the care, including the patient and family This category highlights strategies which are based in the community, the plurality of perspectives and actions of nursing and multidisciplinary teams, as well as people with cancer and their families: We have a very good team [...] psychology, social work, nursing, dental, dentistry actually, and medicine.These professionals gather every Friday, 10:30 -11 am, and do a clinical meeting, [...] when I can go along I take a technician.If not, we do a rotation, I put everyone on the same scale.(Pandora) A feature in the care of the person with cancer is the narrowest emotional involvement of the professional with patients and their families, as usually the treatment is over and hospitalizations and returns are common: My first strategy is listening to the patient, not only him, but the family also, the person who is watching.(Kera) I get involved, I talk to the family, I embrace, I caught in the hand, I say something to try to comfort him, I call the family out of the room and talk, the family vents me, I forward to somewhere if needed.(Iris) The testimonies of some nurses denote the need for this interaction, the formation of groups to favor this confrontation or even performing activities that go beyond the boundaries of the hospital, such as leisure activities: I find it important to carry out activities that take the focus of the work, maintain an active social life, it helps.(Cáris) I think that the exchange of experience among different professionals, group meetings, often with case discussions, help professionals to face better these difficulties.(Selene) Searching for personal and professional improvement In this category, there are the strategies related to the professional qualification process and training to act in a more responsible, humane and ethical way: I never do anything without knowing why and it requires study.(Bia) It is important to seek knowledge at conferences, workshop, not only reading but sharing with fellows.(Kera) As evidenced next, Pandora expressed that the qualification also means developing relational skills in management with patients and their families, from a purposeful way of coping that leads the professional to learn how to deal with suffering, psychobiological and spiritual needs of the person with cancer to improve the listening and sensitivity:

DISCUSSION
Falling ill is a threat to self-image and the existence of all people, it is contact with their finitude, and one way of dealing with the disease is the fact to deny it (7) .In situations where denial can hinder the treatment provided to the patient, it is necessary to build alternatives (8) .Although there is a paradox, as soon as the care is the nursing work object and, therefore, the nurse, the professional relationship with the denial of the disease and thus qualified care to the person with cancer.And this analysis has been thoroughly carried out by studies (9)(10) that address the theme of care to people with cancer.
However, there is another possibility to analyze this denial of the care process.It is shown that when it comes to the act of caring, professional nursing, as well as other professionals, based on their beliefs and values, determine points of behaviors that follow their living habits, building (11) ways of being and behaving in society.Then, it is asked: what values and beliefs this professional conduct that limit or disqualify care as a coping strategy in the care of people with cancer?Values and beliefs that support the idea that cancer disease is articulated to an ambiguous possibility of healing the suffering of the people and death.Thus, it should be considered that the concept of experience is the intersection of different dimensions (thought-action, awareness-body, culture, individuality), which expresses a synthesis between body and culture.Therefore, this means a system of care in health, with the disease as a socially determined cultural language and articulate the beliefs and behavior patterns, symptoms and treatment experience of alternatives (12) .In short, behaviors developed in the care and the way workers express their actions are also related to cultural patterns (13) .Culturally, the resignation before cancer and its consequences prevail among people.There is evidence that the nursing staff uses coping mechanisms to live with suffering: distancing from patients and avoiding involvement, which is the inability to deal with the resulting emotional burden of that daily contact.On the other hand, satisfaction in promoting the relief of another suffering can translate the spare energy, welfare and alleviation of pain, allowing new confrontations and perform better in their work.Recovery and dedication to work, when recognized, generate satisfaction in the nursing team, as they feel valued (14) .Therefore, the data that emerge in the second category imply the possibility of confrontation discussion, both in the anchor/professional staff, as the understanding of how much productive and rewarding understand the multiple ways in which care can be expressed.
Many patients suffering from cancer and limited life expectancy suffer unnecessarily when they do not receive the necessary and proper care to the symptoms that accompany their disease or understanding of their troubles.More and more there is the need of health teams composed of professionals from different areas of training, willing to clarify possibilities for patients and their families coping with this point in their lives, easing the suffering of everyone, including the team itself.It is important the care actions sometimes undervalued, such as touch, being present, clarify doubts about the medication, care, pathology, as well as signs and symptoms that the patient has or may display.In fact, they are reinterpreted the attributes care relationships, emphasizing ethical values, such as trust and autonomy (15) .
The nurse, after joining an oncology unit and adapt to the new environment, shows a strong commitment and passion to his profession and, above all, by the patients and families.That is, the experience is intense, where the link with the area is by understanding that care goes beyond the biological, overcoming suffering and punishment toward a guided perspective in the sense of gratification for their work.
In this perspective, given the difficulty in dealing with people with cancer, the participants of this research demonstrate, in the third category, the professional improvement as a way of coping with caring for people with cancer.Therefore, a continuous preparation to deal with their feelings and patient developing protection mechanisms is necessary because the hospital carries with the idea of suffering, and the routine of the nursing team work generates moments of great emotional vulnerability (16) .
Thus, a way to support the professionals to handle these confrontations is to create prevention strategies of moral suffering, and one way is through education and the development of ethical competence.This becomes important for both job satisfaction and availability in care and for retention of professionals in the workplace (17) .
Being available for the patient, that is, through their presence, attention, care, help, and information, is a way to support emotionally, providing an emotional closeness and favoring meaningful exchanges between patient and professional (10,18) .In oncology, it is essential that the nursing staff can maintain good communication and relationship with the person with cancer and his family, viewed as an inseparable part to the comprehensive care.Another approach that is growing is based on the model of care of the multidisciplinary team, which brings challenges and demands skills to teamwork (19) .
Therefore, it is presented as fundamental that the institutions should provide their employees with a space dedicated to the discussion so that the perspective is also geared to take care of those who care (20) .The creation of spaces for discussion, exchange of experiences, even rounds, can be a way to reduce stress and distress situations.It is must be considered that the scientific and technological innovations require reformulation of nurses in ways of thinking, being and acting on the demands and requirements of care practice (9) .Knowledge of nurses is the result not only of theoretical and technical knowledge acquired through formal training, as well as practical knowledge gained from experience and the relationship established with patients.With time and experience, the nurses learn to mobilize, integrate and transfer knowledge to practice, to develop their skills (9) .
It is identified that continuing education and interdisciplinary activities can result in improvement of professional skill and care provided to patients (21) .

FINAL CONSIDERATIONS
Faced with the complex issues presented, it is considered of fundamental importance the involvement and participation of nurses in discussions involving cancer patients in searching for more knowledge on the thematic.
Nursing has experienced difficulties in the daily life cancer care.In this context, developing several forms of management not to create emotional bonds, being this a paradox, for assistance to the person with cancer, while mobilizing the most varied emotions, demand a behavior protection and management of feelings and emotions.
To the extent that this study addressed nurses from different institutions in two of the capitals of the south of the country, its results are representative of the way of being and doing of a region.However, its scope is limited, not being possible to generalize the results, as each team and institution have very distinct characteristics.