The Living, Dynamic and Complex Environment Care in Intensive Care Unit

OBJECTIVE: to understand the meaning of the Adult Intensive Care Unit environment of care, experienced by professionals working in this unit, managers, patients, families and professional support services, as well as build a theoretical model about the Adult Intensive Care Unit environment of care. METHOD: Grounded Theory, both for the collection and for data analysis. Based on theoretical sampling, we carried out 39 in-depth interviews semi-structured from three different Adult Intensive Care Units. RESULTS: built up the so-called substantive theory "Sustaining life in the complex environment of care in the Intensive Care Unit". It was bounded by eight categories: "caring and continuously monitoring the patient" and "using appropriate and differentiated technology" (causal conditions); "Providing a suitable environment" and "having relatives with concern" (context); "Mediating facilities and difficulties" (intervenienting conditions); "Organizing the environment and managing the dynamics of the unit" (strategy) and "finding it difficult to accept and deal with death" (consequences). CONCLUSION: confirmed the thesis that "the care environment in the Intensive Care Unit is a living environment, dynamic and complex that sustains the life of her hospitalized patients".


Introduction
The care environment involves multiple dimensions of care, and comprises a set of elements that integrate it, and it is necessary to take into account the whole that involves the parts, in the same way as the parts that involve the whole, as is well argued by the idealizer of complex thinking (1) . These aspects, however, are not always considered in the biomedical health care model, whose focus is centered on disease, fragmentation of knowledge, doing and being professional, in which sometimes, not even the being that is cared for is seen as an integrated whole, a being with multiple social relationships, potentiated by the natural and social environment.
In this sense, the care environment requires the creation of conditions favorable to health, promoting a healthy and constructive environment, with harmonious, vitalizing interpersonal relationships that potentiate positive energies for better living (2) .
From this perspective, the health/nursing care environment needs to be better known and understood so that it attains a systemic dimension. It must be apprehended as a circular process that takes into account both the individual who needs care, and the conditions in which this is provided, the human resources and materials available, interpersonal relationships, interactions among health professionals, patients and family members, as well as interactions with the environment.
The care environment in an Intensive Care Unit (ICU), focus of the present study, is an environment intended for the care of seriously ill and unstable patients, who generally remain in the hospital environment, and its complexity is considered high, because it is equipped with leading edge technological and computerized appliances. Here, where aggressive and invasive procedures are performed, the pace is accelerated and the duel between life and death is ever present; and death is frequently imminent (3)(4)(5) .
Therefore, the ICU is frequently stigmatized, and is able to generate erroneous conception with the regard to the care and attitudes of the team (3) . In a similar manner, the ICU is also seen as an environment that generates myths, contradictory sensations and feelings, such as anguish, sadness, pain and suffering, safety and insecurity both in patients and family members, and in professionals who work in this unit.
In this direction, we point out the concepts of order and disorder of Edgar Morin's Theory of Complexity. While the concept of order conveys the ideas of "stability, rigidity, repetition and regularity, in conjunction with the idea of interaction, and necessarily defines itself in its own terms of disorder, which comprises two poles: one objective and the other subjective. The objective pole is that of agitations, dispersions, collisions, irregularities and instabilities, in short, the noise and errors" (6) . Whereas, the subjective pole is that of unpredictability that leads to disorder brings into evidence the uncertainty that brings with it randomness/chance, which is indispensable in the appearance of disorder (1) Complexity also involves diversity, intertwining and interdependence, and must be understood as an open, broad and flexible system of thought; that is, complex thought. This type of thinking leads to a new comprehension of the world, and to the understanding and acceptance of continuous changes in reality, without denying their multiplicity, randomness and uncertainty, but seeking to coexist with them (7) .
Simultaneously, complex thought is also "antagonistic and complementary; contradictory and ambivalent, but is in a constant state of transmutation (8) .
The present study is a summary of the Doctorate Thesis entitled "A sustentação da vida no ambiente complexo de cuidados em Unidade de Terapia Intensiva" (9)(10) , which was based on the following

Method
The method used was the Grounded theory, and the study was conducted based on the principles of theoretical sampling, so that data collection and analysis were performed in alternative sequences and comprised four consecutive stages. In total, the theoretical model was composed of 39 interviews held with 47 differentiated subjects. paradigm was used, recommended by Strauss (11) , as a facilitator instrument that involves an organizational scheme that helps to systematically reunite and put the data into order and classify the emergent connections.
In order to comply with the research ethics criteria, the following were taken into consideration: Unit", has two categories as causal condition, defined as follows: "Caring for and monitoring the patient continuously", and "Using adequate and differentiated technology", which justify the existence of the ICU.
As context, it also has two categories; that is to say, "Providing a suitable environment", and "Having worried family members". The intervening conditions refer to the category "Mediating facilities and difficulties". In its turn, "Organizing the environment and managing the dynamics of the unit" is the category that was defined as

Caring for and monitoring the patient continuously
In this study, "Caring for and monitoring the patient continuously" was determined as one of the causal conditions, because it concerns the actions related to the support given to the seriously ill patient, who requires

Using adequate and differentiated technology
The category "Using adequate and differentiated technology", also considered a causal condition, forms part of the ICU structure; that is to say, it is a determinant condition of the existence of the ICU, and which differentiates it from the other environments.
It has the following sub-categories: "Technological Resources" and "Material Resources".
With regard to technological resources, in an ICU, the use of technology that differs from the type used in other care environments is indispensible . An adequate ICU environment involves suitable technology; that is to say technological appliances, such as infusion pumps, respirators, cardiac monitors, oxymeters and others. As regards material resources, in the ICU there is the need for and use of many materials and items of equipment, and they need to be suitable, sufficient and of quality, in order to avoid exposing patients to risks. There is strict control of materials, and generally, there can be no lack of materials here. The ICU professionals showed great concern with regard to the environment, particularly about the size of the space where patients are found, the presence of natural light, the presence of a window in each box in order to situate patients in time, and to enable them to perceive whether it was day or night; they were concerned about individualizing the patient, preventing one patient from seeing the other; they were alert to the privacy of patients, using curtains around each box.

Having worried family members
The category "Having worried family members" includes the following sub-category: "Reporting the  However, the presence of family members in the ICU is very restricted, and they generally com to the ICU only during the patient visiting hours, which are fractionated and generally occur three times a day; that is in the morning, afternoon and at night, totaling around one and a half to two hours of daily visits.
One of the studied ICUS had visiting hours only in the afternoon and at night, with only 30 minutes at each time.

Mediating facilities and difficulties
Facilities and difficulties are considered intervening conditions in the ICU environment and are inherent to its existence; that is to say, they also form part of the structural conditions of the unit and need to be mediated and taken into consideration for it to work well. In the ICU, as in other environments, professionals find factors that facilitate care, as well as factors that make it difficult.
The category "Mediating facilities and difficulties" is composed of the following sub-categories: "Professional competence"; "Working conditions"; "Demonstrating concern about professional education and encouragement for training/qualification"; "Needing to integrate theory and practice"; "The presence of stress", and "Dealing

Discussion
It is believed that the Grounded Theory was the most adequate method for this study, due to the relevance to the subjective indicators, and because it According to the Ministry of Health of Brazil, the ICU involves a set of elements grouped in a functional manner, destined to care for severely ill patients or those at risk; that is to say, patients who present some condition that is potentially determinant of their instability, and for this reason they require uninterrupted medical and nursing care, in addition to specialized equipment and human resources (13) . visiting hours (14) .
The reality of Brazilian ICUs, in general, does not yet contemplate all of these aspects, such as individual rooms for patients, with a view of nature, an area for the family and free visiting hours. However, the country has increasingly invested in improvements in the ICU care environments, making them more welcoming and humanized and extending the visiting times.
A study conducted in Germany, in order to gain better knowledge the situation of families of patients hospitalized in ICUs, has shown that they live with uncertainty, crushing emotions, in addition to having to assume additional responsibilities (15) . According to the authors, the family members at all times place the patient hospitalized in the ICU in first place and always want to be close to him/her, with or without participating in the care. In addition, they seek to obtain honest information, social support, and at all times try to keep on being hopeful about the patient's improvement.
Another study conducted, sought to review the context of the care environment of the ICU with regard to safety of the patients and quality of care, specifically with respect to the association between health and infection and the problems and solutions that involve the interdisciplinary team. The scope of the topics included the actual and future architectural design and trends in layout; trends that affect the construction of intensive care units and prevention of construction associated with infections related to care, which involve airborne and waterborne risks and design solutions (16) . In addition, they took into consideration, the internal environment in the perspective of planning, analyzed patients and their families, the medical team and the need for space to conduct research into ICU design (17) .
Considering the development of science and social progress, the latter authors increasingly defend the human-center design; that is, design centered on the human being, from thepoint of view of the users, with  Thus, the ICU environment is a place intended for the care of severely ill, unstable and recoverable patients, who are at risk of dying, but who are not hospitalized in the ICU to die.
Nevertheless, due to the severity of the condition in which the patients are found, the limit between life and death becomes a constant presence in this environment, and consequently, the professionals feel satisfaction with the recovery of patients' health, but also feel frustrated and have difficulty in accepting and dealing with their death.
This frustration and difficulty to accept and deal with patients' death in ICU often translates into suffering for professionals. A study that investigated the feelings of suffering of nurses in the ICU, showed that the suffering is related to the care of young critical patient, with the patient's family, teamwork, lack of recognition the work done and the technology at work (18) .