NURSING PROFESSIONALS ’ ANXIETY AND FEELINGS IN TERMINAL SITUATIONS IN ONCOLOGY

Disponible en castellano/Disponível em língua portuguesa SciELO Brasil www.scielo.br/rlae 1 Psychologist, Specialist in Health Psychologist, Master student, Professor, Vale do Acaraú State University, UVA, Brazil, e-mail: daniella-psi@uol.com.br; 2 PhD Professor, Rio Grande do Norte Federal University, Brazil, e-mail: emcmaia@ufrnet.br NURSING PROFESSIONALS’ ANXIETY AND FEELINGS IN TERMINAL SITUATIONS IN ONCOLOGY


INTRODUCTION
Studies have demonstrated that health teams in hospitals are under the risk of stress and tension at work (1)(2) , especially those in nursing, highlighted as the 4th most stressing work in the public sector (3)   .This risk of tension is due to the fact that these professionals deal every day with several occupational stressors, such as working in an environment were death and dying are part of their routine (4)(5) , especially for professionals working with patients with severe diseases (5) , with excessive workload and lack of physical, material and human resources (6) .Other variables may maximize this tension; there are investigations that state that oncology nursing is one of the most stressing activities (7)   , although there are controversies (8) .The fact is that dealing with cancer patients (9) and with terminality (10) is described as stressful and emotionally demanding for nursing professionals (5,(9)(10) , since death is seen as a failure to give efficient and effective care (11) .
In Brazil this becomes more complex, because professionals frequently face a reality where there are more patients than beds, crowded emergency rooms, forcing them very often to select who will be cared for, and how they will be treated (4) .
Due to these issues and the absence, in our environment, of more specific studies monitoring the level of anxiety, and the feelings of the nursing team dealing with terminal cancer patients, this study aimed at: 1. Assessing the level of anxiety of the nursing team dealing with terminal cancer patients, to identify the factors that influence the last; 2. Identifying the feelings of the team regarding terminal patients with cancer; 3. Identifying in which stage of human development (childhood, adolescence, adulthood, or old age, in their corresponding age groups) of these patients they find it harder to perform their job; and 4. What is the possible explanation given by these professionals for the age group chosen?
It is important to highlight that anxiety is one of the stress indicators (personal depletion interfering in the life of individuals) (6) and may become pathologic when it is more intensive (3) .Worsening of this situation may lead to syndromes, such as for example, the Burnout, that involves exhaustion, caused by an excessive burnout of energy.This syndrome is currently studied by several authors (5,12)   , who point out the risk of burnout in health professionals, especially nursing that, as already mentioned, is a career considered extremely stressful (3,12)   .
Thinking about these issues, we believe that the current study will help becoming aware of the triggering factors of anxiety in professionals dealing com dying cancer patients, enabling to identify the level of anxiety of these professionals, as well as the feeling they have when they are working within this reality.Being aware of this may help designing care strategies for professionals that dedicate themselves to this work, so as to reduce high levels of anxiety and stress, extremely harmful to health and to professional performance.

Sample
Fifty nursing professionals (Nurse Assistants and Technicians) from both genders of a reference hospital in the care for cancer in Rio Grande do Norte were contacted.It is worth mentioning the there was a sample loss of 07 participants, that refused to take part in the study, because they declared they had no time to answer to these instruments.Thus, the study had 43 professionals, 18 assistants and 25 technicians.
Inclusion criteria used were: care for patients in terminal stage in all age groups, and written consent to take part in the survey.

Instrument
To assess anxiety, Spielberger State-Trait Anxiety Inventory (STAI) (13) was used in the Brazilian version, known as IDATE.This instrument is the only assessing Trait Anxiety (A-Trait) and State Anxiety (A-State) and it has already been translated and validated into Portuguese (14) .IDATE is a self-applied A-State refers to the moment or certain situation, to something external the triggers the process called anxiety (13) .
A questionnaire was also especially developed with the purpose of tracing the profile of the sample and to collect data referring to feelings of these professionals facing the situation of dealing with dying Initially the researcher explained to nursing professionals the objectives of the survey and the instruments that would be used.When patients agreed to take part on a survey, they gave their written consent, and then IDATE and the questionnaire were individually applied.The time to perform all procedure was approximately 20 minutes.
Anxiety scores obtained through IDATE were assessed following the guidelines of the instrument (13) , then they were tabulated and underwent, together with the data from the questionnaire to statistical analysis using the Statistic program, version 6.0.To assess the outcomes obtained at IDATE, the following theoretical and methodological reference has been considered (14)    When this same analysis was performed for A-Trait, it was possible to see that A-Trait presented a mild correlation with Age and with Time working in the institution r =0.2 and r= 0.32 (respectively) (Table 3).presence of 4 most significant words in Class 1:'Not' (Chi-Square = 17.56), 'Lived' (Chi-Square = 10.86),'Yet/Still' (Chi-Square =10.86), and 'a lot' (Chi-Square = 8.55).ALCESTE selects these words based on the answers described by professionals and the greater the Chi-square, the more significant the word is in the speech.Thus, the explanation given by these professionals for the difficulty in dealing most with children was guided by the reason that children "have still not lived a lot" and because of that they got more involved when children are terminally ill.The following statements can be an example:

ANALYSIS
Based on these outcomes, it was observed that mean level of A-State (48.14) and of A-Trait (46.74) corresponded to mean level of anxiety according to the reference used (14) .This means that, overall, in these professionals anxiety, both as a personality trait and as due to a reaction to a certain event (in this case, the anxiety after caring for a patient with cancer terminally ill) is in the middle level.
However, we must point out that value A-State is almost surpassing the maximum value to consider it High Anxiety (>49), and also that level A-Trait was lower than A-State, suggesting that the situation these professionals face (caring for terminally ill patients) increased their level of anxiety in some way.On the other hand, IDATE was not applied before and after the exposure of professionals to terminal patients, preventing us to state more precisely that this increase in anxiety comes from this care, also because surveys show that hospitals are stressful and lead to anxiety (4) .Thus, this increase in anxiety may be only due to hospital work.that have high load of patients are at risk of stress (1) .
Double jobs are also pointed out as source of stress and tension for health professionals (2)   .
Although the literature points our variables such as the number of hours worked (2) as a factor contributing to tension and anxiety of professionals; in this sample correlations between anxiety and this variable were not seen.There are studies that present a correlation between level of tension and age (12)   .In the present survey, a similar outcome was presented, the literature (13) and the statistical analysis of our study, this means that Age and Working time will not only increase A-Trait but also A-State.This suggests that dealing with this reality may lead to, in the long run, an increase in anxiety of the subject, making this job risky to the health of professionals.
Another essential fact to the discussion in the practice of these professionals is the issue of the death of patients.According to some studies the possibility of death of patients may lead to stress and a feeling of powerlessness of health professionals (10) .This may be understood because society makes these professionals accountable for maintaining life (4) , and when this "mission" cannot be reached it leads to anxiety, despair and frustration (4,10)   .This has also been demonstrated by our study, when 65% of the professionals studied stated that they felt different when they cared for terminal patients, they have also stated feelings such as suffering, sadness, anguish, powerlessness, fear, apprehension, concern.These feeling presented in our study were similar to those of a survey (10) with cancer physicians of the city of Thus, terminal diseases are frequently feared, and it is common that in hospitals, professionals change their shifts to avoid dealing with terminal patients.
Avoiding death in hospitals, however, is not possible, because as medicine had become a practice urban-center and hospital-center, hospitals have become the privileged "site" of death, and in terminal patients, this reality becomes even more present and objective, demanding a realistic attitude of professionals regarding their patients who are dying (10) .
In addition to the issue of terminality, for professionals surveyed, there is another complementary issue: the stigma of cancer as a fatal disease (9)(10) , which may lead to tensions and anxiety for these professionals (5,10) .
However, it is still unknown if working with cancer patients is a more stressful activity than others, because the studies in this area are contradictories (2) .
On the other hand, we may conclude that childhood was the development phase that was most difficult for the assessed professionals to deal with regarding terminal cancer.Overall, the explanation given by these professionals was that children in terminal stage are more difficult to deal with because they have not lived enough and have their whole lives ahead of them.This was one of the initial hypotheses of this study, since death, especially during childhood, is many times seen as medical failure (11) .It is as if childhood death was something unacceptable, against the natural order, and thus, it is transferred to a remote time, the elderly.Therefore, death of the elderly is more acceptable than that of the young people by the team (15)   .This perception seems to be shared by members of our study when most of them pointed out the elderly as the age group where they found it easier to care in terminal stage.
From this study, it was possible to understand better the emotional aspects of the nursing team facing terminality and cancer, issues that lead to anxiety and stress (1,4)   .However, it is important to highlight that this study presents limitations: first, it represents the experience of a single Cancer center, although it is a reference in the State of Rio Grande do Norte; another aspect is the refusal of some professionals to take part in the study, because they had no time.Additionally, we cannot say that the increase in the level of anxiety of these professionals is because they deal with cancer and terminality, this could only be possible if the test had been applied in two times -before and after careand the performance of the survey in another institution dealing with another specialty rather than oncology.
Last, the outcomes of the survey, suggest the need for intervention models of care, as for example, support groups, and/or reflection groups, for health professionals facing this reality, because the emotional suffering of these professionals may interfere not only in their health but also in the quality of care.Thus, further studies are necessary to deepen these issues and also, other studies that not only design but also make support strategies viable for health professionals dealing with terminality so as to contribute to the prevention of occupational diseases and to improve the quality of life of professionals and their patients.
These surveys will definitely corroborate the prevention of occupations diseases.
inventory, made by two different scales designed to measure State (Part I) and Trait (Part II) of anxiety.A-Trait is defined as a relatively long lasting characteristic of subjects that goes beyond the boundaries of time and place, therefore, arising regardless of where they are or what they are doing.
…I find it hard to see children sick, I am very touched.I remember my grandchildren that still have a lot to live they have just lived a little and are already dying… C.L.U (Nurse Technician)....Because they are young patients, children, they have their whole life ahead of them and this situation is very sad, one may be angry, despaired and so on in this situation.The family get sad and professionals too… C.L.U (Nurse Assistant).

For
our sample only the Number of patients cared for per day and Working in another institution presented significant correlation for A-State.Therefore, the more patients professionals see every day, the greater their A-State will be.Thus, high Number of patients cared for per day and working in another institution would be risk factors for these professionals dealing with this demand.More precisely: Multiple Linear Regression could build a model where it is estimated that, on average, A-State increased 0.197 for each increase of one patient cared for per day by these professionals.A similar conclusion was published by a survey where the outcomes show that Lithuanian General Practitioners with a small correlation between A-Trait (anxiety as a more stable characteristic of the subject) with Age and Time working in the Institution: the greater the age and the time working in the institution, the greater A-Trait was.If A-Trait increases with the advance of Age and Time Working in the Institution and if it is correlated with A-State as suggested by

Table 2 -
Correlation matrix for variable a-state make the model.Based on the regression model (Y = β 0 + β 1 X 1 + ε), in which the parameters β 0 and β 1 represent the regression coefficients, Y represents the dependent variable, X 1 , the independent variable, and e the error; the regression model estimated was: Y ˆ= 44.388+ 0.197 X, when: Y ˆ = Estimated A-State, children as the age group where they find most difficult in this type of care.On the other hand, 42% of professionals say that the elderly is the age group where they have less trouble caring for when they are terminally ill.professionals there are some words that were more frequently used in the speech, making it possible to build a representation of what these professionals feel and think when they care for patients in this reality.The Lexical Analysis performed by ALCESTE in the narrative of these professionals highlighted the

Table 3 -
Correlation matrix for variable A-Trait

Trait and with number of patients cared for in the day
2 = 0.23715867) of the variation of A-State of the professionals assessed, where only the variable number of patients cared for was significant to Nursing professionals' anxiety... Faria DAP, Maia EMC.