Proteção radiológica e a atitude de trabalhadores de enfermagem em serviço de hemodinâmica

Estudo qualitativo realizado em servico de hemodinâmica de Santa Catarina, Brasil. Objetivou-se analisar a atitude dos trabalhadores de enfermagem em relacao ao uso das medidas de radioprotecao em procedimentos intervencionistas. Utilizou-se a Metodologia da Psicodinâmica do Trabalho. Tal metodo se desenvolveu em diferentes etapas, a saber: a demanda e a pre-pesquisa, a pesquisa propriamente dita, o material da pesquisa, o metodo de interpretacao e a validacao. Ao todo foram realizados 36 encontros, no periodo de marco a novembro de 2009, totalizando aproximadamente 54 horas de observacao. Os resultados mostraram que os trabalhadores utilizam estrategia de defesa para justificar o uso incorreto, o desconhecimento ou mesmo a nao utilizacao de algumas medidas de radioprotecao, que foram evidenciadas por meio da alegacao do desconforto e do peso das vestimentas de chumbo. Conclui-se que certas atitudes adotadas pelos trabalhadores referem-se tambem a falta de um programa de educacao permanente que aborde essa tematica.


INTRODUCTION
Hemodynamic services are also called the Cardiac Catherization Laboratory (CCL) in the directives of the Brazilian Cardiology Society (SBC), and to understand that this area of knowledge is part of the health services, the concept of CCL was adopted here. 1echniques in this service are guided through the use of fluoroscopy, with the primary objective of diagnosis and treatment of diseases of the cardiovascular system.This technique renders the minimally invasive procedures and benefits to the patients who need to undergo: implantation of a pacemaker, cardiac stent placement, cardiac catheterization, angioplasty, among others.] Considering the praxis of nursing in the CCL, it is worth noting that in order for these employees to perform their activities, they generally have a higher workload than other healthcare workers recognized as performing activities with ionizing radiation, as is the case of the technical professionals in radiology, radiologists, and also interventional cardiologists. 4 Moreover, in his academic development, the nurse in Brazil, regardless of the level of education, whether technical or higher, generally does not receive qualification about the principles of radiation protection for working in this knowledge area. 5t should be remembered that technological advances regarding the use of ionizing radiation have revolutionized health practices and consequently the work of nursing.However, it is clear that the incorporation of these technologies did not bring the end of hard and dangerous work, in contrast, inequalities and social injustice accentuated themselves and caused forms of qualitatively more complex and subtle suffering, so that they are not always perceived by employees, [6][7] notably when it comes to exposure to ionizing radiation.The employees who work in the CCL suffer damages arising from ionizing radiation, without having preparation to minimize the radioactive effects, which brings an important concern when considering the health of these employees, this being one of the questions in this study.
The question arises, therefore, what do employees who work in the CCL do in order to protect themselves from ionizing radiation?Do they know the effects of such a workload?What can be done to minimize such damage?These are some of the concerns that led to the development of this research.
Incidentally, it is worth mentioning the example of Spanish law that determines that all health professionals likely to be exposed to ionizing radiation have education in radiation protection.This legislation also establishes workload for some health professionals, such as the nuclear medicine physician, the radiologist, and others. 8herefore, considering these aspects, this study had as its objective: to analyze the attitude of nursing staff related to the use of radiation protection measures in the interventional procedures.

MATERIAL AND METHOD
We used the psychodynamics of work approach, which, according to its epistemological nature, favors the qualitative aspects in relation to the quantitative. 9This methodology deals with the relationship between pleasure and suffering at work, emphasizing the important role that the work organization exerts over employee health.Such a method has been developed in different steps, namely: demand and pilot study, research, the research material, the method of interpretation, and the validation of data. 9n the psychodynamics of work, demand and pilot study constitute the first stage of research and certain criteria established by Dejours to develop the method must be followed.These include answering: who demanded the research?What is the demand?And, to whom was this demand directed?Therefore, to attend to these criteria, the research was demanded by nursing professionals in seven CCLs in the state of Santa Catarina, Brazil.
In relation to demand, the research considered, above all, the concerns of these professionals, such as, among other inquiries: who must remain in the exam room to assist the interventional physician?How should I use the dosimeter?How should the occupational monitoring of employees occur within this work process?Thus, the acknowledgement of this demand, performed through the pilot study, was essential to ensuring the chain of other steps established by this methodology.
The research itself came from data previously identified and treated in the pilot study, that is, data of the CCL that demanded research.With the information of the seven services that demanded research, the research itself was then begun.
Given this demand, the research was conducted in a CCL headquartered on the premises of a private philanthropic hospital accredited to provide assistance in the area of interventional cardiology in Santa Catarina, Brazil.
The research material was extracted from the observations, colective interviews and documentary analysis.Altogether 36 meetings were held during the period from March to November of 2009, totaling approximately 54 hours of observations.
The meetings occurred during the morning and afternoon shifts, usually at the times scheduled for cardiac catheterization exams and angioplasty, with a duration of one to two hours.
At each meeting, a mean of four to five employees participated.The meetings were recorded with the consent of workers, for later transcription and validation of the data.
In the document analysis, monthly reports of individual dosimetry in the past two years (2008 and 2009), the frequency of the occupational examinations, and documents concerning the organization of work were analyzed, such as: work schedules, norms, routines instituted and reports of the demand for examinations in 2008 and 2009.Institutional documents were also analyzed, such as: service contract for dosimetry, among others.
Data validation occurred in two steps.The first was in the course of the observations, and the second with the inclusion of other employees of the CCL who did not participate in the field research.Data analysis considered the experience of the researchers who interpreted the research material in light of the theoretical corpus proposed in this study, being conducted by the statements of subjective experiences of the employees.
The research was submitted to the Committee on Ethics in Research of the Instituto de Cardiologia de Santa Catarina (ICSC), through CAAE n. 0020.0.145.145-08,receiving a favorable review for its publication, conforming to Protocol n. 101/2008.

RESULTS AND DISCUSSION
When conducting the research, one must start with some questions, such as occurred in this case.But it must be stressed that in addition to concerns present in the development of this study, this was also demanded by seven CCL in the southern region of the state of Santa Catarina, based on the application of a research poll during the pilot study, which made the composition of what Dejours calls the ad hoc collective of employ-ees possible, 9 for whom this research was directed, that is, employees in these services.
The results of this study are the outcome, therefore, of observations and of the word of the collective of employees, and the data presented here refer principally to the observations.Based on the observations, the process of working in CCL and nursing participation in actions involving exposure to ionizing radiation are represented in figure 1.In this figure, activities performed in free areas, supervised and controlled, from the point of view of radiation protection, can also be identified.In the work process, patients and employees are exposed to ionizing radiation.
In addition to nursing, activities in this service involve other health professionals who compose the team, as an example, the radiologist and the radiology technician professionals, among others.
It is important to remember that the exam room in the CCL is an environment that closely resembles an operating room in which the primary instrument of work is equipment that emits radiation.
In this work process, health workers perform actions involving pre-, intra-and post-interventional procedure care, as well as patient reception, preparation, guidance, and acquisition, recording, interpretation and archiving of images, among others.It is in this context that the employee, often lacking in specialized knowledge, is exposed to ionizing radiation.Thus, knowledge about radiation protection constitutes an essential working tool for those employees.] Such measures, when not utilized adequately, contribute to damages to the employee resulting from physical work load, or ionizing radiation.
Using the Dejours methodology to discuss the damages that occured with exposure to ionizing radiation, although its adaptation was necessary given that the available reference addressed the manner of psychological loads, it was possible to give visibility to the diverse workloads present in the daily work in the CCL.This was especially true of the physical loads, which constituted the primary concern, especially in the speech of employees who recalled those who had been exposed to an excessive physical load of ionizing radiation in the past, since radiation is cumulative and may take time to manifest itself, namely, five to ten years after the interaction with the body of the employee.Working without the minimum protective conditions revived situations that preoccupied them, because the research led them to reflect upon their health and radiation safety.Thus, investigating nursing praxis in CCL, and the attitude of nursing staff regarding the need for radiological protection was not an easy task.In addition to the fact that this load was invisible and required time to manifest itself, added to this was the difficulty that employers presented in relationship to such manifestations of this physical work load, and also because this type of damage may occur as a function of other variables, such as the nature of the human being.
Associated with the fact that this load was invisible, there was a "right" to disregard the continuing education of employees, such that in Brazil, the Federal Council of Nursing (COFEN) in 2004 issued Resolution n. 290.12 which regarded the nursing specialties, denominating this as Nursing in Diagnostic Imaging.] However, this resolution did not address the issues of mandatory qualification of this professional for activities in this area.
Because they do not know how to protect themselves, these professionals utilize defense strategies to justify not using some measures of radioprotection, a fact identified in the observations of that praxis.Such strategies could be evidenced by the claim of the discomfort and weight of lead clothing, and the lack of the need to use certain equipment, such as lead glasses and gloves.Yet it was evident that the measures relating to distance from the radiation source and the exposure time were not always adopted, with forgetfulness alleged.
Such defense strategies were evident in the dialectical relationship that was maintained throughout the research process, the method itself, realizing that the ad hoc collective of employees was afraid to talk about these issues, as if this problem was not happening with them and, when asked, the answers were hollow and almost always loaded with apologies.
"The purpose of the collective strategy of defense is the denial of danger; it is the transformation of the subjective situation into its opposite.Potential victims passively exposed to risk [employees] become provocateurs of a purposeful challenge, becoming the challengers to their own peril.:204 exam The analysis of the dosimetry reports showed that employees were being monitored regularly, however, the following issues were frequently noted: the incorrect use of monitors, the forgetfulness within the exam room, and the non-use by employees.When questioned about why these behaviors occurred, employees claimed forgetfulness.Thus, the values found in the reports do not faithfully represent the actual values of radiation doses received by these employees.Figure 2 shows the distribution of individual doses of only five workers that used the dosimeters with some regularity.In this figure it is observed that the doses were within the permitted values, or 20 mSv.However, it is worth clarifying why some employees have relatively higher doses compared to other workers performing the same functions, as is the case for workers 1 and 4, respectively.During this period these employees effectively fulfilled their workday in controlled areas, not reporting departure for any reason.This was in contrast to worker 5, who did not effectively meet his workload in this area in 2008, and did not present a dose of radiation, and in 2009 the dose was 0.3 mSv for a single month in which he effectively enforced his workday.In the remaining months, although he had worked in this area to cover gaps or absences due to illness, the dose remained below the threshold for reading.Thus, it is important to clarify that the radiation dose received by one employee is proportional to the time that he is exposed to ionizing radiation. 15he documentary analysis of occupational exams in the last two years (2008 and 2009) revealed that in 2008 monitoring was conducted every six months, as the law prescribes, but this was not maintained regularly in 2009, thus not complying with what the law prescribes.
With regard to this occupational control, the Nuclear Standard 3.01, of 2005, of the National Nuclear Energy Commission (CNEN), as well as Ordinance 453, of 1998, stipulated that rightholders and employers should implement a program for initial and periodic occupational health assessment of employees occupationally exposed to ionizing radiation. 10,16his program should be based on the General Principles of Occupational Health, with reference to Regulatory Standard NR n. 7, of the Ministry of Labor and Employment, which provides for the Medical Control Programme of Occupational Health (PCMSO).This program mentions the parameters for the monitoring of occupational exposure to certain health risks, including the risk of exposure to ionizing radiation. 11owever, the laws and regulatory standards are not sufficient, if the employees are not aware of them. 17How can one protect oneself adequately, without having this knowledge?Thus, this study made reflections of the nursing staff who worked in the CCL possible, and such a theoretical and methodological framework aims not only to give voice to the employee, but to make it possible to be an active subject in the work process.The findings encountered in this study reaffirmed the conviction that employees engaged in the praxis in the CCL should do it consciously, and that continuing education is a way to enable them to protect themselves from the damages resulting from the work process.

CONCLUSION
To analyze the attitude of nursing staff related to the use of radiation protection measures in interventional procedures was not an easy task, because in addition to being an invisible risk and taking time to manifest itself, employees are reluctant to relate with exposure to ionizing radiation.
However, it was revealed that employees did not associate with exposure to ionizing radiation, making use of defensive strategies expressed by denial and relating them to family inheritance, the fact of being a woman, and even to chance.In short, they trivialized such manifestations and adapted to the situation as if it were something normal, perhaps for fear of losing their jobs, or even one of their jobs, as there are employees who work in two places, both with radiation.
Such defensive strategy was evident in the dialectical relationship that was maintained throughout the method in the research process itself: it is noticed that employees were afraid to talk about these issues as if the problem was not happening to them, and when questioned, the answers were evasive and often laden with excuses.
The majority of employees made reference to discomfort regarding the use of individual lead clothing and the omission of the department to provide some of these, such as glasses and lead gloves.It was also evident that the department did not offer qualification for work in this area, despite the desire of these employees for greater security with qualification of this work process.
Given this evidence that employees are exposed to ionizing radiation, especially, through ignorance, not only of the use of radiological protective clothing, but also the basic measures of how to protect themselves from the radiation, Continuing Education (CE) is a way to change this reality.Listening to the employees talking about their needs and problems experienced in the daily work was crucial, because we can then understand the real needs of the employees, based on problems encountered in practice.In this context, the CE should be designed to generate in employees attitudes consistent with the principles of radiation protection in the CCL.

FlôrFigure 1 -
Figure 1 -Work process in hemodynamics and nursing praxis

Figure 2 -
Figure 2 -Distribution of individual doses expressed in mSv (milisievert) relative to 2008 and 2009