THE OUTCOME OF NURSING ERROR AS ATTRACTIVE TO THE MEDIA

Objective: to interpret, from the perspective of the Theory of Communicative Action, how the outcome of nursing errors can become attractive to the media, highlighting the main implications for the image of the profession and the imaginary of society. Method: qualitative research, carried out in documentary sources using news published in the major newspapers available online in two countries, Brazil and Portugal, from 2012 to 2016. The analysis of the findings was carried out following the steps of hermeneutics, based on the Theory of Communicative Action. The data were organized and coded in the ATLAS.ti software. Results: the research included 112 published news. Four categories emerged from the analysis: The highlights in the headlines - The beginning of persuasion; Combining image and initial text - An explosive mix; The error that is not an error - The error that is a crime; and Applying the validity claims in the discourses. Conclusion: the media are continuous producers of ideologies and, therefore, possess social responsibility


INTRODUCTION
2][3] This reality has generated discussions that have driven positive changes in health practices in several countries.The changes that have occurred relate to the safety culture that has been increasingly implemented in health organizations, along with the use of care protocols, safety goals and health risk management.However, despite the importance of these initiatives, these errors continue impacting negatively on health care.
In nursing, where the professionals are constantly together with the patients and family members, patient safety has been much discussed.Nursing care errors can be very serious, and range from near miss (almost an error) to small lapses (such as changing medication times and major adverse events) that worsen the patient's health condition and can lead to death quickly.These are the cases of substance exchange in medication or exchange of routes of administration of medications. 4ailures in nursing care are derived from many causes and can be related to different factors, with greater emphasis on work organization, such as problems related to the nursing workforce (staffing, turnover, work overload and stress, deficit in training and qualification), materials and equipment (similarity in labeling, packaging and design, lack of material and information about them, physical structure).][6][7][8] The scientific literature has the greater purpose of publishing research results that contribute to the prevention of these events and to the greater control of risks -often inherent to nursing care.Different from that, the media publishes these negative results emphasizing precisely the outcome of the nursing errors. 9he media represented by the print and television media, Internet and social networks have highlighted nursing errors, especially those related to drug administration and negligent attitudes that have resulted in death and very serious sequelae. 9This information provokes feelings of fear, insecurity and even anger when people associate these incidents with nursing care.
Media communication, in general, aims to inform society about facts and events; however, the problem is the way information is written using rhetoric and persuasion techniques, extremely effective for maintaining readers' interest.Thus, this form of communication allows for the induction of certain thoughts to the reader, because what is being reported is not always an absolute truth, although there is an expression in a definite form, and that is precisely where the hasty judgments lie. 10 Rhetoric is designated as art in the use of language resources to influence and persuade the interest of an audience.In Aristotle (384-322 B.C.), the purpose of rhetoric would be to spread the truth but, over time, it has devoted more attention to the way in which language is expressed than to the content of the information. 11In turn, persuasion is strongly tied to ideologies, subjectivity, and historical and social contexts, so it gives rise to hypotheses that can be considered by the readers as important arguments that guide their judgments and future decision-making.Persuading refers to the emotions of the people who read and hear the information, or watch it. 11Persuasion is the act of convincing people to accept certain ideas, not necessarily in the sense of deceiving, but in the constitution of discourse as true. 12hat is observed in the media nowadays is information that tries to seduce the audience into facts that they understand to be important; and for this, there is an intensified exposure of what is intended to be revealed. 10Based on the logic that permeates the market of news and media 4/14 information, the negative result of the nursing work can be an attraction to stimulate the consumption of a reading that, in some cases, does not have the validity that must be attributed to information of such social relevance.
In this logic, with this study it was intended to interpret, under the perspective of the Theory of Communicative Action, 13 how the outcome of nursing errors can become attractive to the media, highlighting the main implications for the image of the profession and the imaginary of society.

METHOD
A qualitative, exploratory and descriptive research, based on documentary study.It was conducted by the Theory of Communicative Action 13 as theoretical framework and by hermeneutics for methodological analysis, with the intention of interpreting the published news that deal with nursing errors, highlighting the outcome of those errors that the media focus on.
To collect the data, we resorted to the newspapers considered to be of great circulation in two countries, Brazil and Portugal, available online, in the period from 2012 to 2016.As criteria for selecting the newspapers, the mean circulation in the country or region and availability to provide the material for analysis were considered.For the choice of the news to be included in the study, the involvement of nursing professionals in episodes of errors during care was considered, within the period stipulated for the research.
Data was organized, stored and coded in the ATLAS.tisoftware (Qualitative Research and Solutions).The process of data analysis followed the steps defined by hermeneutic analysis 14 and started with the reading procedures that marked the beginning of the analysis, seeking the meanings and the main units of analysis; the identification of possible meanings continued, and the previously identified units of analysis went through detailed analysis, being then linked to other parts of the text; in the end, the evident sensitivity was revealed, in which the meaning of the text emerged and clarified the meanings, enabling the construction of analytical categories.
At the last moment of the analysis, the validity claims were used 13 : intelligibility (in the texts, to verify whether the language was arranged in a comprehensive manner); truth (if the contents reported were true); sincerity (if there was sincerity in the facts exposed); and normative correction (if the texts were in accordance with the existing norms and values).
These claims 13 support the validity of a discourse, since it is in communication that truths are placed, because what is said as truth at one moment can be false at another.In this way, the possibility of questioning through communicative action intends to understand the facts in the entire context that is shown and hidden by language.
Regarding ethics, this research used materials in the public domain available to society, either printed or electronic.However, all those involved in the reports, nursing professionals, newspapers and journalists, were not identified.In order to ensure anonymity, the studied news were identified by abbreviations composed of the letter J for the newspapers (Jornais in Portuguese), followed by the initial letter of the country (B -Brazil and P -Portugal), with the letters identifying the region of the country in which the newspaper operates, plus a cardinal number of the order in which they were collected.In the end, four main analytical categories were built based on the title of the published news; the combination of image and initial text; the crime imputed to the error; and the application of the validity claims.

RESULTS
The results of this survey consisted of 112 journalistic texts that gave rise to the interpretations made.In this way, it will be shown what is manifested and what is hidden in the newspapers' printed communication about these episodes.The categories were formulated based on each stage of the methodological framework, to be then discussed according to the theoretical framework.
Initially, like all documentary research, the reading procedures were directed to the titles of the published news (headlines); thus, the terms and words that draw the attention were identified and coded for immediately referring to negative thoughts and the responsibility of the professionals involved.These terms were identified in the headlines of 54 analyzed news, representing almost 50% of the total.The marked highlights are arranged in Chart 1 according to the editorial resources used.
Chart 1 -Terms that stood out in the news headlines.Cidade, Estado, País.Ano.Some terms appear with more emphasis.The term death is emphasized in 56 (50%) analyzed news, and the term homicide in 38 (42.56%), without typifying what type of homicide, considering that there is intentional and unintentional.In the title, the term homicide appears alone and it is up to the readers to continue reading or to interpret it as they wish.
The term execution, which is linked to the intention to kill, was present in one of the published news, which reported the error in the preparation of a drug, a substance that can be very harmful if wrongly administered.Potassium chloride is the same component that, when applied directly to the vein, is used in the execution of the death penalty in the United States and also to kill dogs.In humans, it can only be used when diluted in serum and gradually.Applied directly to the vein causes death (JBNE12).
After reading the titles, the analysis of the text in full content of the news was performed, which usually begins with a short and concise sentence synthesizing the content of the news and then brings the information in more detail.Subsequently, the text was associated with the image illustrated in the news (when there was image).
Of the total analyzed, 64 (57.14%) news carry some image associated with the text.Of these, 29 showed images of the main façade or some sector of the hospital where the incident occurred and 9 included pictures of ambulances and screening wristbands (related to errors in pre-hospital care and emergencies).It is also be highlighted that 26 news (29.12%) included in their texts the following images: photograph of professionals with their heads down (four news), one of them with the professional in handcuffs, funeral's photograph of the patient victim of the error (three news), photograph of family members crying with the image of the victim in hand (three news), and photograph of the victims provided by their families (15 news) -among them, two of older adults patients; and the remaining 13, of children. Figure 1 illustrates some the images analyzed.With respect to the ethical precepts, dark stripes were placed in order not to expose those involved in the incidents.Subsequently, the news that dealt with the attribution of crime to the nursing error were analyzed.It was identified that 31 (34.72%)associated the error with some criminal typicity, being distributed as follows: manslaughter (23), intentional homicide (2), bodily injury no intentional (4), willful bodily injury (1), and willful bodily injury with eventual intent (1).The culpability attributed by the newspapers is related to malpractice, imprudence and, with greater expression, negligence.There is an exception for the Portuguese news, which have a different denomination from the Brazilian referring to crime typicity, being that, in that country, it was negligent homicide.

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Intentionality associated with the fact was present in two cases.The first refers to medication error, since the prescription and administration were wrong.In the second, a mechanical ventilator was turned off.Both cases resulted in the death of the patients, a child and an adult.
This week, the Brazilian Prosecutor's Office (PO) denounced five professionals of the [name of the institution] Hospital, for murder (article 121 of the Penal Code).They are two physicians, a nursing technician, a nurse and a pharmacist.The report refers to the death of an 8-year-old child on June 9 th , 2014, after the patient received a potassium chloride dosage four times higher than recommended by the medical literature.The child died hours after receiving the first of four doses of the drug (JBCO10).
According to head delegate [name of the delegate], the nursing assistant would have been responsible for disconnecting [name of the patient]'s devices and, therefore, she was indicted for intentional murder -when there is intention to kill.According to her, during the investigation, the assistant would have confessed that she had shut down the equipment as instructed by another employee.The person identified by the assistant as being the one that ordered the shutdown said, however, that he only asked the employee to stop the patient's sedation (JBS4).
The willful bodily injury with eventual intention was signaled in one of the news dealing with care during a home delivery.

7/14
The procedure was held on June 27 th last year in the family's apartment.The baby was sitting in the mother's womb and the contractions stopped at the last moment.The child's head got stuck.

The team is accused of willful bodily injury with eventual intention (JPPO4).
There were also professional conducts without any proof of the fact.Eleven-month-old baby who ingested rodenticide died soon after procedure.Mother accuses health center of medical error, due to the stomach washing procedure, done by a nurse minutes before the child dies (JBPE9).

National Institute of Medical Emergencies (Instituto Nacional de Emergências Médicas, INEM) DELAYS HELP TO A SEVERELY ILL PATIENT TO USE AMBULANCE AS A TAXI FOR THE NURSE. The wife of INEM's president, nurse of a medical vehicle and of the [name of the institution]
Hospital, is being accused of having delayed the transportation of a priority patient, with the connivance of her husband (JPPO1) (bold in the news item).
Regarding the validity claims 12 , Chart 2 presents the results that made possible the interpretation of the communicated discourse.

Intelligibility
All the texts were well written and made it possible to understand the message conveyed.

Truth
Of the total, 13 news included the word "nurse", which was later corrected in 9 of them, being 6 technicians and 3 nursing assistants.In Portugal, physicians and nurses were mistaken in 3 news.Other 3 news did not make reference to any professional category, only nursing.
As for the closing of the police investigation, 12 published news made inconclusive statements about it, given the time elapsed between the news being released and the time of the incident, which varied around 12 to 16 hours.

Sincerity
The most difficult claim to interpret in 100% of the texts, especially since it is not possible to verify whether the communication was written sincerely or with the intention of persuading the reader.

Normative Correction
Eighty seven news approached the discourse towards the prescribed norms for the profession, in order to validate the problem of the error as an ethical and professional responsibility issue.The others were not included in this validity claim, due to the absence of consistent information.

The highlights in the headlines -The beginning of persuasion
Editorial rhetorical resources are used to differentiate words and terms with the purpose of highlighting them from the text itself, drawing the reader's attention.These highlights are especially associated with the outcome, the result of the nursing error.The clearest example of this resource is the word death, the most worrying outcome.A more recent study has shown that in the United States 8/14 one death per day caused by medication errors is reported. 15Therefore, highlighting the term death can serve as a warning for this problem and a stimulus to rethink health care.
However, by bringing the terms responsibility, guilt and homicide in the headline seems a little hasty most of the times, mainly because these accusations are based on initial information, such as testimonies from family members, and prior information from the health institutions and the police that are investigating the case.It is important to highlight the police investigations, which take days or even months to be concluded; and, until this process is over, there is no need to talk about guilt, but about suspicions, projections and conjectures -especially when considering the period between the date of the incident and the date of the news item, which was less than 48 hours.From this point of view, the news that passed on the judicial decisions and the conclusion of sentences were excluded, because they do manage to sustain the terms responsibility and guilt.
Regarding the term homicide, the analysis shows the danger of misinterpretations, which could be associated with the intention of the nursing professional to cause harm and death to the patients, which in many cases is not even close to the truth.
Relating a medication error to the term execution and then to the death penalty did not contribute to understand the episode itself, mainly because the prosecutor's accusation of professional negligence for the exchange of medications is included in the same text.[20]

Image-Text combination -An explosive mix
Photographs have proved to be important allies in the dissemination of events, especially when they are related to tragedies.However, images have two aspects: the objectivity of the image and the subjectivity of the perception of the reader. 21The power of images to draw the attention of the readers, retaining the moments in their memory, may be responsible for the so-called press sensationalism.In this sense, memory freezes images; its base unit is the individual image.In an age of information overload, photographs provide a quick means of apprehending something and a compact form of memorization. 22n a study that analyzed the titles and the images illustrated in reports on public emergencies, most of the reports induced a negative interpretation of these services, and this association suggests the possibility that readers can be led to think that they can be one of the victims in the future.It also asserts the importance of analyzing this association, since it shows that, although the text as a whole has a neutral and even positive approach on the subject matter, it can induce early and negative conclusions. 23Therefore, it is important to highlight that, in this mass culture, where information tends to be generalized and content produced at high speed, some values are deflated as well as begin to assume stereotyped and highly manipulable aspects. 13t is common to let emotion stand out when it is a tragedy, both for those who write the news item and for those who read it.The term tragedy is commonly associated with unexpected, unjust and violent deaths resulting from natural causes or from the intervention of people.And, to ensure the success of a news item, there is the generalization and romanticization of the facts, that is, emotions are added to the texts, such as pain and compassion. 24

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In the case of people, individuals who needed nursing care, this emphasis on the result of an error that most often caused the death of patients results in an explosive mix for the readers' emotions.Fear, anguish, apprehension, feeling of powerlessness and anger, among other states; everything goes through the mind while reading this news.

The error that is not an error -The error that is a crime
The error portrayed tends to be seen as a crime and not as an error.By attributing crime to the nursing error, greater attention is given to cases of intentional harms, especially because of the similarity with other reported cases.In this context, the way the news item portrayed intentional harm can induce the reader to believe in the intentionality of the professional involved.Evidently, there are cases like this; however, from the remaining content of the news, it appears that this was not the case.There is no way to identify what is different from other cases of accidental error to have been framed as intentional.
In the case of stomach washing, mentioned, the substance ingested by the child is highly toxic; and, according to the assistance protocols for these cases, the conduct of the team that assisted the child was in accordance with the recommended.The procedure was performed by a nurse with many years of experience and specific training for this type of procedure, facts also alleged in the published news.The content of the news allows the following question: Because the child's mother thinks it was a procedural error, should something be reported as an error, even if the death may have been caused by the poison?
It is in this context that the communication presented can take action.It is in the context of communication that truths are placed, from the apparently true enunciations; through it, the validity of these enunciations can be questioned, since a statement can be true at one moment and false at another, depending on a new enunciate. 13hus, when reporting the misuse of an ambulance by a nurse, which caused a delay in the rescue of a patient, without any other information (the news item is in full, in the evidence presented in the results), a form of partial communication must be considered, without validity and probably without major truths to be attributed.The fact is that, later, the nurse involved filed a lawsuit for defamation of her work, because no solid basis was found for such a report announced by the newspaper.

Applying the validity claims in the discourses
The application of the validity claims 13 was used for the interpretation to provide that moment of validation of the communicated discourse.It was subdivided into four validity claims, adapting the newspaper texts for each of them.As for intelligibility, although all the texts are well written, some passages can hinder interpretation to lack of clarity or to ambiguity.
Regarding the truth, it was validated when it came to the outcome of the nursing error (death, amputation, burn, infection), the age of the victims, the places where the incidents occurred, and the dates of the occurrences.Regarding the type of error and the nursing professional category, some of the news did not know how to expose the information truthfully.In the same sense, the causes of the errors were not investigated, in the vast majority of the news, by skill or any type of detailed analysis, in order that, finally, the cause of the error could be stated.For this reason, in this survey, they have been referred to as possible attributed causes.If the media had adopted this perspective, communication would have been closer to the claim of veracity.
Regarding sincerity, it is said to be based on the assumption that what will be reported must be expressed without exaggerating, augmenting, reducing, deducing or inducing.When it comes to newspaper news, this claim seems to be the least prevalent in the face of the techniques used for 10/14 news production, because every argumentative action is imbricated in a persuasive action.Linguistic acts are loaded with persuasive content, since it is in language that the subject is formed and this is essentially argumentative.Language is by itself a great tool of persuasion.When we speak, we are arguing/persuading and, consequently, materializing our discourse, inevitably contaminated by ideologies and value judgments. 22here is no absolute truth in journalistic texts, but two possibilities: the dialectical discourse, which is based on probable premises, with more than one hypothesis of conclusion; and the rhetorical discourse, which makes use of arguments allied to emotion. 25This is how the media discourse is composed in order to foment emotions and commercialize information. 11,26he gaps found in the search for sincerity claims can be related to the search and partial reproduction of information that do not allow sincerity in written form to stand out.Statements and discourses can be associated with power relations, turning the communicated truth into an inaccurate product.Therefore, Habermas proposes the ideal situation of speech, which guarantees equal opportunity to those who participate in the discourse and follows prescribed norms in search of the truth. 13In the case of this study, in particular, the sincerity claims were not legitimized, although, for referring to the subjective world and to the consequences of action resulting from communication, suppose that the news can give way to a series of negative thoughts and mistaken ideologies that lead society to associate nursing with carelessness, with error, with crime.
Normative correction is linked to the social world, in which the rules and norms recommended for individuals or for a specific group are presented, in this case, nursing professionals.This claim can only be considered valid when it is accepted by all those to whom it is addressed.In this study, it was taken as base to interpret the texts the regulation of the nursing profession (in Brazil, Law of Professional Exercise; and, in Portugal, the Regulation of the Professional Exercise of Nurses; in addition to the deontological nursing codes of both countries), which was cited in the journalistic discourses.It was verified that, for the most part, the published news came close to the discourse prescribed by the rules of the profession.
In the theory of communicative action, there is the substitution of a practical reason (the action oriented by own ends) by the communicative reason, which guides the actions of the individuals to approach the norm.And, in this way, it is necessary to consider the contribution of mass communication so that the norms in force are rediscussed in the daily life of the professionals, in order to avoid that the profession is the target of daily headlines.
The freedom with which the media carry out their work is constantly faced with the right to privacy and to defend the image of those who are the focus of the news.Thus, configured in the terms of scandal, journalism is perverse and goes against a culture of freedom, because any attempt to bar this way of reporting could be framed as an affront to freedom of expression.In this sense, people are forced to support this way of reporting, even knowing that it is a problem of our time, a problem that is difficult to solution.
Studies such as this are significant for the profession, for society and for strengthening a culture of safety in health practices increasingly aimed at quality of care.The study of the phenomenon used online print media data collected in two countries, so that new studies including other types of media and locations could broaden their understanding.

CONCLUSION
Language, loaded with rhetoric and persuasion, tends to stimulate negative ideologies, which have as their greatest representatives the economic domination of the broad circulated newspapers and the priority objective of selling the product-news item; all without evaluating the harms for the professionals involved in the incidents related to health care errors.The media are continuous 11/14 producers of ideologies and, therefore, have social responsibility by inducing misinterpretations that can negatively interfere in the nurse-patient interaction, discrediting a work of unique social importance.
The reconstruction of the validity claims in the interpretation of the discourses reported by newspapers allows inferring that communicators often do not follow a pattern of veracity, impartiality and sincerity in the production of the news, allowing for the non-validation of certain contents.This allows the consumers of these news to have a dialectic attitude, in the sense of accepting or not the arguments presented.In this attitude, there is a stimulus to rescue rationality in other parts of the news item, which go beyond the outcome, such as the possible causes, the work context, and other agents that modify certain realities.
The news were analyzed based on what was exposed in the newspapers at the time of data collection and no other sources of information or clarification about the errors reported, as well as other news that followed, were part of this analysis.
The image of the nursing profession cannot be harmed by non-validated information, which abuses emotional attributes to be consumed.Not even the population, which needs nursing care, can create a negative image of the profession, associating it with fear, insecurity and lack of commitment to human beings.This is, by far, the greatest prerogative for discourse to be rethought in the practice of the communication media, since all people, at some point in life, need nursing care.