ANALYSI S OF PROXEMI C COMMUNI CATI ON W I TH HI V/ AI DS PATI ENTS
Mar li Ter esinha Gim eniz Galv ão1 Sim one de Sousa Paiv a2 Nam ie Ok ino Saw ada3 Lor it a Mar lena Fr eit ag Pagliuca4
Galvão MTG, Paiva SS, Sawada NO, Pagliuca LMF. Analysis of proxem ic com m unicat ion wit h HI V/ AI DS pat ient s. Rev Lat ino- am Enfer m agem 2006 j ulho- agost o; 14( 4) : 491- 6.
This descr ipt iv e and ex plor at or y st udy analy zed t he pr ox em ic fact or s of t he nur sing t eam and HI V/ AI DS pat ient s in a hospit al env ir onm ent in For t aleza - CE, bet w een Oct ober and Nov em ber 2004. Dat a w er e collect ed t hrough non- part icipant observat ion. Fort y- one int eract ions were analyzed, in which no gender influence w as obser ved. The pr ofessional’s posit ion t ow ar ds t he pat ient w as m ainly st anding; int im at e dist ance occur r ed in 21.95% of int er act ions, w hich w er e m ost ly r elat ed t o t echnical pr ocedur es; per sonal dist ance pr edom inat ed in 63.41% of cases, w hich w er e r elat ed t o t echnical car e; social dist ance occur r ed in 14.64% of int er act ions, which were aim ed at conservat ion; obst acles were present in 15 int eract ions; local t ouch was t he m ost frequent cont act behavior; visual cont act was present in 11 int eract ions, wit h a view t o regulat ing t he conversat ion flow; t h e t on e of v oice w as f ou n d alw ay s ad eq u at e. Th r ou g h p r ox em ics, w e can id en t if y im p or t an t f act or s in com m unicat ion w it h HI V/ AI DS pat ient s.
DESCRI PTORS: com m unicat ion; acquir ed im m unodeficiency sy ndr om e; HI V- 1 ; nur se- pat ient r elat ions
ANÁLI SI S DE COMUNI CACI ÓN PROXÉMI CA CON PACI ENTES CON VI H/ SI DA
Est udio descript ivo y explorat orio en que fueron analizados fact ores proxém icos del equipo de enferm ería y port adores del VI H/ SI DA en un am bient e hospit alario en Fort aleza - CE, ent re oct ubre y noviem bre de 2004. Los dat os fuer on r ecopilados m ediant e obser v ación no par t icipant e. El análisis de 41 int er acciones no r ev eló ninguna influencia del sexo. La posición del pr ofesional ant e el pacient e fue en pie; la dist ancia ínt im a ocur r ió en el 21,95% de las int eracciones y, en la m ayoría de los casos, est aba relacionada a procedim ient os t écnicos; la dist ancia per sonal pr edom inó en el 6 3 , 4 1 % de los casos, r elacionados a la at ención t écnica; la dist ancia social ocur r ió en el 14, 64% , con obj et o de conv er sar ; en 15 int er acciones hubo pr esencia de obst áculos; el t oque localizado fue el com port am ient o de cont act o m ás frecuent e; el cont act o visual est uvo present e en once int er acciones par a r egular el fluj o de la conv er sación; el t ono de la v oz fue siem pr e adecuado. Consider am os que la pr oxem ia per m it e ident ificar fact or es im por t ant es en la com unicación con el pacient e por t ador del VI H/ AI DS.
DESCRI PTORES: com unicación; VI H- 1; síndr om e de inm unodeficiencia adquir ida; r elaciones enfer m er o- pacient e
ANÁLI SE DA COMUNI CAÇÃO PROXÊMI CA COM PORTADORES DE HI V/ AI DS
Est e est u d o d escr it iv o e ex p lor at ór io an alisou os f at or es p r ox êm icos d a eq u ip e d e en f er m ag em e por t ador es de HI V/ AI DS em am bien t e h ospit alar em For t aleza - CE, en t r e ou t u br o e n ov em br o de 2 0 0 4 . A colet a de dados foi pela obser vação não par t icipant e. Analisou- se 41 int er ações e não foi obser vado influência do sexo. A posição do profissional em relação ao pacient e foi de pé, a dist ância ínt im a ocorreu em 21,95% das int er ações e est avam r elacionadas a pr ocedim ent os t écnicos na m aior ia delas, a dist ância pessoal pr edom inou em 63,41% relacionadas à assist ência t écnica, a dist ância social ocorreu em 14,64% e foram para conversação; em 1 5 in t er ações h ou v e pr esen ça de obst ácu los, o t oqu e localizado f oi o com por t am en t o de con t at o m ais freqüent e; o cont at o visual est eve present e em onze int erações com a função de regular o fluxo da conversação; o t om de v oz foi sem pr e adequado. Consider am os que a pr ox em ia per m it e ident ificar fat or es im por t ant es na com unicação com o pacient e por t ador de HI V/ AI DS.
DESCRI TORES: com u n icação; sín dr om e de im u n odeficiên cia adqu ir ida; HI V- 1 ; r elações en fer m eir o- pacien t e
Disponível em língua port uguesa na SciELO Brasil w w w .scielo.br/ rlae
1
I NTRODUCTI ON
M
ankind has been living w it h aids for t hree d e c a d e s a n d , a s o b s e r v e d , t h e d i s e a s e h a se x p e r i e n c e d a n u n l i m i t e d g r o w t h , i n c r e a s i n g l y
affect ing individuals at t he height of t heir reproduct ive
lif e.
Now aday s, t h e u se of an t ir et r ov ir als gr an t s
p a t i e n t s a si m i l a r q u a l i t y o f l i f e a n d su r v i v a l i n
co m p a r i so n w i t h o t h e r ch r o n i c d i se a se s( 1 ). Th u s, h ospit alizat ion appear s as a differ en t r esou r ce t h an
w h at w as u sed in t h e fir st decade of t h e epidem ic,
w h e n n e i t h e r e f f i c i e n t t e s t s n o r m o r e s p e c i f i c
( ant iret roviral) drugs w ere available. Today, t he m ain
r easons for hospit alizat ion r esult fr om lat e diagnosis,
m edicat ion int oler ance and oppor t unist ic diseases.
Dur ing hospit alizat ion, indiv iduals leav e t heir
en v ir on m en t t o adapt t o a w or ld an d r ou t in es t h ey
ar e har dly fam iliar w it h. HI V pat ient s r equir e longer
per iods of h ospit alizat ion an d ex per ien ce a h ospit al
environm ent m arked by const ant solit ude. I n view of
con st an t p r eoccu p at ion s w it h t h e ev olu t ion of t h e
disease, pat ient s oft en get isolat ed in t heir hospit al
b ed .
D u e t o b i o sa f e t y m e a su r e s a n d p h y si ca l
isolat ion of aids pat ient s, nursing care at t ribut es very
peculiar charact erist ics t o t his care( 2). Out of fear for con t agion , car e deliv er y is ex t r em ely t ech n ical an d
im per sonal, pr edom inat ed by t he r elat ion w it h t hings
and obj ect s. This gives rise t o concerns and care wit h
differ ent for m s of com m unicat ion.
Com m unicat ion is sim ilar t o breat hing: hum an
bein gs do n ot st op com m u n icat in g( 3 ). I n v iew of it s im p or t an ce, com m u n icat ion is in d icat ed as a b asic
nur sing car e inst r um ent , as it allow s for t he nur
se-pat ien t r elat ion( 4 ). Th u s, m or e t h or ou gh an aly sis is needed wit h a view t o t he proper knowledge and use
of com m unicat ion in daily nur sing pr act ice.
Co m m u n i c a t i o n c a n b e v e r b a l a n d n o n
-verbal. St udies have shown t hat 35% of t he m eaning
of m essages is t r an sm it t ed v er bally an d 6 5 % n on
-verbally( 6). Hence, one of t he aspect s t o be t aken int o consider at ion in com m unicat ion w it h pat ient s is t heir
p e r s o n a l a n d t e r r i t o r i a l s p a c e , c a l l e d p r o x e m i c
com m unicat ion( 5- 6). The t erm proxem ics is a neologism c r e a t e d b y Ed u a r d H a l l t o d e s i g n a t e t h e s e t o f
obser v at ion s an d t h eor ies r elat ed t o h ow m an u ses
h i s sp ace( 7 ). Pr o x em i c co m m u n i cat i o n st u d i es t h e s o c i a l m e a n i n g o f s p a c e , t h a t i s , h o w m a n
unconsciously st r uct ur es his ow n space( 6- 7).
Accor din g t o t h is au t h or, pr ox em ic an aly sis
i n v o l v e s e i g h t f a c t o r s , c o v e r i n g t h e f o l l o w i n g
dim en sion s: 1 . Post u r e- sex code: an aly zes t h e sex
of t h e par t icipan t s an d t h e basic posit ion t h ey m ay
b e in , f or ex am p le: st an d in g , sit t in g an d ly in g ; 2 .
S o c i o f u g a l - s o c i o p e t a l a x i s : Th e s o c i o f u g a l a x i s
d em on st r at es d iscou r ag em en t of in t er act ion , w h ile
so ci o p e t a l i m p l i e s t h e o p p o si t e . Th i s d i m e n si o n
analy zes t he int er locut or s’ angle: face t o face, back
t ur ned, am ong ot her s; 3. Kinest het ic fact or s: These
a r e r e sp o n si b l e f o r p r o v o k i n g cl o se n e ss b e t w e e n
int er locut or s. This dim ension analy zes shor t - dist ance
p h y sical con t act , su ch as t ou ch in g or b r u sh in g t h e
sk in an d t h e posit ion in g of body par t s; 4 . Tou ch in g
behavior: This fact or refers t o form s of t act ile relat ions
su ch a s ca r e ssi n g , g r a b b i n g , f e e l i n g , p r o l o n g e d
h oldin g, pr essin g again st , spot t ou ch in g, acciden t al
b r u sh i n g o r n o p h y si ca l co n t a ct ; 5 . Vi su a l co d e :
verifies t he m anner of eye cont act during int eract ions,
r an gin g fr om ey e t o ey e t o n o con t act ; 6 . Th er m al
c o d e : r e f e r s t o t h e h e a t p e r c e i v e d b y t h e
i n t e r l o c u t o r s ; 7 . O l f a c t o r y c o d e : a n a l y z e s t h e
char act er ist ics and degr ee of odor per ceiv ed by t he
int er locut or s; and finally 8. Voice loudness: assesses
t h e i n t e r l o c u t o r s ’ p e r c e p t i o n i n r e l a t i o n t o t h e
in t er per son al space.
A s a r e s u l t o f o u r c a r e e x p e r i e n c e a n d
research wit h HI V/ aids pat ient s, we believe t his st udy
is needed, w it h a view t o analyzing pr oxem ic fact or s
during int eract ions bet ween t he nursing t eam and HI V/
aids pat ient s in a hospit al env ir onm ent .
METHODOLOGY
We c a r r i e d o u t a n e x p l o r a t o r y a n d
d e s c r i p t i v e s t u d y a t a h o s p i t a l i z a t i o n u n i t i n a
specialized in st it u t ion , w h ich is a r efer en ce h ospit al
for infect ious- cont agious diseases in For t aleza, Cear á,
Br azil, in Oct ober an d Nov em ber 2 0 0 4 . Par t icipan t s
w er e m em ber s of t he nur sing t eam and pat ient s w ho
w e r e h o s p i t a l i z e d a t t h e u n i t a n d a c c e p t e d t o
p ar t icip at e.
Dat a w er e collect ed t hr ough non- par t icipant
an d sy st em ic dir ect obser v at ion of t h e in t er act ion s
t h a t o c c u r r e d d u r i n g t h e n u r s i n g s h i f t b e t w e e n
p r o f e s s i o n a l s a n d p a t i e n t s . We r e c o r d e d a l l
i n t e r a ct i o n s r e a l i ze d d u r i n g t h e o b se r v a t i o n a n d
i d e n t i f i e d p r o x e m i c f a c t o r s , a c c o r d i n g t o a n
par t , w e w r ot e dow n pat ient s’ ident ificat ion dat a; in
t he second t he pr ofessional’s dat a and, in t he t hir d,
w e d escr i b ed t h e o b ser v at i o n s o f t h e i n t er act i o n ,
including: sit uat ion or procedure carried out , durat ion,
p r o f e ssi o n a l ’ s p o si t i o n a n d d i st a n ce , v o i ce t o n e ,
int erlocut ors’ axis, cont act behavior, visual cont act and
ob st acles.
I n o r d e r t o a n a l y z e co m m u n i ca t i o n , t h e
pat ient was observed for t welve hours by a previously
t r ai n ed r esear ch er. Ob ser v at i on s occu r r ed f or t w o
consecut ive hours at m ost in t he m orning or aft ernoon,
bet ween 7: 00 and 19: 00h, during t wo or m ore days.
D a t a co l l ect i o n w a s cl o sed o f f w h en a l l p r o x em i c
f act or s b et w een p r of ession al an d p at ien t h ad b een
ident ified, i.e., we adopt ed t he crit erion of sat urat ion.
The collect ed dat a were analyzed in t he light
o f p r o x e m i c f a c t o r s( 7 ). A f t e r b e i n g s t u d i e d a n d int erpret ed by a first researcher, cat egorizat ions were
confir m ed by t w o ot her r esear cher s, t o allow for t he
descr ipt ion and discussion of r esult s.
The st udy com plied w it h t he det er m inat ions
of Resolu t ion No 1 9 6 on r esear ch in v olv in g h u m an
beings, issued on Oct ober 19t h 1996 by t he Nat ional
Healt h Council. All part icipant s were properly inform ed
and signed a fr ee and infor m ed consent t er m .
DATA ANALYSI S AND DI SCUSSI ON
Su bj ect descr ipt ion
We obser ved 15 nur sing t eam m em ber s and
f i v e p a t i en t s. Th r ee n u r si n g t ea m m em b er s w er e
nurses and wom en; six were nursing auxiliaries, wit h
on e m an ; an d six w er e t r ain ees f r om t h e t ech n ical
nursing course, as t he research inst it ut ion is a t eaching
hospit al t hat r eceiv es st udent s fr om all lev els. Ages
w er e dist r ibut ed as follow s: 3 0 - 3 9 y ear s ( 5 ) , 2 0 - 2 9
y ear s ( 4) , 40- 49 y ear s ( 3) , under 20 ( 2) and 50 or
older ( 1 ) . Eight pr ofessionals w er e w hit e and sev en
w er e m u lat t oes.
Tw o p at ien t s w er e w om en an d t h r ee m en ;
t w o w ere m ulat t oes, t w o w ere brow n and one w hit e.
Ages w er e dist r ibu t ed as f ollow s: 3 0 - 3 9 y ear s ( 3 ) ,
20- 29 y ear s ( 1) and ov er 39 ( 1) . All pat ient s cam e
from Fort aleza. As t o educat ion, t wo had not finished
pr im ar y edu cat ion , on e h ad n ot f in ish ed secon dar y
educat ion, one possessed a higher educat ion degr ee
and one pat ient could only w r it e his nam e. I n t ot al,
w e obser v ed 41 sit uat ions.
Analy sis of pr ox em ic fact or s
Post ur e – sex code
Fi r st , w e a n a l y z e d p a r t i ci p a n t s’ se x a n d
int erlocut ors’ basic posit ion: st anding, sit t ing or lying.
We d i d n o t i d e n t i f y a n y i n f l u e n ce o f se x o n t h e
i n t e r l o c u t o r s ’ p o s i t i o n , a s t h e n u m b e r o f m a l e
p ar t icip an t s w as lit t le r ep r esen t at iv e. A st u d y w it h
laryngect om ized pat ient s did not find any int erference
of sex in t he adopt ed posit ion and at t ribut ed t his fact
t o t he t y pe of pr ofessional t echnical int er act ion( 6). Mor eov er, d iscu ssin g g en d er issu es in t h is
pat ient group is quit e delicat e and com plex, as it boils
d ow n t o d iscu ssin g m er ely t h e sex u al m ean in g of
b e i n g a m a n o r w o m a n . Th e st a n d a r d s, v a l u e s,
percept ions and represent at ions in societ y accom pany
t h ese su bj ect s w h o, in gen er al, do n ot per for m t h e
r oles societ y ex pect s fr om t h em in t er m s of sex u al
iden t it y.
I n a s t u d y o n g e n d e r i s s u e s a n d m a l e
sexualit y in t he age of aids, m an has been considered
t he piv ot al piece in t r ansm ission and r esponsible for
per for m ing sex ual pr act ice, r epr oducing a st er eot y pe
t hat put s t hem in a risk sit uat ion( 8). Alt hough t his st udy d id n ot in t en d t o in v est ig at e h ow t h ey cau g h t t h e
disease, w e inferred t hat sexualit y- relat ed issues and
sex u al p r ef er en ces in t er f er e in in t er locu t or s’ n on
-v er b al com m u n icat ion . Pat ien t s can f eel ash am ed ,
infer ior ized and discr im inat ed against .
I n all ob ser v ed sit u at ion s, t h e p r of ession al
w as st an d in g . A p at ien t w as st an d in g in on ly on e
int er act ion, and sit t ing or ly ing in t he ot her s. When
one int erlocut or st ands while t he ot her sit s, t his social
dist ance evokes an im pression of dom inance( 7). Hence, by sit t ing, som ewhat inferior t o t he care professional,
part icularly when hospit alized and being subm it t ed t o
h o sp i t a l o r d er s a n d r o u t i n es t h a t a r e n o t a l w a y s
pleasant , int er locut or s can block t he com m unicat ion
p r o cess a n d a v o i d ex p r essi n g t h ei r t r u e f eel i n g s,
d ou b t s or f ear s. Healt h p r of ession als n eed t o p ay
at t en t ion t o t h ese aspect s in or der t o opt im ize t h e
com m unicat ion pr ocess w it h t hese pat ient s.
Sociof u gal- sociopet al ax is
Th i s f a c t o r r e f e r s t o t h e i n t e r l o c u t o r s ‘
w illingness ( sociopet al) or unw illingness ( sociofugal)
t o int eract w it h one anot her, and analy zes t he angle
subj ect s’ posit ion: face t o face, side by side or back
t u r n e d . We f o u n d f a c e t o f a c e a n d l a t e r a l i z e d
c o m m u n i c a t i o n i n 1 6 s i t u a t i o n s e a c h , w h i l e
pr of ession als t alk ed w it h t h eir back t u r n ed t ow ar ds
t he pat ient in six int eract ions, even in cases of verbal
com m unicat ion. I n one sit uat ion, t he pat ient had his
back t ur ned t ow ar ds t he pr ofessional.
Po s i t i o n s c h a n g e d d u r i n g i n t e r a c t i o n s ,
p a r t i a l l y d u e t o n u r si n g p r o f e ssi o n a l s’ h u r r y a n d
sit uat ions of “ fleeing” from m om ent s wit h t he pat ient ,
m a i n l y w h e n ( s) h e q u e st i o n e d so m e t h i n g a t t h e
m om ent of int er act ion.
Ear lier st udies ident ified pat ient s’ com plaint s
about t he healt h t eam , relat ed t o indelicacy, invasion
of privacy, dem onst rat ion of indifference, discouraged
facial ex pr ession and r ushing( 9- 10).
I n spit e of t he sm all num ber of int eract ions in
which one int erlocut or had his/ her back t urned t owards
t h e ot h er, w e det ect ed n in et een sit u at ion s in w h ich
t he pr ofessional seem ed discour aged t o int er act w it h
t h e p a t i e n t , a l t h o u g h t h e l a t t e r s o m e t i m e s
d em on st r at ed t h e op p osit e. Th ese sit u at ion s w er e
o b se r v e d w h e n t h e p r o f e ssi o n a l t u r n e d h i s b a ck
t owards t he pat ient while realizing a procedure or even
w h i l e p a s s i n g i n f o r m a t i o n t o t h e p a t i e n t . Th e
pr ofessional look ed at t he t elev ision t hat w as t ur ned
on, t o t he serum equipm ent or t o blood t races on t he
j elco® ex t ension. The t eam m em ber gav e r apid and evasive answers t o t he pat ient s’ inquiries. Pat ient s, in
t urn, carefully looked at t he care professional, at t ract ed
h is/ h er at t en t ion t o a per ceiv ed ch an ge or v er bally
ex pr essed t h eir dissat isf act ion . Th ey addr essed t h e
p r o f e ssi o n a l o r r e se a r ch e r a n d co m p l a i n e d t h a t
nobody paid at t ent ion, no m at t er whet her t heir opinion
about t he subj ect w as being asked.
Pr o f e ssi o n a l s’ d i f f i cu l t i e s t o i n t e r a ct w i t h
pat ient s and pat ient s’ m anifest ed need for at t ent ion
par t ially der iv e fr om one pat ient ’s t er m inal sit uat ion.
Lit erat ure report s t hat m any healt h professionals st ill
do not know how t o handle t he possibilit y of losing a
pat ient w it h an incur able disease and unconsciously
t a k e d i st a n ce . Te r m i n a l p a t i e n t s r e m i n d t h e m o f
hum an fr agilit y and oblige t hem t o t hink and act on
t h e f i n i t e n e ss o f t h e b o d y a n d t h e e x i st e n ce o f
d e a t h( 1 1 ). Pa t i e n t s , o n t h e o t h e r h a n d , l o o k f o r em ot ional par t , w hich t hey gener ally do not r eceiv e
from societ y, or from relat ives. Thus, pat ient s expect
em ot ional and psychological support from persons wit h
w h o m t h e y m a i n t a i n t h e i r l a s t o r p e r h a p s o n l y
cont act s: t he pr ofessionals w ho accom pany t hem .
I n 1 4 in t er act ion s, w e ob ser v ed sociop et al
b e h a v i o r b y a n u r s i n g t e a m m e m b e r, w h o
dem onst rat ed at t ent ion during care delivery or t alked
ab ou t su b j ect s u n r elat ed t o car e. Th ese b eh av ior s
ar e im p or t an t in h ealt h p r of ession als’ r elat ion w it h
p a t i e n t s, a s co m m u n i ca t i o n i s h o w r e l a t i o n s a r e
e s t a b l i s h e d . Ca r e p r o f e s s i o n a l s s h o u l d d e v e l o p
co m m u n i ca t i o n sk i l l s t h r o u g h e m p a t h y, o p e n i n g ,
aut hent icit y and respect , aim ed at est ablishing a help
relat ion wit h a view t o increasing pat ient s’ adapt at ion
and im pr ov ing t r eat m ent r esult s( 12).
Kin est h et ic fact or s
Th e s e i d e n t i f y t h e c l o s e n e s s b e t w e e n
i n t er l o cu t o r s an d d et er m i n i n g f act o r s. Ki n est h et i c
fact or s analy ze shor t - dist ance phy sical cont act , such
a s t o u ch i n g o r b r u sh i n g t h e sk i n , a s w el l a s t h e
posit ioning of int er locut or s’ body par t s.
Ta b l e 1 d i sp l a y s t h e d i st a n ce m a i n t a i n e d
b et w een in t er locu t or s an d t h e t y p e of in t er v en t ion
car r ied out dur ing t he int er act ions.
Table 1 - Dist ances m aint ained bet w een int er locut or s
a n d t y p e o f i n t e r v e n t i o n c a r r i e d o u t d u r i n g 4 1
in t er act ion s
e c n a t s i D e t a m i t n
I Personal Social N %
) % 5 9 , 1 2 (
9 26(63,41%) 6(14,64%) 41 100
n o i t n e v r e t n I e p y
T N % N % N % N %
l a c i n h c e T e r u d e c o r
p 7 77.78 19 73.08 2 33.33 28 68.30
n o it a s r e v n o
C 2 22.22 7 22.92 4 66.67 13 31.70
l a t o
T 9 100 26 100 6 100 41 100
I n t im at e d ist an ce occu r s in lit t le less t h an
21.95% of int eract ions and is m ore frequent ly relat ed
t o t ech n ical p r oced u r es ( 7 7 . 7 8 % ) . Th is d ist an ce is
used for com fort ing and prot ect ing; odor and irradiat ed
heat percept ions are int ensified in t his sit uat ion, wit h
possible m uscle and skin cont act . When st range cont act
occurs, t he basic t act ic is t o st ay im m obile or dodge( 7). W h e n m a i n t a i n i n g t h i s d i st a n ce d u r i n g t e ch n i ca l
n u r si n g ca r e , p r o f e ssi o n a l s m a y i n v a d e p a t i e n t s’
p e r so n a l sp a ce , ca u si n g n e g a t i v e r e a ct i o n s a n d
block in g com m u n icat ion an d t h e est ablish m en t of a
t herapeut ic relat ion bet ween pat ient and professional.
The space of hospit alized HI V pat ient s, alm ost always
dom inat ed by differ ent feelings, depr essed, r ev olt ed
or frust rat ed about t he possibilit y of im m inent deat h,
Personal dist ance was found in m ore t han half
o f t h e s i t u a t i o n s w e o b s e r v e d ( 6 3 . 4 1 % ) .
Ap p r ox im at ely 7 3 . 0 8 % of t h ese in v olv ed t ech n ical
care. When m aint aining personal dist ance, body heat
i s i m p e r ce p t i b l e , t h e i n t e r l o cu t o r s’ t r a i t s a r e n o t
v isu ally d ist or t ed an d t h eir u p p er ex t r em it ies can
t o u c h . Th i s d i s t a n c e i s a d e q u a t e f o r d i s c u s s i n g
p e r so n a l q u e st i o n s( 7 ), r e co m m e n d a b l e i n p a t i e n t t each in g pr ocesses( 6 ).
We obser ved social dist ance in a m inor it y of
i n t e r a ct i o n s. At t h i s d i st a n ce , m o st i n t e r a ct i o n s
involved conversat ion wit h t he pat ient ( 66.67% ) , when
pr of ession als passed in f or m at ion or w h en ev olu t ion
occur s. Non- v er bal signs ar e har d t o per ceiv e. Thus,
social dist ance is im pr oper for v er bal com m unicat ion
w it h t he pat ient , w hich w e m ore frequent ly observed
in social dist ance int er act ions.
We st udied t he obst acles t hat exist ed dur ing
in t er act ion s d u e t o t h eir in f lu en ce on t h e ad op t ed
dist ance and t he difficult ies t hey im pose on phy sical
c o n t a c t . We f o u n d 1 5 s i t u a t i o n s i n w h i c h
com m u n icat ion ob st acles p r ed om in at ed . Th e m ost
com m on im p ed im en t s in clu d ed t h e u se of a m ask ,
alt h ou g h t h e p at ien t d id n ot p r esen t an y air b or n e
disease; ser um suppor t in bet w een t he int er locut or s
and t elev ision t ur ned on, dist r act ing t he subj ect s. I n
t w o sit u at ion s, pr of ession als obser v ed blood t r aces
on t he j elco® ext ension, which deviat ed t heir at t ent ion during com m unicat ion wit h t he pat ient . Ot her obst acles
w er e t he height differ ence bet w een int er locut or s and
t he pr ofessional being occupied w it h anot her act ivit y.
Th ese o b st acl es, p ar t i cu l ar l y t h e u se o f a
m ask and t he pr ofessional’s at t ent ion dir ect ed at t he
blood on t he j elco® ex t ension w hile t alk ing w it h t he p at i en t , m ay i n d i cat e t h ese p r o f essi o n al s’ f ear o f
infect ion and relat ed diseases. At a hospit al specialized
in infect ious- cont agious diseases, unhealt hy condit ions
a r e f r e q u e n t a m o n g h e a l t h t e a m m e m b e r s a n d
r ep r esen t a r isk t o t h ese p r of ession als. Th er e is a
need t o ident ify act ual r isk s and how t o pr oceed so
t h at pat ien t s do n ot feel ign or ed as a r esu lt of t h e
d i sease.
Con t act b eh av ior
Th is f act or r an k s t h e t act ile r elat ion s t h at
o ccu r r ed as f o l l o w s: car essi n g , g r ab b i n g , f eel i n g ,
pr olon ged h oldin g, pr essin g again st , spot t ou ch in g,
accid en t al b r u sh in g or n o p h y sical con t act . We d id
n o t f i n d a n y sk i n b r u sh i n g a m o n g i n t e r l o cu t o r s.
To u ch i n g w as f o u n d i n h al f o f t h e i n t er act i o n s at
int im at e dist ance and t he rem ainder at close personal
d ist an ce.
Spot t ouching occur r ed in 1 8 sit uat ions, 1 4
of w hich w er e associat ed w it h t echnical pr ocedur es.
Three aim ed t o at t ract t he pat ient ’s at t ent ion or wake
h i m u p an d on e t o t r an q u i l i ze a p at i en t w h o w as
m e n t i o n i n g p a i n . Re s e a r c h d e s c r i b e s t h e
pr edom in an ce of in st r u m en t al t ou ch in in t er act ion s
b e t w e e n n u r s i n g t e a m m e m b e r s a n d p a t i e n t s ,
w h e t h e r d u r i n g h o s p i t a l i z a t i o n o r i n o u t p a t i e n t
appoint m ent s( 13- 14). I n m ost int er act ions, no cont act behavior was found, in view of professionals and HI V/
aids pat ient s’ m ut ual int er act ion difficult ies.
Visu al code
Th i s f a c t o r v e r i f i e s h o w v i s u a l c o n t a c t
o ccu r r ed d u r i n g i n t er a ct i o n s, su ch a s ey e t o ey e
cont act or no cont act . Visual cont act w as pr esent in
1 1 int er act ions, all r elat ed t o v er bal com m unicat ion
and probably aim ed at ident ifying non- verbal language
signs, as v ision is m ank ind’s m ost specialized sense
and provides t he nervous syst em w it h a m uch larger
quant it y of infor m at ion t han t ouch and hear ing. The
eyes are able t o ident ify an individual’s em ot ions, such
as signs of surprise ( great er eye opening) , happiness
( shine) or sadness ( sm aller ey e opening)( 7). Anot her fu n ct ion of t h e look is t o r egu lat e t h e con v er sat ion
f low . Th er ef or e, t h is f act or is essen t ial f or p at ien t
in t er act ion .
We did not analyze t he t herm al and olfact ory
code dim ensions, described as proxem ic fact ors 6 and
7, due t o t he fact t hat t he dat a analysis m et hod did
not allow us t o det ect t his inform at ion.
Voice lou dn ess
This fact or analy zes int er locut or s’ per cept ion
of int erpersonal space by ranking voice loudness and
in t en sit y du r in g in t er act ion s: w h isper in g, scr eam in g
or norm al t one. Loud voices were not present in any
si t u a t i o n . I n m o st i n t er a ct i o n s, v o i ce t o n es w er e
norm al ( hearable) . Low voices were found in only five
int er act ions. I n t hese cases, com m unicat ion dist ance
was int im at e or personal, so t hat pat ient s could hear,
alt hough t he researcher did not know what was being
sa i d . N o v e r b a l co m m u n i ca t i o n o ccu r r e d i n f i v e
I n all int eract ions, t he vent ilat or was loud. I n
22 cases, t he t elevision was t urned on and in seven,
t he volum e was high. I n four int eract ions, noise from
const r uct ion w or k s w as pr esent . Env ir onm ent al noise
is con sid er ed an in v asion of h osp it alized p at ien t s’
per son al an d t er r it or ial space, en t ailin g a ser ies of
h u m a n r esp o n ses t h a t t o o k t h e f o r m o f f eel i n g s,
a t t i t u d e s , v a l u e s , e x p e c t a t i o n s a n d d e s i r e s( 1 0 ). Pr of ession als sh ou ld pay at t en t ion t o t h ese n oises,
w hich can int er fer e in com m unicat ion w it h pat ient s.
On e p a t i e n t p r e s e n t e d p r o d u c t i v e a n d f r e q u e n t
t ossing, w hich t ur ned com m unicat ion m or e difficult .
CONSI DERATI ONS
We o b se r v e d t h a t p r o f e ssi o n a l s’ p o st u r e
t ransm it s t he idea of t heir dom inat ion and suprem acy
t ow ar d s p at ien t s, st r en g t h en ed b y t h e in st it u t ion al
or g an izat ion of t h e p r ox em ic en v ir on m en t . Not all
p r o ce d u r e s a l l o w p r o f e ssi o n a l s t o ch o o se o n e o r
an ot h er posit ion . How ev er, w e r ecom m en d t h at , at
l e a s t d u r i n g c o n v e r s a t i o n s w i t h p a t i e n t s , t e a m
m em bers sit down, at t he sam e height as t he pat ient
an d w it h t h eir f ace t u r n ed t ow ar ds h im / h er, m ain ly
when com m unicat ing wit h HI V/ aids pat ient s, who are
frequent ly m arked by t he st igm a of disease and deat h.
D i s t a n c e s w e r e n o t a p p r o p r i a t e t o t h e
si t u a t i o n s w e o b se r v e d . Te ch n i ca l p r o ce d u r e s a t
i n t i m a t e d i s t a n c e s h o u l d b e a v o i d e d . A l t h o u g h
p r of ession als can n ot alw ay s ob ey t h is r u le, d u e t o
t ech n ical r equ ir em en t s t o in v ade pat ien t s’ per son al
sp ace, w e cou ld p er ceiv e p at ien t s’ in d isp osit ion b y
t h eir n on - v er bal lan gu age an d, t h u s, deal w it h t h e
sit u at ion . Teach in g pr ocesses sh ou ld be car r ied ou t
at per sonal dist ance, as t he int er locut or s’ t r ait s ar e
not dist ort ed and body heat does not int erfere in t he
in t er act ion . Social dist an ce sh ou ld n ot occu r du r in g
conv er sat ions w it h pat ient s, as non- v er bal signs ar e
har d t o per ceiv e.
Pr ox em ics can be u sed w h en obser v in g t h e
com m unicat ion process bet ween nursing professionals
and pat ient s t o assess t he delivered care by ident ifying
t he differ ent pr oxem ic fact or s. Then, it is possible t o
in t er f er e in t h ese f act or s, r econ sid er in g b eh av ior s
d u r i n g p r o f essi o n al - p at i en t co m m u n i cat i o n an d , i f
possible, changing t he space of t he int er act ion, w it h
a v iew t o im p r ov in g in t er p er son al r elat ion s in t h e
hospit al env ir onm ent and est ablishing m or e efficient
com m u n icat ion .
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