Responsibility in health care: regarding
the time we live as intensive care nurses
*O
riginal
a
r
ticle
Responsabilidade no cuidaR: do tempo que nos toca viveR como enfeRmeiRos/as intensivistas
Responsabilidad en el cuidaR: del tiempo que nos toca viviR como enfeRmeRos/as intensivistas
* taken from the dissertation “bioética em discurso: efeitos sobre os processos de constituição do sujeito enfermeira/o na terapia intensiva”, Graduate nursing program, universidade federal de santa catarina, 2008 1 Rn. ph.d. in nursing, universidade federal de santa catarina. adjunct professor, universidade
do vale do Rio dos sinos. member of the praxis Group at universidade federal de santa catarina. coordinator of the specialization course in intensive care nursing at universidade do vale do Rio dos sinos and at universidade corporativa Hospital mãe de deus. porto alegre, Rs, brazil. maraav@unisinos. br 2 Rn. post-doctoral degree in education, universidade de lisboa. ph.d. in nursing philosophy, universidade federal de santa catarina. associate
professor, nursing department and Graduate nursing program, universidade federal de santa catarina. cnpq Researcher and leader of the praxis Group.
RESUmo
Invesigação qualitaiva, balizada na ana -líica foucauliana, com ênfase na noção de governabilidade, consituiu como ob -jeivos: analisar a ariculação da tecno -biomedicina e bioéica, como discursos da contemporaneidade implicados na produ -ção da subjeividade do/a enfermeiro/a no contexto da Unidade de Terapia Intensiva (UTI); e abordar a responsabilidade no cui -dar como um dos desdobramentos estra -tégicos e tecnológicos de diferentes dis -cursos, gerando determinados modos de conceber e intervir do sujeito enfermeiro/a na UTI. Nessa perspeciva, dos múliplos vieses que poderiam emergir ao se fazer uma leitura críica dos textos analisados e das entrevistas com os/as enfermeiros/as, a temáica da responsabilidade do cuidar foi desdobrada em categorias que expres -saram a responsabilidade diante das novas linguagens e da enfermagem como guardiã de certos atributos da UTI.
dEScRitoRES
Unidades de Terapia Intensiva Bioéica
Enfermagem
Cuidados de enfermagem
AbStRAct
This qualitaive invesigaion was support -ed by Foucault’s analysis with emphasis on the noion of governability, and had the following objecives: to analyze the relaionship between techno-biomedicine and bioethics as discourses of the contem -poraneousness implied in the producion of nurses’ subjecivity within the context of the Intensive Care Unit (ICU); and ap -proach the responsibility implied in health care as one of the unfolding strategies of technology of speech of bioethics and biotechnology, creaing certain forms of the nurse understanding and intervening in the Intensive Care Unit (ICU). From the perspecive of the muliple ways that can emerge when analyzing a criical reading of analyzed texts and interviews with nurses, responsibility in health care was unfolded into categories that expressed the respon -sibility in front of new languages and of nursing as a guardian of certain atributes in the Intensive Care Unit (ICU).
dEScRiPtoRS
Intensive Care Units Bioethics
Nursing Nursing care
RESUmEn
Invesigación cualitaiva, basada en la ana -líica foucauliana, con énfasis en la noción de gobernabilidad, que objeivó: analizar la ariculación de la tecnobiomedicina y bioéica como discursos de la contempo -raneidad implicados en la producción de subjeividades del enfermero/a en contex -to de Unidad de Terapia Intensiva (UTI) y abordar la responsabilidad del cuidar como uno de los desdoblamientos estratégicos y tecnológicos de diferentes discursos, gene -rando determinados modos de concebir e intervenir en el sujeto enfermero/a en UTI. En tal perspeciva, de los múliples puntos de vista que podrían emerger al efectuarse una lectura críica de los textos analizados y las entrevistas con enfermeros/as, la te -máica de la responsabilidad en el cuidar fue desdoblada en categorías que expre -san la responsabilidad ante los nuevos len -guajes y de la enfermería como guardia de ciertos atributos de la UTI.
dEScRiPtoRES
Unidad de Terapia Intensiva Bioéica
Enfermería
intRodUction
An editorial issued in 1938(1), enitled Obrigações
le-gais da enfermeira em relação ao médico e ao doente
[Legal obligaions of the nurse towards the physician and the paient], writen 17 years before the irst Law on Pro -fessional Nursing Pracice No 2.604, issued on September 17th 1955, expressed that nurses, if employed by an insi
-tuion, was not the main responsible for her acions and conduct. Thus, physicians and employing insituions were Always held accountable in case nurses performed some inadequate pracice that entailed possible paient dam -age. In 1985, a paper recommended that nurses should study and follow the evoluion of scieniic knowledge, so as to efecively assume the responsibility inherent in their funcion as nurses(2). In 2008, i.e. nowadays, we are
confronted with a Bio/ethics discourse ariculated with nursing. A ime, an ariculaion that states, in diferent tones and forms, what our responsibility is as nurses, that details measures they should use to guaran
-tee their responsibility in care.
Responsibility, then, which entails a meaning of obligaion, task, commitment or duty to comply with or perform something about whose compliance or performance an agreement was reached. Legal accountability refers to compliance with the clauses of the Law of Professional Nursing Pracice; ethical responsibility is mistakenly understood as compliance with Nursing Professionals’ Eth -ics Code (CEPE), in view of the understanding that no ethics code manages to fully cover all ethical dilemmas experienced in view of en -hanced scieniic and technological develop -ment(2).Besides, the change in the itle, from
Nursing Deontological Code to CEPE marks an atempt to broaden its range towards cur -rent imes, as concern with nurses’ account -ability and duies, as a member of society, is expressed throughout the text(3).
We jusify the accomplishment of this study based on the belief that we consider that responsibility locates us in a ime of living nursing linked with the values and inter -ests of a society that privileges the health market. And, at many imes, these values and interests lead us to a para -dox between the responsibility of should be and autono
-my with the ability to choose – an exercise of autono-my is linked with knowledge on a given topic, which turns into a condiion for the ability to choose. One can talk about ad -equate knowledge when understanding exists: about the nature of the acion, the foreseeable consequences and possible results of execuing the acion or not(4).
Thus, instead of producing the erasure of the para -doxical relaion between professionals’ responsibility and autonomy at health insituions, we decided to explain the muliple combinaions of autonomy and responsibility
levels in detail. The idea is to qualify the paradox, demon -straing that intensive care professionals work on the bor -derline, in a space that ariculates, touching a bit more or less, depending on the case, the bioethical discourse, legal discourse, moral discourse, scieniic discourse and eco -nomic and administraive discourse. In this perspecive, we developed a Foucaulian analysis and focused on the discussion about techno-biomedicine in its ariculaion with bioethics and intensive care nursing, signaling and mapping some processes in which a set of governability pracices was intensiied, maximized and improved, which we call care responsibiliies, which are establishing (for in -tensive care nurses) ways of being and doing.
objEctiVES
To analyze the ariculaion between techno-biomed -icine and bioethics, as contemporaneous discourses im -plied in nurses’ producion of subjecivity in the context of
the Intensive Care Unit (ICU).
To address responsibility in care as one of the strategic and technological develop -ments of diferent discourses, producing certain ways the nurse subject conceives and intervenes at the ICU.
LitERAtURE REViEW
Care responsibility will be addressed her through governability pracices, construct -ed in the relaions nurses establish among themselves, with health insituions and with clients and in relaion to the profes -sion. The intent is to problemaize, produce estrangement about a daily reality that may be perceived and valued as normal and, who knows, as unquesionable and permanent. Updaing Foucaulian thinking, we present represen -taives from philosophy, law, the techno-biomedicine industry, theology, ethics commitees, professional asso -ciaions, hospital managers, medicine and nursing itself as some of the – what we call – unambiguous authoriies in bioethics and techno-biomedicine discourse. We consider unambiguous authoriies as subjects who are capable of saying and doing what they say and what they do, pre -cisely because they operate a discourse that incorporates other discourses from diferent knowledge areas. Hence, that is whom we should ask how to behave, and they also say how we should conduct other subjects. Therefore, these unambiguous authoriies present themselves as ca -pable of governing subjects, of governing the people that govern the subject and of consituing, thus, a general government pracice: government of oneself, government of others. So, how do these unambiguous authoriies, how do bioethics and techno-biomedicine ariculate the need for their own presence with the consituion, devel ...we consider that
responsibility locates us in a time of living nursing linked with the
values and interests of a society that privileges the health market. and, at many
opment and organizaion of the individual, of the pracice they develop in intensive care nursing? What instruments do they propose? Or, beter, through what insituional mediaions does bioethics intend the unambiguous au -thoriies, in their existence, in their pracice, in their dis -course, in the advice they will provide, to allow listeners to develop pracice, take care of themselves and reach what they are proposed as an object and target, and which they are themselves? In short: how does one establish, set and
deine the relaion between true-saying (veridicion) and the subject’s pracice?(5)
In that sense, Foucault, through the governability no -ion, makes the most of the subject’s freedom, discovering
the mater of ethics at the heart of all social relaions(5). In
governmentalized socieies, power is expanded because it is directed at free men, who perceive themselves as au -tonomous individuals(6). Hence, poliical power is increas
-ingly exercised through delicate alliances among a range of authoriies, permiing the aggregaion of realiies that range from economic relaions to individual conduct. And these individuals are not addressees, but intervenient in power games and operaions. Thus, power has less need to repress us than to administer and organize our daily reality. Foucault, when considering poliical power, establish -ing this topic as the most general governability quesion – as a strategic ield of mobile, transformable and reversible power relaions(6) – theoreical and pracically discusses
an ethics of the subject, deined by the relaion to one -self and the other. This means that power/governability/ government relaions to oneself and others compose a network, and that it is around these noions that one can ariculate poliics and ethics.
This ariculaion, in turn, is called governability of ethi -cal distance, as an intervallum between the aciviies the subject pracices and what consitutes him/her as a subject of these aciviies. Required by self-care, this intervallum promotes a retreat from the aciviies we are involved in, coninuing, however, to maintain the distance for a nec -essary state of surveillance between ourselves and our acions. An ethical subject never coincides perfectly with one’s role; this subject exerts sovereignty over oneself and that is what deines the tangible reality of poliical power(5).
Hence, self-care, far from producing inacivity, makes us act as proper, where and when proper. Far from iso -laing us from the human community, it appears, on the opposite, as what ariculates us with that community, as the relaion with oneself should allow the subject to dis -cover him/herself as a member of a human community. The subject uncovered in self-care is totally opposite to an isolated individual: it is a ciizen of the world. Self-care is, hence, a principle that regulates acivity, our relaion with the world and with others. It consitutes the aciv -ity, provides its measure and form, and even intensiies it. Finally, the self-culture should be conceived as a way to keep up poliical civil, economic and family acivity within the limits and forms that are considered convenient.
Self-culture is not the alternaive to, but a regulatory element of poliical acivity(5).
mEtHod
This paper is part of a thesis in which the ariculaion between techno-biomedicine and bioethics was analyzed, as contemporary discourses implied in the producion of nurses’ subjecivity in the ICU context. The study was developed in two phases: one literature review and one empirical phase. In the literature review, the documentary
corpus comprised Brazilian nursing papers published be
-tween 1984 and 2007. Papers were included if they were published in Brazilian nursing journals that reached, dur -ing any year between 2000 and 2007, classiicaion A or B Internaional according to the Qualis system (Revista Laino-Americana de Enfermagem; Revista Acta Paulista; Revista Texto & Contexto Enfermagem; Revista Escola de Enfermagem USP). In addiion, REBEn was also included, as it represents an emblemaic Brazilian Nursing journals, as well as Revista O Mundo da Saúde, aware of the fact that many nurses publish in journals that privilege the discussion of bioethics themes. In these journals, we de -limited 113 papers through a manual and broader search, addressing themes that could enrich the discussion about bioethics and ICU issues. Hence, the search went beyond the descriptors bioethics and ICU and nursing, ethics and ICU, bioethics and nursing as, although papers did not ex -plicitly menion the term bioethics, the addressed topics
reproduced themes directly related with bioethics and ethics. Among these 113 papers, we delimited 27 that al -lowed us to address responsibility in ICU nursing care.
In the empirical phase, an exploratory study with a qualitaive approach was accomplished. The populaion comprised 20 nurses working at diferent ICUs in the Met -ropolitan Region of Porto Alegre. Therefore, semistruc -tured interviews were recorded with one or two nurses per insituion, with at least six months of experience. First, we contacted them by phone and asked about the possibility of answering an interview. In case they ac -cepted in advance, a day, ime and place were set, ac -cording to their availability. Approval was obtained from the Insituional Review Board (Opinion No 186/07/CEP/ UFSC) and subjects manifested their acceptance through the Informed Consent Term, in compliance with Resolu -ion 196/96. Then, they answered two guiding ques-ions: 1) Describe one workday at the ICU during which posiive situaions happened; 2) Describe one workday at the ICU during which one or more situaions happened you per -ceived as bad.
language, during the meeing between the researcher and research subjects; documents that gained diferent mean -ings were analyzed in the context of the theoreical frame -work, the age and the social and cultural circumstances. On the other hand, the papers, also as narraives, com -plied with what was exposed above, but perhaps showed a number of authorized subjects in a more decisive way, supported by insituional status or as specialists that disseminate an academic discourse, when talking about themselves and others, when describing and character -izing the others. Thus, mainly with regard to the papers, building a general panorama helped us to orient the re-reading of the texts, and possible changes in the ways of developing themaic groupings, graning them meanings based on the framework considered for the analysis. In short, we work with the interviews and papers as a con -necion between ariculaing, overlapping, joining or, also, difering or contemporizing discourses.
RESULtS
Based on the selected papers and interviews with the nurses, we unfolded our analysis into Responsibility to -wards new discourses and Responsibility that maintains
nursing as a guardian of certain ICU atributes.
It should be explained that, in the secion
Responsibil-ity towards new discourses in paricular, we analyzed the papers instead of the interviews. And that makes sense here, as the papers allow us to reveal greater conluence between what the nurses who write and act, respecively, on themselves and other nurse subjects, say and leave unsaid. Besides, the issue of ‘new’ discourses could make us select much more than the 27 papers already chosen. Thus, the criterion was that these papers should certain a certain discursive regularity patern regarding the expres -sion responsibility in nursing or responsibility in care.
diScUSSion
Responsibility towards new Discourses
The complex situaions that demand decision making at ICU require nurses prepared to cope with ethical prob -lems(7). In this context, the principle of care delivery is un
-derlined, providing goods and servicing that enhance cli -ents’ saisfacion as much as possible, with a minimum, if not total absence of risks and errors that can compromise the desired quality and safety. Thus, nurses are responsible for prevening, detecing and acing on complicaions early, immediately and efecively. In short, to respond to techno -logical, social and economic transformaions, nurses have been gaining responsibiliies that have also reallocated them as unambiguous authoriies. And, through this posi -ion, they need to work with interdisciplinary language.
Some of the selected papers detail the nurses’ respon -sibility or, beter, jusify nurses’ necessary and perinent
inserion in each of the possible phases of an enire struc -ture, organized for the development of the organ captur -ing, donaion and transplantaion process. They limit this perinent inserion through statements like: nurses are the professionals with the proile and condiions to per -form and paricipate acively in the diferent phases of the organ donaion, capturing and transplantaion process(8);
women, with a noion of morality diferent from most men, perceive responsibility towards others more, as well as the importance of relaions and solicitude(4); nurses can
humanize the organ donaion, capturing and transplanta -ion process in diferent ways(9).
Two papers were found that orient nurses to prob -lemaize some of the current health discourse. One of them(10) evidences nurses’ conduct of omission in paient
informaion, this nursing works much more with aspects related to the beneits, to the detriment of the risks and consequences of the organ transplantaion process. It also focuses on the high social cost and technology used in transplantaions, bringing to mind the need for studies that assess the problems met. In that sense, it guarantees that professional pracice, within ethical-legal principles, should makes nurses’ intensify their aitude of surveil -lance, paricipaing with clients and the community in discussions about discrete manipulaions by corporaist groups. The other paper(11) addresses the associaion be
-tween total quality and ethics, evidencing the ideological nature of ethics when considering this associaion. It ana -lyzes that the possible concordance between the words quality and ethics centers around a type of discourse
with idealisic concepions, to the extent that the pro -posed quality in Brazil has jusiied, in educaion as well as health, excluding acions, which privilege some few to the detriment of diferent majoriies. Finally, arguments are presented in favor of constant and atenive relecions, as naïve acions can provoke socially harmful results, in which people get involved in certain professional respon -sibiliies, seeking the intended total quality, but what hap -pens is once more a process of condiioning, so intense that the subject only experiences the search for total quality in his/her producion and work.
In another group of papers, a hospital humanizaion discourse is required as a prerogaive for nursing to ‘bal -ance’ the premise that current technological advances in hospital care seem to be more associated with proposed investment in the physical structure of buildings and with other processes that do not necessarily imply changes in the organizaional culture, enhancing the humanizaion of work and care as ethical expression. They refer to the need for the CEPE to establish accountability for promot -ing this humanized care.
Another combinaion of papers explores nursing’s re -sponsibility in the palliaive care team and in its adequate communicaion with paients in terminal condiions, hos -pitalized at ICUs or in hospices. One of these papers(12) re
nurses in the full sense of the word, as it is the ime of soli -tude, of abandonment, when all safety in life disappears. Another paper(13) analyzes nurses’ omission to inform pa
-ients about the prognosis, beyond therapeuic possibili -ies. The aricle jusiies this omission by the feeling of pa -ternalism, to the extent that nurses somehow atempt to protect the paient against this harmful informaion.
Some of the papers under analysis explicitly advise nurses to seek support from bioethics to minimize such diverging aitudes and, with litle or no scieniic founda -ions to deal with the problem at stake, merely based on personal experiences and values.
This represents responsibility in care translated based on an ariculaion among ‘new’ discourses. Hence, in the papers, one can acknowledge a paricular ariculaion of discourses produced based on current social demands (organ donaion, capturing and transplantaion, terminal -ity, palliaive care, total qual-ity, leadership and hospital organizaion) and, at the same ime, producing other dis -courses (ethical dilemmas, safe pracices, hospital human -izaion, total quality, terminality, palliaive care, leader -ship and hospital organizaion). In other words, discourses produced based on demands and which generate or real -locate other demands. To give an example, the discourse of organ donaion and capturing ariculates techno-bio -medical, bio/ethical and legal discourses and, in turn, its pracice as a process triggers the ariculaion of at least one more discourse: that of hospital humanizaion. The bio/ethical discourse itself represents an efect of techno-biomedical discourse demands.
When considering the humanizaion discourse in the context of intensive care therapy, one can signal its am -biguous and problemaic nature. That is, when intensiied, techno-biomedicine has been used as something capable of dehumanizing care. But, dealing with intensiied tech -nology in daily reality at an ICU implies dehumanizaion based on what referent? Or also, should the increasing unfeasibility of ofering technology at the service of life and health to public health system users not be consid -ered an important form of humanizaion as well?(14).
The way Foucault discusses humanism, which we could use to discuss the ambiguous and problemaic nature of humanizaion discourse, can serve as an example to show these ariculaions. According to the author, humanism is a set of themes that reappear on diferent occasions over ime in society; themes always connected with value judg -ments and with a criical principle of disincion (human -ism as criical to Chrisianity; human-ism hosile and crii -cal to science; or another that, on the opposite, puts its hope in the same science). Hence,
one should not conclude that everything demanded as hu-manism should be rejected, but that the humanistic theme is by itself very malleable, very diverse, very inconsistent
to serve as an axis for relection. And, it is true that, at
always been obliged to rest on certain conceptions of man that are borrowed from religion, science, politics. Human-ism serves to color and justify man’s conceptions, which
he was deinitely obliged to turn to(15).
In short, this ariculaion makes us see that
what we know and consider as a unit is in fact the always provisional result of a historically situated connection among many different discourses or some of their elements, a net-work woven by and based on multiple correspondences,
power relations, incongruences and conlicts(16).
Thus, we map discursive ariculaions that put the re -sponsibility for care on the agenda, which in turn relects some of the ways of being and doing intensive care nurs -ing. Now, let us move on to the analysis of the responsi -bility that maintains nursing as a guardian of certain ICU atributes.
Responsibility that maintains nursing as a guardian of
certain ICU atributes
May one say that nursing, like other health areas, is fundamental for a given society? In a way yes. Nursing works for health issues that correspond to what is of inter -est at that ime(17). Someimes through a form of historical
cooperaion atributed to women (through some theorei -cal branches), which is a way of assuming responsibility and taking care of the other; someimes through charita -ble ethics, linked with the religious feeling of compassion and abnegaion, through which the client is seen as de -pendent and submissive, reinforcing professional duty. Al -so, through philanthropist ethics, mobilized by the State, to atend to the needy and, in return, the same State de -termines the subject’s conducts, generally by controlling care agents’ acions(18). Also, a inal and more subtle op
-ion, and therefore more ‘compaible’ with the discussion form based on the governability concept, in which nurses join: sensiivity to assume responsibility, because they see to human needs that refer to nursing pariculariies; ac -countability for the health and wellbeing of the subjects under their care; communicaion skills with a view to con -sidering paients as valid interlocutors; ability to enhance people’s autonomy(19). In other words, nurses are a group
that, besides creaing policies and knowledge, helps the State to govern at a distance, or society to govern itself. Nurses perceive themselves as responsible for organizing the work environment(20).
with care-ethics; integraing principles and technical com -petency, in a climate of care and accountability to the oth -er. Care providers move along with the people they take care of to promote their health and deal with their suf -fering, in a double funcion: that of experts and counsel -ors; experts as, with diferent personal and professional knowledge, they master a picture of competencies that allow them to recommend the necessary intervenions and glimpse alternaives, increasing the range of possible routes; counselors, not because they recklessly distribute advice and orientaions but because, provided with a true discourse, they clarify paients about the opportuniies, risks and diiculies associated with each opion, nurtur -ing an autonomous choice and contribu-ing to put the de -cision made in pracice(19).
Based on these iniial arguments, it is inferred that nurses consitute their subjecivity, also as guardians of certain ICU atributes; guardians that use diferent re -sources. Below are some situaions nurses experience in care pracice:
bad situations are common and translated in different ways: a nursing team that acts automatically, without think-ing of the individual they are takthink-ing care of; this same team that does not remember that they are part of a larger group and need to serve as collaborators; with the medical team, often uncommitted, not granting proper attention to the patient, postponing care and the sudden loss of a patient they were taking care of. all of these situations occur al-most every day, to a greater or lesser extent and, despite attempts to revert them, they are repeated (s2).
nowadays, nurses are greatly involved in accountability for actions practiced on the patient. at our icu, we were trying to put in practice the cvp [central venous
pres-sure] establishment and veriication routine in patients with
their headrest at 30° or 60°, as there are different stud-ies signaling that this form is more adequate and safe for them. the medical team was divided; but one female and one male physician insisted on the level headrest. look, it
was dificult to argue against them, as both are well rep -resented at this icu. nevertheless, nursing defended its understanding about cvp establishment and managed to alter that routine (s11).
These statements reveal that nurses are guardians of a commitment to take care of the other. In other words, in the irst statement, nurses police other health team members’ professional commitment, also highlighing other members’ lack of responsibiliies and possible con -sequences; in the second statement, the nurse assumes the commitment, based on speciic and technical compe -tence, to alter ways of doing nursing, provided that she believes she can sustain a truer discourse.
In other words, to highlight lack of responsibiliies and signal best pracices, nurse subjects need to turn them -selves into subjects that say the truth. That would mean making true discourse subjecive(5). But these subjects do
not need to tell the truth about themselves in any way;
they do need to say what is true to themselves: they need to believe in what is true.
Paradoxically, based on the governability concept, the guardian’s conduct, with a true discourse, makes nurses idenify, ‘quite’ easily, situaions to invest and apply tech -nical resources to paients with negaive cli-nical condi -ions without condi-ions for recovery, tests, procedures and other doubful treatments. In these situaions, nurses assume an inquisiive aitude towards these doubful treatments and, at the same ime, exempt themselves from responsibility through the collecive(21).That aspect,
in a way, is translated in the statement below:
a good workday at the icu is when a patient arrives with a reserved prognosis, in come and hospitalized for a long time, achieves clinical improvement, recovers conscious-ness, interacts positively with the team and is discharged, going to the hospitalization unit, and is grateful for the care delivered during his icu stay (s7).
What calls our atenion in this statement is precisely the peculiarity in which a society (including physicians, family members, paients, nurses and other individuals and professionals) expects from an ICU. IN other words, this statement is by no means separated, detached from a world that worships a health ideal and hopes for recovery
possibiliies and care potenial.
Sincerely, I ind it very interesting this oscillation in nurses’ autonomy at the icu, according to the work shift. during the day, they are supposed to perform exclusively their tasks as nurses, which by the way already demands great responsibility; during night shifts, this same nurse should do and know everything and even more, so that they do not need to call the physician on duty. i would not like to be unfair to some physicians who are very responsible in their activities independently of the work shift, but some physicians on duty, if called to see to some situation with a patient, get out, saying that nursing is very dependent and does not manage to solve anything by itself (s5).
The later statement refers to a mix-up of the borders between medicine and nursing and between autonomy and responsibility in the ICU context. One of the results of the change in an environment that enhances the use of current medical technologies is that knowledge about science and the principles of medicine, which were rela -ively unimportant unil some years ago, have become in -dispensable in the care process. Hence, at the ICU, some -imes it is diicult to say the speciic and strict funcions of physicians as well as nurses. It is almost impossible to deny that, in the strictly legal interpretaion of the ex -pression medical pracice, many nurses are pracicing act that technically and legally it into the medical area. Thus, in some situaions, nurses simple perform intervenions
beyond their technical competency and are concerned with performing them meiculously and friendly, thus sustaining a conduct as guardians. In short, nurses as -sume other professionals’ responsibiliies with a view to
We cannot ignore that professions like nursing and medicine have disinguished experiences in coping with the tensions of their situaions as knowledge and prac -ice ield, nor the degree to which these diferences were historically established, to the extent that they represent disinct subjects, despite their neighboring objects. At this point, a subtly demonstrated percepion of fragility/pre -cariousness should also be acknowledged here though, of what show to be solid and legiimate statutes of profes -sional acion at other imes – the moment when these dis -incions do not seem to respond to urgent needs, to what needs to be done, to what is simply agreed upon in the si -lent agreement among the stakeholders. In short, yet an -other paradox: between a strict movement that atempts to maintain strictly professional and corporate interests or to guarantee knowledge and pracice monopolies and the lexible movement that presents a ield of knowledge and pracices, necessarily open to disseminaion among professionals.
concLUSion
Wriing about such a complex theme, based on the reading of 26 papers and statements from 20 interviews,
would be impossible in so few pages if it were not for the fact that, despite assuming the risk of simplifying and re -ducing the wealth of the corpus, an exercise is proposed: that of demonstraing, through the polysemy of themes found, not just the burden put on intensive care nursing, but what this nursing has apprehended from this ‘burden’ as something characterisic, something it Is linked with, or which permits a bond between the required acion, the calculated responsibility and the subject one is.
Also, when drawing a current map of what we call re -sponsibiliies in ICU nursing care, the complexity of these diferent events the same nursing is involved in is surpris -ing; by the way, have academic and clinical nursing, real -ized this? Therefore, we consider that the ime that drives us to live as intensive care nurses also delegates us the responsibility of relecing on our way of being, trying to understand the causes that inluence them and their con -sequences. It is only based on broader understanding of the situaions that we can act criically. At each moment, if we ask ourselves a quesion, if we should act like that, and seek answers in the belief that what each of us does entails consequences not only for him/herself or only for others, we will be modifying our history.
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