1 Nurse, Sc. M. in Nursing, Hospit al Moinhos de Vent o, Port o Alegre, Rio Grande do Sul, Brazil, Professor, FEEVALE Universit y Center, Brazil, e- m ail: ffabibock@hotm ail.com ; 2 Advisor, PhD in Nursing, Associate Professor, Nursing Departm ent, Santa Catarina Federal University, Brazil, e-m ail: padilha@nfr.ufsc.br; 3 Nurse, PhD in Nursing, Hospit al Universit ário of t he Sant a Cat arina Federal Universit y, Professor UNI SUL, Brazil, e- m ail: luciam ant e@gm ail.com
Disponible en castellano/ Disponível em língua portuguesa SciELO Brasil w w w .scielo.br/ rlae
COMMUNI CATI ON BETW EEN NURSI NG STAFF AND CLI ENTS UNABLE TO COMMUNI CATE
VERBALLY
Lisnéia Fabiani Bock Or dahi1 Mar ia I t ay r a Coelho de Souza Padilha2 Lúcia Nazar et h Am ant e de Souza3
Ordahi LFB, Padilha MI CS, Souza LNA. Com m unication between nursing staff and clients unable to com m unicate verbally. Rev Lat ino- am Enferm agem 2007 set em bro- out ubro; 15( 5) : 965- 72.
This is an experience developed during the Master program in Nursing at UFSC. I t aim ed to reflect on the nursing care delivered to the patient unable to verbally com m unicate, based on Paterson and Zderad´ s Theory and to analyze the com m unicational process between nursing and client. The experience was carried out in the I ntensive Care Cent er of a privat e hospit al in t w o st ages: non- part icipat ing observat ion and t hree exist ent ial w orkshops, involving nine nursing technicians. Each participant acquired self knowledge and was known by other participants in the intuitive dialogue. Alternatives of non- verbal dialogue were suggested during the scientific dialogue. The scientific-intuitive fusion em erged when there was a need of each one to position them selves about the totality. The study on t he com m unicat ional process revealed t he need t o enlarge t he approach regarding t he care t o t he client unable t o verbally com m unicat e, especially t raining t he t eam for t he int erpersonal and dialogical relat ionship.
DESCRI PTORS: nur sing car e; com m unicat ion; non- v er bal com m unicat ion
COMUNI CACI ÓN ENTRE LA ENFERMERÍ A Y LOS CLI ENTES I MPOSI BI LI TADOS DE
COMUNI CARSE VERBALMENTE
Se t rat a de una experiência desarrollada en la Maest ría en Enferm ería del UFSC. El obj et ivo fue refleccionar sobre el cuidado de enferm ería al client e im posibilit ado de com unicarse verbalm ent e., baj o la Teoría de Pat erson y Zderad, y analizar el proceso com unicacional ent er la enferm ería y el client e. La experiencia se desarrolló en el Cent ro de Terapia I nt ensiva de un hospit al privado en dos et apas: observación no part icipant e y t res oficinas exist enciales, incluyendo la part icipación de nueve t écnicos en enferm ería. En el diálogo int uit ivo, cada uno de los par t icipant es se aut oconoció y fue conocido por los ot r os par t icipant es. En el diálogo no cient ífico, el equipo sugir ió alt er nat iv as de diálogos no v er bales. La fusión int uit iv a- cient ífica sur ge cuando hay necesidad de un posicion am ien t o de cada u n o de ellos sobr e el r est o. El est u dio sobr e el pr oceso com u n icacion al r ev eló la necesidad de am pliar el acer cam ient o par a el cuidado del client e im posibilit ado de com unicar se v er balm ent e, involucrando pr incipalm ent e la prepar ación del equipo para la relación int erpersonal y de diálogo.
DESCRI PTORES: at ención de enfer m er ía; com unicación; com unicación no v er bal
COMUNI CAÇÃO ENTRE A ENFERMAGEM E OS CLI ENTES I MPOSSI BI LI TADOS DE
COMUNI CAÇÃO VERBAL
Tr at a- se de ex per iência desenv olv ida no Mest r ado em Enfer m agem da Univ er sidade Feder al de Sant a Cat ar in a. O obj et iv o f oi r ef let ir sobr e o cu idado de en f er m agem ao clien t e im possibilit ado de com u n icação v er bal, sob a t eor ia de Pat er son e Zder ad, e analisar o pr ocesso com unicacional ent r e enfer m agem e client e. A ex per iên cia ocor r eu n o cen t r o de t er apia in t en siv a de u m h ospit al pr iv ado, em du as et apas: obser v ação não- par t icipant e e t r ês oficinas ex ist enciais, env olv endo a par t icipação de nov e t écnicos de enfer m agem . No Diálogo I n t u it iv o, cada par t icipan t e se au t ocon h eceu e f oi con h ecido pelos ou t r os par t icipan t es. No diálogo cient ífico, a equipe suger iu alt er nat ivas de diálogo não- ver bal. A fusão int uit ivo- cient ífica sur giu quando houve a necessidade de posicionam ent o de cada um sobr e a t ot alidade. O est udo sobr e o pr ocesso com unicacional r ev elou a necessidade de am pliar a abor dagem acer ca do cuidado ao client e im possibilit ado de com unicação v er bal, env olv endo pr incipalm ent e o pr epar o da equipe par a a r elação int er pessoal e dialógica.
I NTRODUCTI ON
H
u m a n co m m u n i ca t i o n w a s f i r st d o n e t hrough gest ures, im ages and sounds. Lat er, hum ans began using graphical signs to refer to fam iliar sense-p er ceiv ed ob j ect s t h at u sed t o b e com m u n icat ed t h r ou g h g est u r es. Ver b al com m u n icat ion m ar k ed hum an t ransit ion from concret e anim al int elligence, l i m i t ed t o t h e p r esen t , t o a sy m b o l i c o r m en t al representation of the world( 1). For nursing, appropriatecom m unicat ion aim s t o r educe conflict s and r each solu t ion s f or p r ob lem s t h at ap p ear d u r in g clien t hospitalization. The dynam ics of sending and receiving m essages depends on int erpret ing what is expressed and on the nursing team ’s attitude. I t involves feelings, i d ea s, a g r eem en t s, d i sa g r eem en t s a n d p h y si ca l proxim ity, and is reached through gestures, postures, facial expression, body language, som atic singularities, nat ural or art ificial, obj ect organizat ion in space, and ev en t h r o u g h t h e d i st an ce r el at i o n sh i p b et w een individuals( 2).
At a n I n t en si v e Ca r e Un i t ( I CU) , v er b a l com m u n icat ion is som et im es im pair ed. Th er ef or e, clients only have gestures and looks, often anguished, to try to express them selves( 3). Weighing and acquiring
knowledge about non- verbal com m unicat ion perm it s t o develop professional capacit y t o precisely ident ify feelings ex pr essed t hr ough look s and t ouches and, t hus, t o overcom e client com m unicat ion difficult ies. D u e t o i t s co m p l e x i t y a n d cu r r e n t i m p o r t a n ce , num erous st udies and invest igat ions have looked at com m unicat ion. I n healt h, and especially in nursing, com m unication is considered essential to m eet sim ple h u m a n n e e d s( 4 ). Th e t e a m sh o u l d d e co d e a n d
under st and t he m eaning of t he client s’ m essage so as t o offer adequat e care, consist ent wit h t heir real necessities. For nursing, com m unication is an essential i n st r u m e n t , a co m p e t e n cy a n d a sk i l l t o b e dev eloped( 5). The I CU ex per ience show s t hat m ost
client s are unable t o com m unicat e verbally and t hat their conscience levels are affected, ranging from lucid and oriented to deep com a. This im plies the need not only to control the equipm ent, but also to understand hum an, social, psychological and spiritual dim ensions. St udies wit h I CU pat ient s show t hat t he t ouch from r elat iv es, n u r ses an d doct or s, can ch an ge clien t s’ heart beat or reduce it by holding t heir hands( 6). The
com m unication process during I CU care points at the i m p o r t a n ce o f n u r se s’ se l f k n o w l e d g e a n d se l f -per cept ion . Mor eov er, it sh ow s t h at dialogu es ar e r ecr ea t i o n a l m o m en t s f o r t h o se i n v o l v ed i n t h e int eract ion( 3,7).
Pat erson and Zderad’s Hum anist ic Theory( 8) p r op oses t h e ap p r ox im at ion b et w een n u r ses an d clien t s as an ex ist en t ial ex per ien ce in w h ich t h eir ex pr essiv eness and pot ent ialit y ar e ev idenced. The au t h or s also see n u r sin g as a h u m an ex per ien ce, including all the possible hum an answers to a situation, regarding people in need as well as people helping, in which bot h part icipat e according t o t heir own way of being. This t heory is also an im port ant reference involving encount ers ( m eetings between hum an being,
expect ing t hat t here will be som eone t o deliver care and som eone t o be cared for) , pr esence ( t he qualit y of being reciprocally open t o t he ot her) , r elat ionship
( b ein g w it h t h e ot h er, m ov in g t ow ar d s t h e ot h er, of f er in g an d en ab lin g au t h en t ic p r esen ce) , an d a callin g an d an an sw er ( int er act iv e com m unicat ion, eit her verbal or non- verbal)( 8).
I n t his sense, t he obj ect ives of t he present st udy were out lined: t o reflect on nursing t eam care toward clients unable to com m unicate verbally, guided by Paterson and Zderad’s theory; and to analyze the com m unicat ion pr ocess bet w een nur sing t eam and client s unable t o com m unicat e verbally.
METHODOLOGY
This experience was carried out at t he adult I CU of a privat e hospit al locat ed in Port o Alegre, a cit y in Rio Grande do Sul St at e, Brazil. The unit has 3 1 b ed s, a r r a n g ed i n i n d i v i d u a l b o x es so a s t o guarantee the clients’ tranquility and privacy with their r e l a t i v e s. Fi r st , t h e I CU n u r se su p e r v i so r w a s in f or m ally appr oach ed, w h o appr ov ed t h e pr esen t study after getting to know its purposes* . Nine nursing t echnicians from t he night shift agreed t o part icipat e in t he m eet ings. They com plied w it h t he follow ing inclusion cr it er ia: hav ing w or k ed at t he unit for at least one year, and agree to provide written consent. Th e p r o j ect w a s a n a l y zed a n d a p p r o v ed b y t h e I nst it ut ional Review Board at Sant a Cat arina Federal Univ er sit y.
This study was perform ed in two stages: the first consisted of non- participant observation; and the second involved exist ent ial workshops. The purpose of non- participant observation of nurse staff work with I CU pat ien t s w as t o collect dat a f or plan n in g an d dev elopin g t h e ex ist en t ial w or k sh ops. Hen ce, t h is stage was carried out at a different m om ent than data collection; that is, during m orning and afternoon shifts, with a total of six hours of non- participant observation. A field j ournal was used t o t ranscribe t he observed context, including a description of dialogues and health care set t ing( 9). The day nursing t eam has a six- hour
daily shift , while t he night t eam has a 12- hour shift , wit h rest int ervals of 60 hours.
The exist ent ial workshops( 3) were perform ed
befor e t he par t icipant s’ w or k hour s, and aim ed t o analy ze t he t eam ’s act iv it ies w it h client s unable t o com m u n icat e v er bally. Th ey also aim ed t o collect i n f o r m a t i o n f o r t h e f u r t h e r d e v e l o p m e n t o f a n ed u cat ion al p r ocess w it h t h e n u r sin g t eam ab ou t d eliv er in g car e t o clien t s u n ab le t o com m u n icat e verbally, guided by Paterson and Zderad’s theory. The three workshops took place in June 2005 and followed st a g e s o f se n si t i za t i o n , i m p l e m e n t a t i o n , a n d ev al u at i o n . Each ex i st en t i al w o r k sh o p l ast ed an average of 60 m inut es.
The them e of Exist ent ial W orkshop # 1 was
w ho am I ? This m om ent aim ed to provide the group
w it h an op p or t u n it y t o r ef lect ab ou t t h em selv es, e x p e r i e n ci n g t h e i r b e l i e f s a s p e r so n s a n d professionals. Ex ist e nt ia l W or k shop # 2 was about t he possible form s of com m unicat ion, and was called
h ow do I com m u n ica t e w it h I CU pa t ie n t s? This
w o r k sh o p a i m e d t o p r o v i d e t h e g r o u p w i t h a n o p p o r t u n i t y t o r e f l e ct a b o u t t h e f o r m s o f com m unication used during nursing care, focusing on v er bal and non- v er bal com m unicat ion, and seek ing t o ident ify, fr om t he gr oup’s per spect ive, t he easy an d d if f icu lt asp ect s of com m u n icat in g w it h I CU pat ient s. The t hem e for Ex ist e n t ia l W or k sh op # 3
was dialogical int eract ion, and was called dia logica l
int eract ion represent at ion”. The aim was to reflect
on t he dialogical int eract ion involved in nursing care delivery t o I CU pat ient s. I n t he first w orkshop, t he participants were allowed to choose flower nam es for t h e i r i d e n t i f i ca t i o n . Th e ch o se n n a m e s w e r e :
Ca r n a t ion , Lilly, Tu lip, Or ch id, H ibiscu s, Pa n sy, R o se , V i o l e t a n d D a i sy. Th e est a b l i sh ed t r u st relationship granted participants the right to no answer, n o r e v e l a t i o n o r v e i l e d r e v e l a t i o n , r e sp e ct i n g
appropriat e revelat ion lim it s so as t o preserve t heir pr iv acy( 9).
DETAI LI NG THE EXPERI ENCE
I nt uit ive dia logue was observed especially
in t he fir st w or k shop, w it h t he const r uct ion of t he subj ect s’ per cept ion of t he st udy t hr ough dynam ics that encouraged them to think about them selves and about how t hey com m unicat ed wit h client s. Thinking about t e ch n ica l- scie n t ific dia logu e, t hem es w er e organized wit h sim ple guiding quest ions t o approach t he percept ions report ed by t he group, ending wit h
i n t u i t i v e - sci e n t i f i c f u si o n b y e v a l u a t i n g e a ch part icipant t hough oral and writ t en evaluat ions.
The first st age, non- part icipant observat ion, is t he m om ent when t he researcher was present in t h e si t u a t i o n b u t w i t h o u t i n t e r a ct i o n( 9 - 1 0 ). Th i s
observat ion m et hod perm it t ed inform at ion collect ion, such as indiv iduals’ char act er ist ics and condit ions, verbal and non- verbal com m unicat ion, act ivit ies and environm ent al condit ions, w it hout int erference from t h e obser v er in t h e dy n am ics of t h e set t in g. Tw o si g n i f i can t m o m en t s o f d i r ect p at i en t car e w er e n o t i ced d u r i n g t h e si x o b ser v ed h o u r s, a n d a r e described below. The first is t he descript ion of non-car e t o w ar d t h e cl i en t , an d t h e seco n d m o m en t r epr esent s em pat hy and nur se- client int er per sonal r elat ionship.
The nursing t echnician ent ers t he box where client C is, and says: j ust a lit t le prick, referring to capillary glycem ia m easurem ent. The client gives an unsatisfied look and lowers her head (sad). The nursing technician asks: Would you like t o have lunch now?The client nods her head, showing she agrees. Aft er checking her wat ch, the nursing technician adds: If you don’t eat now, t he doct or
w ill w ant t o use a lit t le feeding- t ube. At t his m om ent t he patient frowns and shows she is upset, and sighs when the worker leaves the box.
The nurse was sitting next to the client, holding his hand, explaining she needed his help t o insert a feeding tube, and that he needed this tube due to his inability to eat regularly. The client was awake, lucid, int ubat ed, but collabor at iv e. The nur se st ar t ed t he procedure with som e difficulty, because the tube kept rolling in the client’s m outh, which dem anded a great effor t fr om him . Many unsuccessful at t em pt s w er e m ade, and t he nost rils were som ewhat t raum at ized. The nurse did not want to continue. With tears in her eyes, she t ried t o calm t he client down, holding his h an d s an d sh ow in g af f ect ion . Th e clien t in sist ed t hrough facial m ovem ent s t hat she should cont inue, because he believed it was necessary and im port ant for his treatm ent. After som e tim e, the procedure was accom plished and t he nurse rem ained by t he client ’s side until he fell asleep. She seem ed worried with the discom fort t hat had been caused.
The nurse sought t o int uit ively get t o know t he client , perceiving t he sit uat ion t hrough his eyes and understanding his experience, which was difficult. Sh e t r an sm it t ed secu r it y an d con f id en ce t h r ou g h t ou ch , fr agile facial ex pr ession an d dialogu e. Th is m ade t h e pat ien t r ealize t h e n eed t o per for m t h e procedure for his treatm ent and health im provem ent. I n phenom enological nursing, t here is no descript ion f or a n u r sin g p lan f ocu sed on on e g oal, b ecau se hum anist ic nursing is concerned wit h being wit h t he ot her in need, in which being bet t er or w ellbeing is achiev ed t hr ough d ialog u e( 8). This obser v at ion w as ext rem ely im port ant because, from t his m om ent , it was outlined how the Existential Workshops would be dev eloped.
I n the second stage, a reflexive process was dev eloped abou t t h e f in din gs f r om t h e ex ist en t ial w or k shop, based on Pat er son and Zderad’s t heor y. The existential workshops were characterized through t h r ee ph ases, accor din g t o t h e pr esu pposit ion s of Pat er so n an d Z d er ad ’s t h eo r y ; t h at i s, I n t u i t i v e Dialogue, Scient ific Dialogue, and I nt uit ive- Scient ific Fusion. I n Ex ist e n t ia l W or k sh op # 1, par t icipant s were asked to write, on a spiral drawn on cardboard, their expectations regarding the upcom ing workshops. Aft er all part icipant s were done writ ing, t he following words were read out loud:
Gr ow t h , t oget h er n ess, k n ow ledge, gr ow t h and togetherness, to grow as a hum an being, getting along and lear ning, hum anizat ion and am usem ent , co m p a n i o n sh i p , si n ce r i t y, m o r e k n o w l e d g e a n d understanding toward patients and colleagues, building
sk i l l s a n d co m m i t m e n t , r e sp e ct , g r o u p u n i t y, friendship and j oy.
Th e idea w as for par t icipan t s t o u se t h eir int uit ion t o det er m ine t he sear ch for k now ledge in or der t o enhance t heir int er per sonal r elat ions and ev er y day nur sing t ask s. Par t icipant s w er e ask ed t o create a poster using pictures or texts from m agazines, answering t he following guiding quest ions: W ho a m
I ? At hom e ? At w or k ? They looked at m agazines,
so m e si l e n t l y, o t h e r s e x ch a n g i n g i d e a s a n d co m m e n t i n g a b o u t t h e w o r k sh o p . A m u si ca l background was set t o help part icipant s t hink about t he t wo proposed quest ions. Aft er accom plishing t he individual t ask, each part icipant hung his/ her post ers on t he w all and r ead t hem out loud. This m ade it possible t o relat e t heir percept ion wit h t he program cont ent for t hat m om ent . The st at em ent giv en by
Or chid illust rat es t his phase:
I did som e past ing, like, t his one of a m ot her wit h her
child. I ’m a proud m ot her, I like m y son and I enj oy playing wit h
him . This is anot her pict ure ( point s at a happy, em braced couple) ,
when m y husband is hom e at t he weekend, it is t he m om ent I can
enj oy being wit h him and I leave house work for t he ot her days. I
also like t o spend som e t im e alone, I like t o pray, have som e t im e
t o t hink about what I did wrong, what I could im prove. Most of t he
t im e I ’m hom e, I ’m rest ing ( pict ure of crossed feet , represent ing
rest ) . At work, I can appear t o be a serious, det erm ined person. I
try to concentrate on what I ’m doing. I ’m open to criticism , opinions.
I ’m flexible and I list en t o what people have t o say.
Par t icipan t s cr eat ed a r et r ospect iv e abou t their self, which, according to Paterson and Zderad( 8),
I n Ex ist e n t ia l W o r k sh o p # 2, t he ball of w ool dy nam ics* w as used. At t his m om ent , V iole t
m ade t he following st at em ent .
...it ’s like when we m ove t he pat ient in bed wit h a
blanket . I f one of us let s go of t he blanket , t he client m ight fall.
Com m unicat ion is essent ial.
I t w as si g n i f i can t t o r em em b er t h at an y a ct i o n , e sp e ci a l l y cl i e n t ca r e , sh o u l d i n cl u d e a p p r o p r i a t e co m m u n i ca t i o n a n d m u t u a l under st anding.
Th e se co n d m o m e n t a d d r e sse d t h e im portance of com m unication with clients and am ong t he gr oup, and t hat com m unicat ion can be v er bal, non- verbal and paralinguist ic ( wit h som e explanat ion about each) . I n scientific dialogue, intuitive knowledge const ruct ion was support ed by t he body of lit erat ure on client- nursing staff com m unication and interaction. Th e e x p l a n a t i o n a b o u t v e r b a l a n d n o n - v e r b a l com m u n icat ion g av e t h e g r ou p ch an ces of b ein g
pr esen t in t he self- ot her relat ionship. This confirm s t he dialogue process experienced t hrough gest ures, em otions, looks, silence, body and facial expressions, voice int onat ion and ot her part icipant behaviors( 8).
Next , part icipant s were asked t o form t hree sm all gr ou ps, so each cou ld per for m an ev er y day scene, representing how people com m unicate at work, showing the easy and difficult aspects involved. At the end, part icipant s explained aspect s t hat were unclear or am bigu ou s. Each gr ou p r em em ber ed fact s t h at occurred with certain clients, easy and difficult aspects, em pathy, beliefs, em otional attachm ent with client and relatives, and difficulties of working with various health care professionals. The group form ed by Tulip, Rose
and D a isy was quit e prepared for t he present at ion,
with various notes about their thoughts. Daisy sat in front of the desk and began saying:
First , we will t alk about som e t hings t hat are im port ant
f o r a d i a l o g i c a l i n t e r a c t i o n . Th i n g s t h a t r e a l l y h e l p i n
com m unicat ion: having a fixed client list , so I t ake care of t hat
client unt il hospit alizat ion is over. This helps m e underst and t he
client bet t er , especially if he/ she is unable t o com m unicat e
verbally. Day by day, you st art learning lit t le t hings t hat will
help you t ake care of your client ; observing t he client as a whole,
not only clinical signs.
Accor ding t o t he gr oup, a fix ed pat ient list would perm it closer approxim at ion wit h client s and, t h u s, cr e a t e p r o f e ssi o n a l - cl i e n t e m p a t h y a n d
at t achm ent . This is ex pr essed t hr ough at t ent ion t o t he client ’s pr efer ences r egar ding sleep hour s, bed posit ions, r oom t em per at ur e, t oilet ing and ot her s. Ch a n g i n g cl i e n t s e v e r y sh i f t i m p a i r s d i a l o g i ca l r e l a t i o n sh i p s a n d t h u s co n t r i b u t e s t o cl i e n t dissat isfact ion.
A l o w a n d t e n d e r v o i ce t r a n sm i t s se cu r i t y a n d
t ranquilit y. Som et im es, one t hing we see t hat really shocks us is
when t he neurosurgeon com es and ent ers t he room yelling wit h
t he client : “ Mr. So- and- so?” And pinches t he client t o check if
t here is any react ion. The client gives a j erk because of t he scare,
or t he cold… or it could have really hurt . We know t his approach is
im port ant t o evaluat e conscience level, but t here are ways t o do
it . I f you put yourself in t he client ’s place, it is shocking and
aggr essive. ( Daisy)
At t achm ent , as previously described, m akes professionals pay attention to these occurrences. They t r y t o pr ot ect client s fr om fact or s t hat could cause st r e ss, d i st u r b t r a n q u i l i t y o r i n cr e a se cl i e n t s’ discom fort, especially when they cannot com m unicate verbally. Professionals who focus only on evaluat ing t he pat ient m ight forget t hat t he m om ent should be m ade into a significant encounter. Moreover, this does not involve only physical cont act , in which doing for
could be r eplaced by doin g t o, as pr oposed by t he hum anistic theory. Health care, in addition to zeal and concern, m eans solicit ude, at t ent ion and dedicat ion, which can pose agitation and a sense of responsibility on caret akers( 12- 13).
Observing t he client ’s signs and react ions; and also
using ot her resources, like a board wit h let t ers and num bers so
t hey can use t heir hands and fingers t o form phrases t hat t ranslat e
t heir needs; also using pen and paper, a m agic board; and of
course fam ily support for int erpret at ion. We realized t hat anot her
difficult y is t he lim it at ion t o m ake decisions in nursing. We oft en
need t o m ake fast er decisions, but we need t he aut horizat ion
from anot her professional t o go t hrough wit h t hem . The physician
on dut y, for inst ance, does not look aft er t his client int egrally,
and when we request an evaluat ion, because t he client is t rying
t o say he/ she is in pain, t hey doubt t he t eam ’s st at em ent s and
do not perm it giving t he pat ient any pain killers. ( Daisy)
Usi n g su p p o r t m a t e r i a l a n d f a m i l y participation in the com m unication process favors the dialogic r elat ion sh ip bet w een t h e st aff an d clien t s unable t o com m unicat e verbally. “ People, when open or av ailab le, ar e u n d er st ood as p r esen ce.”( 8 ) Th e
abov e st at em ent show s t hat t he nur sing t echnician
identified the need, but em phasized that certain actions depend on ot her professionals t o act ually be carried out . Act ions should be m ade v isible t hr ough t ouch and int eract ion, so as t o m eet t he needs m anifest ed by t he client . Mor eov er, client s’ feelings should be r ecognized, and not j udged. At t he w or k shop, t he group stated it is im portant to sensitize people about client care and hum an respect. After a few discussions, t he group form ed by Viole t , Or chid and Ca r na t ion
started its perform ance. Violet introduced the group.
Or chid w ill be t he client ( lucid and int ubat ed) , and
Carnat ion will be t he nurse t echnician. The client m akes signs
with her hands, up in the air, as if cooling herself. She has a t ense look, because t he nurse t echnician does not under st and her. Car nat ion ask s v er y hur r iedly :
what do you need, m a’am ? Do you want t o cover yourself? Are you
out of breat h? Do you want t o raise your legs? Angry, he says:
Just a second, I ’ll call m y colleague t o see if she underst ands
you. Upset, the client starts slapping her hands on her legs. Th e ot h er n u r sin g t ech n ician s ar r iv es, Violet her self, and sit s nex t t o t he client . She m akes t he following com m ent: now , t ry t o speak very calm ly, and show
m e what you need. The client starts laughing and at the sam e t im e shows her frust rat ion, point ing her hands t o t he orot racheal t ube, t rying t o express t hat it is im possible for her t o speak, since she is int ubat ed. Violet put s her hands on her w aist , defensiv e and showing she understands she has followed the wrong conduct ( ever yone laughs at t he colleague’s er r or ) . Orchid points at the pillow, and Violet asks: Should w e
flip your pillow? Replace it wit h a higher one? Orchid m oves
her head as to confirm her need and puts her hands t oget her as if pr ay ing, show ing she is r eliev ed she w as underst ood. Violet began t he discussion saying sh e f i n d s i t d i f f i cu l t t o u n d e r st a n d cl i e n t s w h o com m unicat e t hrough gest ures, lip m ovem ent s, and other signs. I t is best if, w hen t aking care of a client , you
cont inue t aking care of him / her in t he ot her shift s, because you
already know his/ her needs, habit s, sleep hours, ways of feeding,
t oilet ing, prom ot ing privacy, com fort in bed and com m unicat ing
bet t er. I don’t like t o swit ch client s every shift , because I don’t
know him / her as well as a colleague who has already t aken care of
him / her.
Once again, t he t eam m em ber s point ed at t he need t o know t hem selves and ot hers in order t o p r o v i d e ca r e a n d ef f ect i v e co m m u n i ca t i o n . Th i s
evokes t he need for a fixed client list . I f caret akers always paid at t ent ion t o client s’ callings, m ost ly non-verbal, t hey could be cared for w it h sensit ivit y and have their expectations m et. The art in nursing is the abilit y t o speak w it hout w or ds, car e int uit iv ely and em pat hically, value encount ers, and t ranscend what is visible( 14).
I n Ex ist e n t ia l W or k sh op # 3, par t icipant s
were welcom ed using t he balloon dynam ics* . Som e inst ruct ions about t he dynam ics were given and t he Workshop began. The part icipant s’ t ext s and post ers, as w ell as t he non- par t icipant obser v at ion abst r act w er e hung on t he w alls. The v ideo of par t icipant s’ p er f or m an ces w as also sh ow n . Nex t , p ar t icip an t s ex ch an ged t h e m at er ial an d silen t ly an d car ef u lly observed it for t hirt y m inut es. Then, each part icipant spoke about how they perceived this collective picture production and answered the following questions: H ow
h a s co m m u n ica t io n o ccu r r e d a t t h e I CU ? An d
w h a t is e a ch p e r son ’s op in ion a b ou t h ow t h e
com m u n ica t ion pr oce ss sh ou ld be ? Par t icipant s’
observations were used to prom ote a reflection about dialogic interaction, and to seek associations with the reflect ions from previous workshops. Their com m ent s sh o w an an al y si s o f t h e co m m u n i cat i o n p r o cess between the team and clients unable to com m unicate v er bally :
The t hings observed have really becom e aut om at ic,
and we don’t not ice t hat anym ore during our pract ice. We don’t
not ice t hat we go by wit hout t alking wit h our client s. We don’t
infor m w e’r e going t o per for m a pr ocedur e, lik e r espir at or y
aspirat ion. Client s are int ubat ed, but t hey are lucid. We becom e
robot s and j ust don’t realize. We oft en don’t int roduce ourselves
as t heir caregivers. What m ust t hey t hink? ( Rose)
Client s oft en do not speak, but t hey are list ening. Even
if t hey are in a com a, we should t alk wit h t hem . You don’t know
t he level of t he client ’s com a. ( Pansy)
I keep t rying t o pict ure what t he client s t hinks, I t ry t o
put m yself in t heir place, som e can’t see, ot hers can’t speak.
I m agine if som eone com es over and st art s t ouching m e, wit hout
m y knowing what will happen. I ’ve had t he experience of being
carried on a st ret cher. I t ’s horrible. When we t urn t he client in
bed, t he im pression we have is t hat t hey feel t hey’re going t o fall
off t he bed, t hey hold t ight on us. There are so m any t im es we
t u r n t h em w it h ou t say in g an y t h in g . I t m u st b e a h or r ib le
experience. ( Orchid)
The com m unicat ion process m oved from t he t r iv ial t o a p h en om en olog ical ap p r oach , an d t h e phenom enon was unveiled showing sensit ive people t h i r st y f o r k n o w l e d g e , se l f - k n o w l e d g e a n d cont ex t ualizat ion of t heir ex per ience. Acquir ing t he p o w er o f cl ai m i n g i m p l i es g r o u p co h esi o n , sel f -co n f i d e n ce , a s w e l l a s d e v e l o p i n g e x p o si t i o n , ar gum ent at ion and per suasion sk ills; w hich ar e all based on com m unicat ion( 3,15). The int uit ive- scient ific
f u sion em er g ed w h en t h er e w as a n eed f or each par t icipan t t o st at e h is/ h er posit ion r egar din g t h e gr oup of ex per ienced sit uat ions. The confr ont at ion bet w een t h eir in t u it ion abou t t h em selv es an d t h e workshop content im plied developing awareness about t he possibilit ies regarding t heir pract ice.
Becau se w e d on ’t k n ow h ow m u ch t h ey act u ally
underst and. They m ight be hearing everyt hing. There are m any
report s of client s who had been in a com a and report ed having
heard voices and com m ent s m ade by t he healt h t eam , but t hey
were unable to m ake or express any reaction. After our last m eeting,
I began m y shift and t hought a lot . I received a client t hat was
lu cid, h ad been t h r ou gh a dif f icu lt sit u at ion an d h ad been
m anipulat ed a lot . When I ent ered t he “ Box” , you know when you
feel t here’s som et hing wrong wit h t he client ? I greet ed him and
st art ed t o t alk, and he st art ed t o cry. I don’t know if at any ot her
m om ent I would have had t hat behavior, of sit t ing next t o him ,
holding his hand t ight ly, t rying t o give him som e sense of securit y
an d con f id en ce, w it h ou t w or r y in g ab ou t m y t ask s, t h in g s
involving ot her client s and t he sect or. But aft er t he reflect ion in
t he second workshop, I was very sensit ive and concerned about
m y at t it ude and life reflect ion. ( Daisy)
There is som et hing else I not iced in t he non- part icipant
observat ion. We use t he dim inut ive t oo m uch when speaking t o
people. I ’m going t o give you a lit t le prick, a lit t le suct ion, insert
a lit t le t ube, m om m y, granny, a lit t le bat h, a lit t le t urn, we act like
children and it ’s disrespect ful of t hose lying t here. We want t o be
nice t o people, be affect ionat e, when we are act ually offending.
( Lilly )
Th i s a n a l y si s w a s co n si d e r e d t h e m o st p r eci o u s m o m en t o f t h e ex p er i en ce, b eca u se i t sensitized participants to self- reflection about how they t h i n k a n d b e h a v e i n p r a ct i ce . A t h e r a p e u t i c com m unicat ion r equir es e x p r e ssion, cla r if ica t ion
and v a lida t ion( 16).
I t s h o u l d b e c l e a r t h a t n o n - v e r b a l com m unicat ion fully covers verbal em ission, since it r ev eals f eelin g s an d in t en t ion s. Th er ef or e, sig n s should be clarified and quest ioned wit h a view t o a b r o a d c o m p r e h e n s i o n a b o u t t h e e x p e r i e n c e d m om en t .
The gr oup show ed a need t o cont inue w it h t he m eet ings in order t o ret hink and t o recycle, as som e st at ed, as w ell as t o sensit ize about car e t o others and to people close to us. The m eetings seem ed t o have been very valuable t o creat ing t he expect ed dialogic relat ionship, and t he changes yielded bet t er professionals and people. Part icipant s were asked t o i n d i v i d u al l y w r i t e ab o u t h o w t h ey p er cei v ed t h e workshops and how they felt now, at the end.
Every lesson t hat adds good t hings and allows us t o
evolve as people and professionals is valid and very welcom e. I
t hink t hese w or kshops r em inded us of m et hods, t echniques,
t enderness, pat ience and t he good will t hat is oft en asleep in our
m inds due t o t he everyday rush or t im e of profession. I t showed
t here is no recipe t elling us how t o com m unicat e and behave in
every sit uat ion. There are m om ent s when t he rule does not apply
t o t he sit uat ion, and good sense, int uit ion and percept ion of t he
client s’ real needs should be evident and receive appropriat e
at t ent ion and respect . ( Rose)
These m om ent s show ed a sy nt hesis of t he realit y t hat was known, wit h concept s elaborat ed by the group, perm itting new thinking about practice, and expanding nur sing know ledge, especially for people who did not part icipat e in t his experience.
FI NAL CONSI DERATI ONS
This study contributes to a significant change in the work environm ent, adding a hum anized look to n u r si n g - cl i e n t r e l a t i o n sh i p s. Th i s sh o w s t h e applicabilit y of Pat er son an d Z der ad’s Hu m an ist ic Theory( 8), since it offers support to a reflection about
t r a n sf o r m i n g a “ r o b o t i ze d e n v i r o n m e n t ” i n t o a “ h u m a n i ze d e n v i r o n m e n t ”. No n - p a r t i ci p a n t ob ser v at ion an d t h e w or k sh op s sh ow ed t h at t h e d i a l o g i c r e l a t i o n sh i p r e m a i n s i m p a i r e d . Nu r si n g t echnicians were able t o experience t he possibilit y of change t hrough post ure, at t ent ion, and pat ience, in t h eir look or w ay of appr oach in g clien t s, sh ow in g
d o n o t sp e a k t h e sa m e l a n g u a g e a n d d o n o t contem plate holistic care. The com m unication process, as p ar t of n u r sin g p r act ice, in v olv es t r an sact ion s bet w een indiv iduals t hr ough w hich infor m at ion and under st andings ar e ex changed. This could m ak e it easier to apprehend and understand the client’s needs, m aking care aut hent ic( 7).
Study results indicate that the team im proved and t hat t heir at t it udes changed. The inst it ut ion and
nursing supervisors becam e interested in this proposal as a continuing education activity for the I CU nursing team . This activity would be a form of equipping and dev eloping t he com m unicat ion pr ocess w it h client s unable to com m unicate verbally. This was a step toward understanding the com plexity of this them e, perm itting pr ofessionals t o dev elop sk ills for a m or e accur at e ident ificat ion of feelings, doubt s and difficult ies when clients are unable to verbalize them .
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