Family visitors and companions of hospitalized elderly and adults: analysis of the experience from the perspective of the nursing working process

Abstracts

Trata-se de estudo qualitativo, utilizando-se como referencial metodológico a Grounded Theory e como referencial teórico o Processo de Trabalho em Enfermagem, para compreender o papel assumido pelo enfermeiro perante as normas e rotinas hospitalares, relativas aos familiares visitantes e acompanhantes de adultos e idosos internados em um Hospital Universitário. A análise dos dados permitiu a identificação do tema: definindo-se a modalidade de apoio familiar durante a hospitalização, que reúne duas categorias principais: tornando-se familiar visitante e tornando-se familiar acompanhante. Por meio da análise, pôde-se aprofundar a compreensão do quanto as regras estabelecidas, com o objetivo de disciplinar e tornar eficiente o trabalho desenvolvido no hospital, podem explicitar o desprovimento de autonomia no processo de trabalho, para modificar as relações nesse contexto e o quanto a apropriação do familiar como parte da equipe de saúde, está distante de ser pensada no concreto das instituições.

enfermagem; enfermagem familiar; relações profissional-família; adulto; idoso; trabalho

Se trata de un estudio cualitativo que utiliza como referencial metodológico la Grounded Theory y como referencial teórico el Proceso de Trabajo en Enfermería para comprender el rol asumido por el enfermero frente a las normas y rutinas hospitalarias, de los familiares visitantes y de los acompañantes de adultos y ancianos internados en un hospital universitario. El análisis de los datos permitió la identificación del tema: definiéndose la modalidad de apoyo familiar durante la hospitalización, que reúne dos categorías principales: tornándose un familiar visitante y tornándose un familiar acompañante. Por medio del análisis, se puede profundizar la comprensión acerca de las reglas establecidas que, con el objetivo de disciplinar y hacer eficiente el trabajo desarrollado en el hospital, permite explicar la ausencia de autonomía en el proceso de trabajo, para de esta forma, modificar las relaciones en este contexto y resaltar la integración a la institución del familiar como parte del equipo de salud.

enfermería; enfermería de la familia; relaciones profesional-familia; adulto; anciano; trabajo

ORIGINAL ARTICLE

Family visitors and companions of hospitalized elderly and adults: analysis of the experience from the perspective of the nursing working process¹

Silvia Cristina Mangini Bocchi^I; Lucía Silva^II; Carmen Maria Caquel Monti Juliani^I; Wilza Carla Spiri^I

^IPhD, Professor at Universidade Estadual Paulista "Júlio de Mesquita Filho" Medical School of Botucatu, e-mail: [e-mail], [e-mail], [e-mail]

^IIRN, Master Student, University of São Paulo at Ribeirão Preto College of Nursing WHO Collaborating Center for Nursing Research Development, e-mail: [e-mail]

ABSTRACT

This is a qualitative study using Grounded Theory as the methodological reference and the Process of Work in Nursing as the theoretical reference in order to understand the role assumed by nurses regarding hospital norms and routines applied to family visitors and companions of adult and elderly patients in a teaching hospital. Data analysis identified the theme: defining the modality of family support during hospitalization. This theme aggregates two main categories: becoming the family visitor and becoming the family companion. Through the analysis, it could be observed how established rules, which aims at disciplining and developing an efficient work in the hospital, can expose the lack of autonomy in the work process to modify relations in this context and how the familiar appropriation, as part of the health team, is far from being considered in the institutions.

Descriptors: nursing; family nursing; professional-family relations; adult; aged; work

INTRODUCTION

This article emerges from the need for a deeper understanding of the experience of family companions and visitors of hospitalized adult and elderly patients, from the perspective of the nursing work process.

During our experience as nurses, we have reflected on the situation of hospitalized patients, who are mostly unaccompanied by their family members and receive visits at times previously set by the institution. Few relatives get the opportunity to become companions. Companions are considered to be people who stay with the elderly patient full-time.

This condition is supported by law. Article 16 of the Statute of the Elderly⁽¹⁾ and article 26 of the State Law on Patient Rights grant elderly patients the right to a companion, but submit the patient-family relation to the institution's control power, by declaring that "the right to a companion, if wanted, during appointments as well as hospitalizations, the visits of family members and friends must be disciplined at compatible times, so as not to affect medical-health activities"⁽²⁾.

Base don this initial observation, we developed an earlier study, with a view to understanding the interactive experience of family visitors and companions during the hospitalization of adult and elderly patients, within the theoretical-methodological perspective of Symbolic Interactionism and Grounded Theory.

The analysis demonstrated that, when a closer and therapeutic relation is established with the nursing team, the family companions start to consider and act in solidarity with the difficulties the institution itself imposes on the nursing work process⁽³⁾.

On the other hand, family visitors' experience shows that they perceive that nurses assume a controlling role and relegate the opportunity of letting them get close to their loved one to comply with institutional standards. They do not manage to understand the challenges nurses and their team face in the realization of the work process in a broader sense⁽³⁾.

The research demonstrated that the family starts to understand the nursing team, led by the nurse, as symbolic and central in the patient-nursing-family interaction process, vested with the legitimate and normative institutional power, and as a barrier against the exercise of the family's autonomy and against the free movement between the roles of family visitor and companion ⁽³⁾.

Considering that the results presented in that earlier study are closely related with the nursing work process at hospital institutions, we believe that this study is pertinent in view of an analysis from this perspective.

We feel the need to: understand nurses' role in terms of hospital standards and routines, as acknowledged by family visitors and companions of hospitalized adult and elderly patients.

We consider the work process as the way man produces and reproduces his existence and, in doing this, establishes social relations and objectifies his subjectivity⁽⁴⁾.

In health, the work process acquires complex dimensions, as this work is essential for human life and is part of the service sector, that is, it is part of the non material production sphere and is completed in the act of its realization. The product cannot be dissociated from the process that produces it. It is the realization itself of the activity⁽⁵⁾.

An analysis of the nursing work process in concrete realities can reveal the contradictions and dynamics in practice and contribute to strategies aimed at changing reality, as this allows for a better understanding of the social reasons for this work, its possibilities and limitations⁽⁴⁾.

It is important to deepen and specify analyses of studies about the nursing work process, in order to better understand the social reasons for this work and articulations with the health sector, in concrete institutional micro-spaces and their particularities⁽⁴⁾.

These same authors indicate management as a work instrument, or as a secondary activity, whose central action rests in articulation and integration. At the same time as it allows for the transformation of the work process, it can also be transformed through the determinations present in the daily reality of health organizations.

In nursing work, management action is essential and its dimensions need to be reconsidered, to provide for an activity from the perspective of the emancipation of social subjects, whether these are the agents present in the work process or clients using health services⁽⁴⁾.

In this context, it should also be reminded that care delivery and management cannot be dissociated and are dimensions of human care, if we consider the patient as the focus all actions are directed at, in any of these situations⁽⁶⁾.

This study aimed to analyze the phenomenon of family support during hospitalization from the perspective of the nursing work process.

METHODOLOGICAL TRAJECTORY

We carried out a qualitative study of nine subjects, identified as family visitors or companions of adult or elderly patients hospitalized at clinical and surgical units of a large public university hospital in the interior of São Paulo State, for more than seven days. Five subjects were visitors and four were companions. The number of subjects was defined after the theoretical saturation, which occurred in the ninth interview.

Saturation occurs when no new or relevant data emerge and when the theory or history is complete⁽⁷⁾.

Eight of the nine subjects were women and one man. They were between 26 and 52 years old and had served as a family visitor or companion during seven days up to three months. The degree of kinship was distributed between one wife, one son, five daughters, one cousin and one niece. Four participants were housewives, one was a retired teacher, one clerk, one machine operator, one administrative assistant and one production aid.

Data were collected in the second semester of 2002, through the recording of non-structured focalized interviews, guided by the following question: - What has been your experience as a family visitor or companion of a hospitalized person?

We emphasize that this study was assessed and approved by a Research Ethics Committee and that all relatives who agreed to participate received detailed explanations about its goal and objective and signed the Free and Informed Consent Term to Participate in a Scientific Study.

Data were recorded by making notes during the events or, in case the site was inappropriate, immediately afterwards.

Data analysis was based on the methodological framework of Grounded Theory, following the basic strategies presented for the constitution of categories⁽⁸⁾.

Categories, according to the authors, are abstractions of the phenomenon observed in the data and constitute the main analytic category of Grounded Theory. Theory is developed by working with the categories, which gives rise to the central category. This is generally a process that derives from the analysis⁽⁸⁾.

The phases of data analysis are: discovering categories, connecting categories, developing memoranda and identifying the process⁽⁸⁾.

The process was consolidated through the discovery of the central category "Moving between the roles of family visitor and family companion in view of the nurse's signs: sharing an experience of little please in solidarity with hospitalized adult and elderly patients". Therefore, we interrelated the two phenomena: LIVING IN EXPECTATION BECAUSE OF HOSPITALIZATION AT THE UNIVERSITY HOSPITAL and ASSUMING THE ROLE OF FAMILY VISITOR OR FAMILY COMPANION, attempting to compare and analyze them in order to understand how their components interacted. This strategy allowed us to identify the key categories and subcategories that would evidence the family's movement during the hospitalization of one of its members⁽³⁾.

For this paper, we worked with the theme that constituted the second phenomenon: DEFINING THE FAMILY SUPPORT MODALITY DURING HOSPITALIZATION.

The choice of this theme for analysis was due to its importance in the nursing work process, particularly in the nurse management sub-process.

RESULTS AND DISCUSSION

The theme joins two main categories: becoming a family visitor and becoming a family companion. In turn, these join subcategories that will be mentioned below and discussed in the light of the nursing work process.

A1 Becoming a family visitor

This is the first support mode the family offers to the adult and elderly hospitalized patient, in situations when it does not manage to break the normative barriers for visiting, as well as in those experiences when they cannot give up their activities in order to assume the role of companion or when the client does not express the need for constant family support, with a view to saving his/her own family the suffering.

A.1.1 Not managing to break the normative austerity to become a companion

This means that, when demonstrating the availability to serve as a companion for the client, the family is confronted with barriers in hospital standards, imposing restrictions due to the fact that it does not comply with the requisites for becoming a companion. Hence, the family moves to break the rules and ends up being restrained by the nursing team, which is responsible for control of the standards. This arouses a feeling in the relatives that they are not welcomed by the institution's health team.

The whole day would be better (for the visit), but that is not possible either...I'm saying this because who lives elsewhere cannot come every day...even more when you have transportation difficulties and live elsewhere... (5)

The work process concept can be decomposed in three elements: the work object, which the activity is applied to and which will be transformed during the process, constituting a product; the work means and instruments and the activity that is adequate for a goal, that is, the work itself⁽⁹⁾.

The historical constituents of the nursing profession show that, from the start of its organization in the 19th century, it has undergone countless transformations. However, the transformation that does not seem to have been fully assimilated yet today, perhaps because human suffering still causes astonishment, resulted in distancing between professionals and clients and, consequently, their family members, generating an authoritarian relation between them. Thus, "the patient was replaced by the disease and the work focus was removed from the subjects involved in the therapeutic process and placed on the care structure. Routines and methods became more important than the subject who possessed the shortage that gave rise to the work, or more important than the workers themselves"⁽⁵⁾.

On the other hand, the routine makes it possible to respond to daily occurrences and is part of an institution's normative experience, that is, the team's actions are aimed at maintaining order⁽¹⁰⁾.

In this perspective, this routine needs to be considered as an instrument in the work process and not as its goal.

A1.2 Being confronted with the rules to become a companion

This means that, during their first visits, the relatives start to recognize the rules to become companions, through notices placed on the hospitalization units' main access doors. They perceive that one of the conditions to achieve the condition of companion is that the client needs to be older than 60.

We can see it as soon as we arrive: authorization... only enter... that is the rule. It's written like that over there, on the door, I think that for people over 65 and the other one I don't remember... (8)

When I came as a visitor, I already saw those rules over there… (8)

The Statute of the Elderly⁽¹⁾ guarantees this permanence and the health team cannot control this.

Historically, the structure of the Brazilian Health System, which is hospital-centered, did not consider the companion. This is a relatively recent discussion and guarantee. In a way, institutionalized care, which is fragmented and extorted from subjectivities, has been sustaining an unfair health model that is directed at capitalist interests⁽¹¹⁾.

This context contributes to the established rules' alienating or obscuring the right to become a companion.

A1.3 Feeling restrained by the rules to become a companion

Family members feel repressed to take the initiative and ask the nurse for permission to become a companion, when their case does not attend to the conditions which the rules on the notices impose.

I was afraid because as soon as we arrive we already see them (the rules)... we're like: can I stay or not... I don't know, if she (the nurse) hadn't said it if I would have asked... (8)

Nurses' "ethical conduct" in their management activities is still ruled by the search for efficiency, in line with institutional standards⁽¹²⁾.

The rigid compliance with rules and regulations can impede fast and efficient solutions, representing a dysfunction of bureaucracy⁽¹³⁾. Another factor that negatively affects nurses' decision making is caused by the lack of time involved in their work. However, this can be minimized by setting priorities during the day⁽¹⁰⁾.

Arguments are presented in favor of a new logic of care, exercising a support that means power and, as such, both subjugates and emancipates. Assuming the political nature of care as an analytical reference and change-inducing proposal means betting on a help that prioritizes the liberation of tasks, deconstructing the shackles that imprison it and making possible confrontations with oppressive situations⁽¹⁴⁾.

Nurse managers coordinate joint work. In nursing, decision power remains small and dependent on the institution's functioning rules, thus delimiting professionals' action possibilities⁽¹⁵⁾.

An English study on work satisfaction among hospital nurses appoints that nursing's good relation with the institution, as well as with the medical team and other professionals not only expands its action possibilities, but also constitutes one of the most significant factors permeating satisfaction and personal growth in nursing work⁽¹⁶⁾.

A1.4 Perceiving the variations in visiting rules according to place

This means that, in living the experience of family visitor during the hospitalization process of one of its members, the family is exposed to the rules that guide the support modality it will offer, which are posted on the main entry doors of the hospitalization units. When reading them, the family perceives that it is not granted the freedom to choose the time and the number of people, and that rules are stricter at hospitalization units for patients in critical conditions in comparison with clinical and surgical hospitalization units.

I was very satisfied that my mother came here (nursing ward)... because over there, at the ICU, we came for one hour, sat down rapidly, you arrived and had to leave already (7).

I wasn't allowed to stay there, no way (ICU)... I wasn't allowed to sleep there on the bench at the ICU, no way...(9).

Institutionalized health establishes hierarchical relations in which the subjects-patients and, consequently, their families, gradually lose their subjectivity dimension, with little autonomy to defend their presence, due to the subordination to institutional rules which, in the case of care complexity, make it difficult to discuss and reflect on the importance of their presence so as to include other dimensions.

The subjectivity dimension of health can be related with the concept that classifies health care as humanitarian and affectionate and, therefore, an interpersonal relation or a therapeutic intervention⁽¹⁷⁾.

A1.5 Accepting the rules

This means that, in those experiences when family members perceive the patient as an independent person, with emotional balance and stable health, they accept the rules because they understand that the patient does not need permanent family support and, therefore, they do not feel the strictness of the visiting norms. Thus, they confirm the institution's imposition and comply with the rules, expropriating the ill subject from the stay of a companion.

I think that, if it were one single person (visitor), he could spend more time... and, also, sometimes the patient wants to sleep or has a lot of pain and the person keeps on talking, sometimes it's irritating, I think, right?(5)

It seemed that the nurse would already start saying something to us, that you can't... I think that we also bother, right? Sometimes they want to give a bath, apply medication… (6)

The professions have progressively disciplined care in procedures, tasks, technologies and hospital routines in order to deal with illnesses, fragmenting the person into distinct specialties⁽¹⁴⁾. This fragmentation ends up imposing, due to the complexity the organization acquires, acceptance of the rules.

A2 Becoming a family companion

This is the second support mode the family offers to the hospitalized patient in situations when they are considered more dependent on nursing care, as well as when a family member is available to take leave from daily activities to assume the role of companion.

A2.1 Feeling welcomed by nursing

The family expresses this feeling when the health team treats it with care and consideration, and when it sees that this treatment is extended to the patient.

Now, as we stay as a companion... we get to know more, ask what we feel we need to ask ... before, something impeded me from asking but not now... we feel freer... I feel more confident… (8)

The nurses are nicer, very humane, mainly because my father is 75 years old already...in terms of care, medication and patient-doctor relation he is also being taken care of very well... (5)

In a study that aimed to validate an index of relatives' needs at Intensive Care Units, these persons considered "feeling that the employees take interest in the patient" as the most important need⁽¹⁸⁾.

When the family perceives the nurse as the person who informs, guides and supports, the profession is strengthened through a role defined with a formal identity⁽¹⁹⁾.

In the hospital environment, nurses, more than any other health professionals, have frequent opportunities to facilitate and show respect for patients' rights. As team leaders, that is, assuming the leadership of patient care delivery, nurses are the main source of personal, close and continuous contact with the patients, despite their involvement in technology and hospital bureaucracy⁽²⁰⁾.

Depending on the involved person's personal characteristics, moments of integration may occur, when the team welcomes the subject and considers his/her biopsychosocial dimensions, involving the family in this process. In this aspect, management is considered an open process that is loaded with possibilities within the health work process⁽⁴⁾.

In the nursing care process, which involves the team, the patient and his/her family, the historical and cultural baggage which each of them brings in a disease situation must be taken into account⁽¹⁷⁾.

A2.2 Being obliged to adapt to the hostile scenario

This means that, when becoming companions, the relatives find themselves obliged to change their habits, to share other experiences of suffering and to learn how to behave in hospital situations. The health team advises them to adapt to the events, as these cannot be modified in order to guarantee their comfort. In this context, the relatives start to accumulate other roles besides that of companion, and become caregivers, when they perceive that the quality of nursing care is affected by the lack of human resources in the area.

When the night comes...it is kind of a difficult situation... the companion... there is no place for us... you have to sleep on the floor, there's a mattress there... (4)

Yesterday, they had to do some tests there... in a lady...and there was this bad smell...and we complained and the nurse turned and said: you have to get used to it because that's how it is...we're used to it already... (4)

This delegation of the caregiver role to the relative displays the fragmentation of the work that is normally done by nursing, affecting the integral approach of the patient. In this situation, nursing exempts itself from responsibility for a global care delivery and bonds less with the patient. The institution does not manage to provide the necessary quantity of human resources for integral care and, thus, makes it difficult to offer a more comprehensive form of care delivery.

The nursing work organization models are directly related with work overload or satisfaction. Some authors argue that, when models are adopted in which employees are responsible for integral care delivery to a patient during their entire shift, satisfaction at work is evident⁽¹⁶⁾.

Besides greater worker satisfaction, the work process with integral care favors interaction and stronger bonding with clients and relatives, thus increasing their satisfaction as well.

FINAL CONSIDERATIONS

This new reading of the role played by companions and visitors of hospitalized adult and elderly patients from the perspective of the nursing work process allowed us to rescue important aspects: the first (visitor) refers to the elucidation of the barriers relatives meet to become companions, such as: not managing to break the normative austerity, being confronted with rigid rules, feeling restrained by the rules, perceiving that these rules vary and accepting them due to the fact that one cannot break them; in the second (companion), the relative feels welcomed by nursing, despite trying to adapt to a hostile scenario.

The study helped to understand the extent to which established rules, whose main aim is to discipline and make hospital work effective, can express the deprivation of autonomy in the work process to modify relations in this context, and also the extent to which relatives' appropriation as part of the health team is far from considered in institutions' concrete reality.

The management role nurses have been playing exempts them from generosity, mainly towards themselves, so that they do not enjoy the benefits of a work based on other values that coincide more with their human nature⁽¹²⁾.

When working in institutions, it is important for nurses to maintain a balance between the management and care processes, considering clients and their families. On the other hand, it should be highlighted that choosing one work organization form or another is not isolatedly an individual or institutional choice, but is determined by historical conditioning factors and their multiple mediations, such as social and health policies, care models, work conditions and others⁽⁹⁾.

We believe that this study allows us to reach a broader understanding of the complexity the institutional context is inserted in and to seek possibilities for effective and well thought through actions in this practice.

2. Secretaria de Estado da Saúde [homepage na Internet]. São Paulo: Secretaria de Estado da Saúde; [Acesso em 2002 fevereiro 17]. Controle social do SUS: direitos do paciente; [1 tela]. Disponível em: http://www.saude.sp.gov.br/csocial/html/paciente.htm

Recebido em: 2.8.2005

Aprovado em: 18.9.2006

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1

Study funded by FAPESP, process 01/13273-8, Presented in the 56º Brazilian Nursing Congress - Gramado, RS - 2004

Publication Dates

• Publication in this collection
  29 May 2007
• Date of issue
  Apr 2007

History

• Received
  02 Aug 2005
• Accepted
  18 Sept 2006