Abstracts

ORIGINAL ARTICLE

Communication between nursing students and patients with AIDS

Comunicación entre estudiantes de enfermería y pacientes con AIDS

Ivana Cristina Vieira de Lima^I; Marli Teresinha Gimeniz Galvão^II; Ênia Costa^III; Julyana Gomes Freitas^IV; Lorita Marlena Freitag^V

^IMaster’s student in Nursing, Graduate Nursing Program, Universidade Federal do Ceará. CAPES grantee. Fortaleza, CE, Brazil. ivanacristinalima@gmail.com

^IIPh.D. in Tropical Illnesses. Professor, Nursing Department and Graduate Nursing Program at Universidade Federal do Ceará. Fortaleza, CE, Brazil. marligalvao@gmail.com

^IIIRN. M.Sc. in Nursing, Graduate Nursing Program, Universidade Federal do Ceará. CNPq grantee. Fortaleza, CE, Brazil. enia@bol.com.br

^IVRN. Master’s student in Nursing, Graduate Nursing Program, Universidade Federal do Ceará. FUNCAP grantee. Fortaleza, CE, Brazil. julyanapitt@yahoo.com.br

^VPh.D. in Nursing. Full Professor, Nursing Department, Universidade Federal do Ceará. Coordinator of LabCom_Saúde. CNPq researcher. Fortaleza, CE, Brazil. pagliuca@ufc.br

Correspondence addressed to

ABSTRACT

This study was performed with the purpose to analyze the communication between nursing students and patients with AIDS during peripheral venous puncture. Video recordings were made of six pairs (student-patient) while performing the venous puncture procedure in May 2009 at a day-hospital in Fortaleza-Ceará. As a group, four judges evaluated the interactions established between the pairs. The analyses were categorized in: Valuing technique over communication; Mask: a barriers to communication; Private space invasion; Interference of the environment in the communication. It was concluded that different factors increase the difficulty establishing an effective communication, especially the need for students to be trained about the importance of establishing communication during care, so as to promote humanized and individual care, in which sensitivity and empathy overlap fear and insecurity.

Keywords: Communication; Students, nursing; Acquired immune deficiency syndrome; Interpersonal relations.

RESUMEN

Se propuso analizar la comunicación entre estudiante de enfermería y paciente con AIDS en ocasión de punción venosa periférica. Se filmaron seis duplas (estudiante-paciente) durante ejecución de punción venosa en mayo 2009 en hospital-día de Fortaleza-Ceará. En grupo, cuatro jueces evaluaron las escenas de interacción establecida en cada dupla. Los análisis se categorizaron en: Valorización de técnica versus comunicación, Máscara: barrera para la comunicación, Invasión del espacio personal, Interferencia ambiental en la comunicación. Según se concluyó, diferentes factores dificultaron la efectividad comunicacional, particularmente la necesidad de que el estudiante recibiese entrenamiento sobre la importancia de establecer comunicación en el cuidado, apuntando a viabilizar una atención humanizada y singular en que sensibilidad y empatía se sobrepongan a miedo e inseguridad.

Descriptores: Comunicación; Estudiantes de enfermería; Síndrome de inmunodeficiencia adquirida; Relaciones interpersonales.

INTRODUCTION

Among other definitions, communication is a functional behavior motivated by a hierarchy of needs, starting with primary needs like foods and fluids, with increasing complexity as relations are established and maintained. Different reasons to communicate can exist, particularly: need for satisfaction, social expression, regulation of others, information collection, passing information transfer and personal expression⁽¹⁾.

To fully understand the world and communicate, human beings have developed two types of language – verbal and non-verbal – which are often complementary and simultaneous. Non-verbal communication permits unconscious message transfer, through facial expression, body language, physical characteristics, touch and distance. According to experts, the lesser the dissociation between discourse and expression, the more integrated and complete the person will be. Hence, as one can infer, the importance of words in a relationship is only indirect, i.e. words merely represent a pretext or a start^(2-4).

A clear relation exists between communication and care, as both are basic phenomena intrinsic in human beings and, therefore, established in a natural, flexible and unconscious way that can be learned⁽⁵⁾. In general, communication constitutes a primary instrument for nursing care practice, as it permeates all patient interaction situations with the patient and support the understanding of the person who receives care in the holistic sense. As literature guarantees, through effective communication, these professionals can help patients face their problems and establish a relationship of trust and bonding with the latter⁽⁶⁾.

In case of nursing care for HIV/aids patients, a group that faces social rejection, economic dependence, affective shortage, among others, can reveal conflicting feelings coming from the nursing team, indicating the need to enhance communicative skills.

In this perspective, when nursing students communicate with patients in clinical practice, they experience anxiety and feelings of tension. Moreover, students’ skills for communication with clients are deficient. Regarding care delivery to HIV patients, due to biosafety measures and fear of accidental communication, nursing care has peculiar characteristics. Out of fear of contamination during nursing care, care delivery becomes extremely technical and impersonal. In this care, the relation with things and objects predominates^(7-9).

In view to the large number of HIV-seropositive patients who need daily injectable medication, for this study, the peripheral venous puncture technique was chosen to assess how students interact with clients. Besides, as a procedure nurses perform daily, this technique demands technical-scientific knowledge and psychomotor skills for its accomplishment, and also involves communicative interaction between nurses and patients, so as to mitigate discomfort and invasion of patients’ personal space⁽¹⁰⁾.

This research is also justified by the lack of studies on care delivery in case of HIV with nursing students as subjects. Mainly, at bottom, the primary intent is to propose the valuation of the teaching-learning process directed at communication in undergraduate programs, with a view to humanistic care delivery to HIV/aids patients, a population that is still stigmatized in society and arouses fear and insecurity among professionals.

OBJECTIVE

The goal is to analyze nursing students’ interaction with HIV-positive clients during peripheral venipuncture in the hospital environment.

METHOD

Exploratory, descriptive and qualitative study. According to literature, the qualitative approach permits the elaboration of answers to intricate and particular questions, as it works with the universe of meanings, values, beliefs, motives, aspirations and attitudes. Thus, its focus goes beyond the mere operationalization of variables and covers a deeper space of relations, processes and phenomena⁽¹¹⁾.

Developed in the first semester of 2009, at the day-hospital São José for Infectious and Contagious Diseases in Fortaleza-Ceará, the research involved the following subjects: six nursing students doing extra-curricular training at the hospital and six adult aids patients using intravenous medication. The students were last-year nursing students from public or private universities in Fortaleza, who were taking an extra-curricular training program at the institution. Clients were monitored at the service and received some type of intravenous drug, which needed to be infused in hospital. Thus, in this study, six pairs participated (nursing student-client).

The filming technique was used as a resource for data collection. As some studies reveal, videos are a valuable instrument for data collection and production, to the extent that they guarantee research reliability and neutrality, and also permit careful data analysis, as researchers can reassess the films countless times⁽¹²⁾. Semistructured forms were also used to identify students and clients.

Images were captured with a digital camera handled by the researcher, at an appropriate height and angle to maximize images of the pair. At the day hospital, the patients were seated in a reclining and comfortable armchair to receive the intravenous infusion. Besides the armchair, a piece of equipment was placed to hold the flask from which the medication dripped. A bedside table was placed at some distance from the armchair (more or less 1.20m).

The students were advised to perform the procedure as naturally as possible and, with a view to avoiding anxiety, no maximum duration was set to perform the technique.

After capturing the communication that occurred during the peripheral venipuncture, the collected material was edited. Each film was converted to digital format (DVD), after with all scenes were joined in the same digital file, whose duration was 24 minutes.

Four judges participated in the analysis of the material, who were chosen according to the following criteria: a) being a nurse with at least a Master’s degree; b) having developed or developing research on communication in health; c) having published on communication in health; d) past or current activity in teaching for nursing students.

All judges were informed about the research goals and the way data would be assessed. They received printed material with essential factors for communication analysis. The following factors were indicated: non-verbal care behaviors – distance, posture, axis/position, space, contact behavior, visual contact, facial expression, verbal manifestation and verbal care behaviors.

Next, the digital file was shown to the judge group in order to analyze the pairs’ interactions. At a room, the images were projected on screen and frozen at the end of each venipuncture phase (pre-puncture, puncture, post-puncture). As requested, the judges then commented in group about the communication between student and patient. The judges’ statements were then recorded, transcribed and analyzed based on Content Analysis theory⁽¹³⁾ and generated the following categories: a)Valuation of technique as opposed to communication; b)Mask: a barrier for communication; c) Invasion of personal space; d) Interference of the environment in communication.

As determined, this study complied with the recommendations of resolution 196/96 on research involving human beings. Approval was obtained from the Institutional Review Board at Hospital São José de Doenças Infecciosas, under protocol number 35/2008. All subjects’ agreement was formalized through the signing of the Informed Consent Term.

RESULTS

Study participants were six pairs, with last-year nursing students and adult clients with aids. The six nursing students were mostly female (only one male), with ages ranging between 22 and 28 years. As observed, they revealed previous experience in venipuncture, knowledge on HIV infection and, during the course, they informed having received contents on communication theories and nurse-patient interaction relations. Moreover, the students came from different universities in Fortaleza and were approved for extra-curricular training after a theoretical and technical skill assessment test held by the hospital.

As for the clients, all patients were in the advanced stage of the disease (aids), ages ranged from 26 to 48 years, with a predominance of male and single patients. All clients voluntarily accepted to participate in the research. At the time of the filming, Amphotericin B^® and Ganciclovir^® were used as intravenous drugs.

To assess the communicative focus in the peripheral venipuncture situation performed by the nursing students and aids patients, after watching the video with the interactions, the judges started to assess them. Based on the judge group’s statements or testimonies, Table 1 could be elaborated. This table displays the categories and main excerpts related to the communication between the student-client pairs.

DISCUSSION

The judges highlighted the valuation of the technical procedure. It was observed that the students fully concentrated on the accomplishment of the venipuncture technique. Thus, they pushed the establishment of an interpersonal relation with the client into the background. In most interactions, care delivery was strictly technical, mechanic, fragmented and centered on the limb that would be punctured. Hence, the patient did not receive holistic care.

In Brazil, a study that assessed Undergraduate Nursing students’ experiences in daily hospital training situations showed that the students affirmed that, during the training, the emphasis of care turned to technical know-how, detached from a comprehensive understanding of the patient⁽¹⁴⁾.

As holistic care defends, however, it is essential for clients to be understood primarily as a person and only then as a patient. In other words, they should not be seen merely as a set of tasks, but as complete persons with biopsychosocial and spiritual needs, with rights to be respected, and their ethical dignity should be guaranteed. Therefore, in their praxis, nurses need to master not only basic and technical aspects, but also the human aspect of care. Thus, priorities can be set towards the humanization of health care^(15-16).

Combined with the valuation of the technical procedure was the factor fear of contagion risk by HIV during the procedure. This factor interfered in the type of communication between student and client.

Studies departing from an approach that is based on the relation between health communication and care delivery to clients with HIV unanimously affirm the multidisciplinary health team’s lack of preparation to establish effective communication with these clients. The main justification for this deficiency is related to the emergence of feelings like insecurity and anxiety, resulting from the risk of contamination by the virus⁽¹⁷⁾.

As these study results show, clothing for care delivery was excessive. To give an example, although none of the patients suffered from an airborne disease, the students used a mask at the time of the puncture. This indicates their fear to deliver care to patients with HIV/aids, due to the potential risk of transmitting airborne and respiratory infections.

The use of the mask showed to be an obstacle for communication, as it not only hampered the perception of clients’ non-verbal communication aspects, but also impeded a complete understanding of the student’s expressions. This situation is in accordance with an analytic study on the proxemics factors of the nursing team in care delivery to HIV/aids patients, which appointed the respiratory protection mask as one of the obstacles for communication⁽⁹⁾.

It is fundamental for students to know about universal precautions related to this disease. Often, however, fear, fantasies and prejudices towards a stigmatizing and incurable disease overlap with scientific knowledge and, thus, generate insecurity, during care delivery to HIV patients. Precautions undeniably need to be taken with any and all patients receiving care, as any person can be HIV-positive. Thus, precautions refer to any procedure during which one may have contact with secretions, independently of the disease⁽⁸⁾.

The results also alert to the need to identify true risks in care delivery to HIV patients, with a view to making the procedure feasible in a way that the patient does not feel ignored, rejected or treated differently because of the disease. All patients are entitled to be treated with equality and justice. Hence, these premises cannot be infringed on due to an HIV-positive status. According to ethical principles, HIV patients are equal to all other clients, despite specific care needs.

The judges mentioned other aspects, specifically the invasion of space and the distance maintained between the interlocutors. According to experts, the way an interlocutor takes a position interferes in the communication process. Consequently, the need to observe the distance between professional and client is evidenced. Nurses need to respect variations in the distance that needs to be maintained in different situations of interaction with the patient, so as to minimize the feeling of anxiety about the invasion of personal space and enhance the patient’s adaptation during nursing care⁽⁹⁾.

During the venipuncture, like a majority of nursing procedures, the invasion of personal space and maintenance of intimate distance are unavoidable, as the invisible bubble the patient is involved in needs to be surpassed in order to touch/palpate the vein or manipulate the limb for puncturing. Thus, nursing professionals touch the body and constantly expose the patient, without his/her previous authorization. This form of acting can reveal the nurse’s posture of power over the client⁽¹⁸⁾.

In general, clients hardly question this invasion because, according to them, it is fundamental for their recovery. Nevertheless, their privacy/individuality is infringed upon and they demonstrate constraint, shame and embarrassment through non-verbal, such as facial and bodily expression, or verbal communication signs. The clients’ reactions to the invasion of their space are subtle, such as ceasing to look the professionals in the eyes, giving short answers to the questions asked, contracting one’s muscles, remaining still, among others⁽¹⁹⁾. At these times, nurses need to pay attention to these reactions, mainly to show clients their concern with their feelings and respect for their individuality.

This invasion can be mitigated, however. Therefore, professionals need to be aware of this limitation and use some strategies. These include communicating with patients before touching them; maintaining intimate distance only when necessary; paying attention to proper organization of the material to avoid contact between invasive objects like the garrote and the patient for extended periods (contamination); and avoiding that objects like the dish rest on the client’s body.

Also, better use of the surrounding environment is recommended, as the judges suggested students should do in this research. According to them, adopting a more lateral position towards the patient is more comfortable and moderates the invasion of personal space. In addition, the sitting position should be preferred for both subjects in the interaction. Advantages include: permits eye contact, mitigates a possible power relation, facilitates visualization of the vein for puncturing and is ergonomically healthier for the student.

As for the environment where the puncture occurred – the day-hospital – it was considered inappropriate to develop communication. Certain factors contributed for the environment to function as a communication barrier. These included environmental noise (television, parallel dialogues), lack of privacy due to the intense flow of people and the lack of support to rest the patient’s upper limb. Although patients were sitting in a reclining chair, it was considered comfortable for patients but uncomfortable for procedures like venipuncture, as the armrest was very low. This factor made students adopt an uncomfortable and even invasive position towards the patient’s personal space.

According to specialists, both the environment where communication takes place and its properties (physical space, furniture, lighting, ventilation, temperature, noise), are marking components for the quality and success of communicative interaction, due to their influence on the stakeholders’ emotional, physical and psychological conditions. This factor compromises the expression and perception of ideas. Thus, the environment can stimulate or inhibit interaction between the stakeholders. As affirmed, in an environment that is considered favorable to the establishment of communication, the best possible conditions exist according to its reality, that is, where patients are offered safety, comfort and privacy. In general, the noise present in the environment can hamper the understanding of the message and response, interfering in communication as a whole⁽²⁰⁾.

CONCLUSION

The assessment of student-client interaction by judges who were experts in communication was fundamental, mainly due to the perception of implicit aspects of interaction among the subjects. The categorization of the judges’ statements indicates factors that hampered the communication effectiveness.

Like other procedures, the venipuncture showed to be intensely connected with the invasion of personal space, as it demands intimate distance for its accomplishment. This was underlined by the patients’ non-verbal responses, such as muscle contraction, tension and looking towards another direction. In view of the above, students are advised to use strategies to mitigate the invasion of patients’ space, including presenting oneself before the procedure, explaining patients about the procedure, warning them before assuming a position of intimate distance, asking to touch the clients’ body, among others. About the posture, the importance of students remaining seated during technical venipuncture care is highlighted, because this position facilitates visual contact, permits better accommodation and mainly moderates the power relation.

The environment where most of the punctures were performed, the day-hospital, functioned as a space-barrier for the establishment of effective communication, due to excessive noise, the intense flow of people and inappropriate furniture to perform the procedure.

In view of the results, the need to train students on the importance of interaction and communication during care delivery is emphasized, with a view to improving their interpersonal relation when performing invasive and uncomfortable procedures like peripheral venipuncture for example. The larger intent is to offer humanized and peculiar care, during which sensitivity and empathy overlap with fear, insecurity, judgment, prejudice and stigma, feelings that are strongly linked with care delivery to HIV patients.

As perceived in this research, filming showed to be a good resource for data collection, as it permitted judges’ careful and reliable analysis of each detail in communicative interaction between students and clients. On the opposite, it may have caused a disadvantage regarding students’ spontaneity, making them act artificially or feel intimated when communicating with the client. The students were also concerned out of fear of making a mistake in the procedure while being filmed. This situation caused some degree of constraint and shame. Hence, based on this study, the researchers hope to improve communication between students and clients during the procedures they perform, and specifically during peripheral venipuncture for aids patients.

REFERENCES

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