ARTÍCULO ORIGINAL / ORIGINAL ARTICLE/ ARTIGO ORIGINAL

The nursing team and the family member accompanying adult patients in the hospital context. An exploratory study

El equipo de enfermería y el familiar acompañante del paciente adulto en el escenario hospitalario. Un estudio exploratorio

Thayane Dias dos Santos¹; Alessandra Cristina de Oliveira Aquino²; Carla Lube de Pinho Chibante³; Fátima Helena do Espírito Santo⁴

¹RN, Specialist. Escola de Enfermagem Aurora de Afonso Costa da Universidade Federal Fluminense (EEAAC/UFF), Brasil. email: thaydsantos@hotmail.com.

²RN, Specialist. EEAAC/UFF, Brasil. email: Ale.aquino@hotmail.com.

³RN, Specialist. EEAAC/UFF, Brasil. email: Carla-chibante@ig.com.br.

⁴RN,Ph.D., Professora EEAAC/UFF, Brasil. email: fatahelen@hotmail.com.

Receipt date: May 29, 2012. Approval date: February 4, 2013.

Article linked to research: As faces da hospitalização para o idoso: contribuições ao cuidar em enfermagem.

Subventions: none.

Conflicts of interest: none.

ABSTRACT

Objective. To identify the actions of family members who accompany adult hospitalized patients and to describe the nursing team's role regarding that person. Methodology. In this qualitative, descriptive and exploratory research, a questionnaire was applied to 30 nursing team members at a teaching hospital located in the State of Rio de Janeiro, using open questions. To interpret the answers, thematic analysis was applied to categorize the identified qualitative variables. Results. Eighty-nine percent of the participants were female. When analyzing the information contained in the answers to the questionnaire, two types of actions were found: the actions the companion can perform for his/her relative and the actions the nursing team needs to perform. In each action, the following categories were verified: affective dimension, practical dimension, moral dimension and inclusion of the family in care. According to the nursing team, the companion plays a very important role in emotional support and help with the patient's basic hygiene, although this care should be offered under nursing orientation. Conclusion. Family companions and nursing team members work together to improve the quality of patient care, with positive reflections for their integration in hospital care, which will enhance its continuity in the home-care context.

Key words: nursing; family; institutionalization.

RESUMEN

Objetivo. Identificar las acciones del familiar acompañante del paciente adulto hospitalizado y describir qué papel tiene el equipo de enfermería con este familiar. Metodología. Investigación cualitativa, descriptiva y exploratoria, en la que se aplicó un cuestionario con preguntas abiertas a 30 personas del equipo de enfermería de un hospital universitario localizado en el Estado do Rio de Janeiro. La toma de la información se realizó en 2010. Las respuestas fueron interpretadas por análisis temático, categorizando las variables cualitativas identificadas. Resultados. El 89% de los participantes pertenecía al sexo femenino. Al analizar la información de las respuestas a las preguntas del cuestionario se encontraron dos tipos de acciones: las que puede brindar el acompañante a su familiar y las propias a desempeñar por enfermería. En cada acción se verificaron las categorías: dimensión afectiva, dimensión práctica, dimensión moral e inclusión de la familia en el cuidado. Para el equipo de enfermería el acompañante tiene un papel muy importante en el apoyo emocional y en la ayuda con la higiene básica del paciente, pero este cuidado debe brindarse bajo la orientación de enfermería. Conclusión. El acompañante familiar y del equipo de enfermería buscan conjuntamente la mejoría de la calidad del cuidado del paciente, lo que se refleja positivamente en su integración en el ámbito de la atención hospitalaria, lo que favorecerá la continuidad del mismo en el espacio domiciliario.

Palabras clave: enfermería; família; hospitalización.

INTRODUCTION

Hospitalization is a common event for some individuals who suffer from non-transmissible chronic conditions (NTCCs), which entails changes in the routine, distancing from relatives and friends, which affects the individual and the entire family structure, as it tends to be perceived as a stress-producing threat, causing feelings of insecurity, guilt, loss of control, autonomy and changes in socioeconomic aspects. When establishing a closer and more therapeutic relationship with the nursing team, however, the family can start to notice and act in solidarity with the difficulties the institution itself and the dynamics of nursing team work impose. On the other hand, even if the family generally possesses internal potential to get reorganized rapidly, when it serves as a companion, specific needs emerge related to the hospitalization, demanding systemized information and orientations from nurses about how to participate in the care process for these patients as family companions, support the nursing team members during the hospitalization, developing knowledge and skills to continue this care in the home context after the patients are discharged from hospital.

Families need to be considered as allies for the health team, supporting the promotion of comfort and humanization for the patients, helping them to regain trust and thus investing in their recovery. As they are an element of support for hospitalized patients, it is important to maintain this family/client bond in order to make the hospital environment safer and less frightening.¹ The family's interaction with the health team is relevant for everybody, as the valuation of that interaction is based on further participation in the development of the care plan, in which the family is sensitized and actively involved in this context. When assuming the family as a partner in the patient care process, it should be considered and acknowledged that family members represent an additional nursing care focus and that the family's participation in patient care is fundamental for recovery.

Family companions' stay with hospitalized clients requires transformations in the nursing team's practice. Hence, the team needs to adapt to this situation, changing attitudes, postures and demonstrating receptiveness towards the presence of these companions in daily care.² In that context, nurses need to participate and demonstrate their ability to establish an interaction that can benefit the nursing team's relationship with the client, in the attempt to integrate the companion as an element in the client's recovery and advise him/her throughout the health-disease process, during the hospitalization period, considering that the family generally needs to take responsibility for patient care at home after discharge from hospital.

When family companions are present in the hospital context, the nursing team tends to be more concerned with making them comply with institutional rules and routines, expecting them to comply with their care obligations and not to interfere in nursing activities. Nevertheless, nurses are responsible for guaranteeing family members' presence with the hospitalized client, encouraging their participation in the care process.² The implementation of public policies has encouraged the family's inclusion in the hospital context, aiming for the humanization of care and the family members' approximation with hospitalized patients. This is a slow process though, as institutions do not offer a favorable physical and organizational structure yet to receive companions.^3,4

The approval of laws and decrees that regulate the right to a companion for some specific groups permits the humanization of the hospital environment. According to Laws No. 8.069/90, 10.741/03 and 11.108/05, children, adolescents, elderly and women giving birth are entitled to a companion during hospitalization. As regards adults, however, the National Health Humanization Policy recommends the presence of a family companion, but this decision is left to the institutional clearance, whose compliance nurses decide on in most cases.^5-7 Hence, the experience of family companions in the hospital context can trigger different situations of discomfort. To mitigate these situations imposed on patients and companions during hospitalization, nursing team actions and interventions are needed to enhance the former's wellbeing and comfort.⁸

In view of this problem, the following questions guide this study: what are the tasks of family companions to hospitalized clients? What is the role of the nursing team towards family companions of hospitalized clients? Hence, the aim in this study was to identify the tasks of family companions to hospitalized clients and to describe the role of the nursing team towards family companions of hospitalized clients.

METHODOLOGY

A qualitative, descriptive and exploratory research was undertaken. Information collection involved the application of a questionnaire, including identification data and two open questions, to 30 nursing team members who worked at clinical and surgical hospitalization units of a teaching hospital located in the State of Rio de Janeiro, between May and June 2010. The following criteria were applied to include the subjects: having worked at the units for at least three months, availability and interest in participating in the study properly registered in the informed consent form. The research protocol was submitted to and received approval from the institutional Ethics Committee under number 133/08. All study participants received orientations about the research objectives and signed the informed consent form, in accordance with the Recommendations of National Health Council Resolution 196/96.

In that sense, the nursing professionals under analysis answered a questionnaire with open questions about the theme, besides an objective part with identification questions, including: gender, age range, professional category, professional experience and activity sector. The open questions were as follows: According to you, what is the role of a family companion? What is the role of the nursing team towards that companion? Based on the answers to the questionnaire, thematic analysis was applied, a content analysis modality that 'consists in discovering the groups of meaning that compose a communication, whose presence or frequency mean something for the analytic objective aimed for.^9:209

After applying the thematic data analysis, the following categories were elaborated: affective dimension; institutional dimension; moral dimension; inclusion of the family as a care unit. The transcribed discourse was identified using a combination of letters and number, with P referring to 'Participants' and the numbers distinguishing among their answers. Thus, the ethical requirement of anonymity was respected.

RESULTS

Thirty nursing team members participated in the research (100%), 19 (63.3%) of whom were nursing technicians and 11 (36.6%) baccalaureate nurses. Twenty-six (86.6%) of these professionals were female and four (13.3%) male. The subjects' age ranged between 18 and 51 years, with the group between 21 and 38 years as the most prevalent age range. Concerning the activity sector, 16 worked at the surgical clinic (53.3%) and 14 at the medical clinic (46.7%). Professional experience ranged between three months and 25 years.

When analyzing the answers to the two questions in the questionnaire, two attributions were identified: the companion's and the nursing team's. In each attribution, themes were identified that gave rise to interrelated categories, that is, the institutional and the affective dimensions present in both attributions. The practical dimension, on the other hand, only relates to the companion's attribution. The moral dimension and the family's inclusion as a care unit, on the other hand, are part of the nursing team's attributions.

The responsibility of the family companions

When asked about the companions' role inside the hospital, the answers were ranked in three categories: practical dimension, affective dimension and institutional dimension.

Practical dimension. The following answers were classified: Staying at the patient's bedside to help with basic activities: oral hygiene, diet and using the bathroom (P6); Helping the patient to offer food and accompanying him for physiological necessities... (P1); Helping with some tasks like meals and position changes, when possible...(P8). The practical aspect is related to biological needs, like helping with meals and hygiene, offering water, placing and removing the bedpan, changing diapers and helping with locomotion, in a wheelchair and while walking. The practical dimension was only identified in the family companion's attributions, corresponding to 70%.

Affective dimension. The following were classified: Emotional support to the patient, which ends up extending to the family member... participating in training about the care needed for patient discharge (P3); Staying with the loved one...P(10); Accompanying him with safety and dedication in order to feel emotionally well (P20). During the analysis of the professionals' discourse, affection was related with psychosocial needs, such as providing safety, company, being thoughtful, promoting comfort and kindness. This dimension was identified in the family companion's attributions with 83.3%.

Institutional dimension. As this is a legal right... (P1); Giving orientations about the routine in the sector... (P25); Always clarifying the limits between institutional protocols and nursing care routines... (P13); Restricting themselves to their clients, complying with institutional standards... (P4). The institutional dimension was identified in the family companion's attributions, corresponding to 43.3%. In most of the nursing team's discourse, this dimension was perceived as a clarification of hospital conducts and rules, besides clearly revealing in some statements that the family member's presence at the hospital is guaranteed by law.

The role of the nursing team towards the family companions

The answers were ranked into four categories: institutional dimension, affective dimension, moral dimension and inclusion of the family as a care unit.

Institutional dimension. Informing about hospital times and conducts... (P24); Giving orientations about the routine in the sector (P3); Clarifying the standards and routines at the sector and informing about the companion's role for the patient. (P13); Providing all orientations and clarifications about institutional standards (P16). The institutional dimension was identified in the nursing team's attributions, corresponding to 73.3%. The nursing team members consider that their role for the family companions is to establish standards and rules, through orientations, so as to allow them to serve as active elements in holistic care delivery to hospitalized clients, including the physical, emotional and social aspects.

Affective dimension. Giving emotional support... (P30); Welcoming the companion... (P5); Being thoughtful towards the relative and demonstrating satisfaction about being able to count on his presence (P11). The affective dimension was identified in the nursing team's attributions (30%).

Moral dimension. Having a good relationship with the companion to enhance the client's wellbeing (P1); Being partners in the professional/companion relationship and establishing a base of respect with a view to harmonious contact (P12); Turning the relation as peaceful as possible... (P17); Mutual respect between team and companion...(P4). The moral dimension was identified in the nursing team's attributions only, corresponding to 33.3%. This dimension is related to respect and partnership in the relation between professionals and family companions.

Inclusion of the family as a care unit. Orientation about the care the companion will provide after the client's discharge (P26); Orientation about the family member's importance in the accompaniment of care delivery (P5); Showing the importance of having the family member together with the client to transmit greater safety and wellbeing... (P18); Showing that the family member's presence together with the hospitalized client is important for health promotion and recovery... (P21). The inclusion of the family as a care unit is present in the nursing team's attributions, corresponding to 63.3%. In some statements, the professionals allow the companion to perform activities together with the patients, demonstrating interest in their stay, helping with psychological and biological care.

DISCUSSION

When people get ill, they find themselves obliged to change their life habits, mainly when hospitalized. This generates a range of feelings and expectations in view of the new challenge, consequently compromising their emotional security.¹⁰ In that context, the family is the primary element of support for the patient. Hence, they cannot be detached from the environment they live in, as the family as a group prevents, tolerates and corrects its members' health problems. Therefore, this family member should be considered an ally of the nursing team, serving as an element of support in the promotion of comfort and humanization for the patient.¹

The family's interaction with the health team is relevant to both, as the valuation of that interaction is based on its further participation in the care plan, as they are sensitized and involved in this context.¹¹ Communication difficulties can trigger crisis situations in the team/client/family relation, in the same sense as good communication can be effective to dilute tensions. It is important to raise nurses' awareness about competent practice to assess and intervene in family care situations, through cooperative relationship between nurses and families.¹ Therefore, the importance of the family companion's role towards clients and their integration with nursing team members is highlighted with a view to the complete performance of their role, demanding emotional control, goodness and the capacity to provide aid and dedicate themselves.

Hence, the nursing team and the family companions should maintain a relationship of trust, security and mutual respect. In addition, the interpersonal relationship and interaction between both result in effective communication, facilitating nurses' interventions and care delivery to hospitalized clients.

In fact, the companions' stay during the hospitalization period is fundamental because of the emotional support this can grant to the patient, who goes through a critical phase in life.¹² In addition, this companion can be important to maintain some care that benefits the client. Therefore, the companions need training and orientation about care throughout the hospitalization period, with a view to keeping up this same care after the patients' discharge. In some statements by the nursing team members, it was verified that family companions can also be useful when, in case of any change in or doubt about the client's condition, they request the help or presence of the nursing team for assistance, favoring immediate care in some situations. It should be added that, in hospital care, some professionals consider the family's interference as positive in two senses: when the companions help nursing to take care of the client or when they provide information about their condition. Some professionals, however, see family interference as negative, as the family members question all care the nursing team provides. Perhaps the team does not understand that, when the family members interfere, they may be expressing their affection towards their loved one.

After the data analysis, it was identified that the nursing team members consider that the companions are responsible for providing emotional support and/or delivering basic hygiene care, like changing diapers, bathing and helping with meals. This demonstrates that, although the nursing team members attribute negative aspects to the companions' presence in the hospital context, they consider that, when standards and rules are established through orientations, the companions can act as active elements of support in holistic care delivery to hospitalized clients, covering the physical, emotional and social aspects. It should be reminded that the way the relation with family members is conducted in care delivery to hospitalized clients is coherent with the current healthcare humanization policy, as the focus on principles like holistic care, equity and users' social participation demands the reconsideration of daily practices, creating a dialogic space in the care process.⁴

The family's presence represents an important source of support for the recovery of hospitalized clients. In that sense, it is important for nursing team members to interact with the companions, aiming to minimize their anxieties and anguish in order to make them participate actively in the recovery of the hospitalized relative, and also serving as a measure that strengthens the professional team's relation with the companions.^1,13 In that sense, nurses' participation is needed, demonstrating their capacity to establish an interaction that can benefit the relationship between nursing team members and patients, in the attempt to integrate the companions as elements of support in their recovery and to advise them throughout the health-disease process, during the hospitalization period, as the family generally assumes the responsibility for patient care at home after discharge, thus favoring the continuity of the care started in hospital, contributing to reduce the incidence of complications that culminate in new hospitalizations that affect the clients' quality of life and increase institutional costs.¹⁰

Hence, the inclusion of the family as a care unit allows the family to accompany the evolution of the hospitalized patient's health-disease process. This is a moment to prepare the companion and offer important orientations related to discharge, avoiding the re-hospitalization process and contributing to maintain the quality of life.

FINAL CONSIDERATIONS

When establishing a closer and therapeutic relationship with the nursing team, the family can start to envisage and act in solidarity with the difficulties the institution itself and the nursing work process impose. Thus, with the family as an element of support for hospitalized patients, it is important to maintain this family/client bond to make this hospital environment safer and more welcoming. When considering the family as a partner in the patient care process, it should be taken into account and acknowledged that it represents an additional nursing care focus and that its participation in the patient care process can turn it into an important element for this client's recovery and health maintenance after discharge.

Therefore, inside hospitals, a systemized orientation and support program is needed for family companions, with a view to enabling them to help with care and to offer emotional support, enhancing the recovery of hospitalized clients. These companions' presence throughout the hospitalization and their involvement in client care should not be considered as a delegation of responsibilities though, or as a complementation of nursing human resources. In fact, the role of nursing professionals is to close partnerships with companions with a view to a better quality of care delivery to hospitalized clients. In this research, the family's inclusion as a care unit is significant because, although some professionals referred to the relative's presence as negative due to interference in patient care, more than half of the interviewees referred to this presence with hospitalized patients as positive, as the companions are capable of providing emotional support needed for the better recovery of these clients. In addition, it is important for the nursing team to participate in the interaction process with hospitalized clients, in the attempt to integrate family companions into these clients' recovery and advise them throughout the health-disease process, as the family generally takes responsibility for patient care at home after discharge from hospital.

As regards the companion's attributions, the team believes that the role of the companion is the provision of psychological support and aspects related to support activities to attend to the patient's basic needs, such as feeding, hygiene and locomotion support. The professionals mentioned, however, that the companions can perform these functions in accordance with the institutional protocols, clearly showing the existence of the institutional dimension in the team's discourse. Therefore, it is essential for the nursing team to contribute to the creation of a climate of wellbeing, effectively interacting with the companion, that is, establishing a positive interpersonal relationship with the companion. This relation permits the exchange of formal and informal knowledge, so that the family member trusts and feels safe to clarify, participate, help and interact with the nursing team in care delivery to hospitalized clients. Thus, this study reveals perspectives of the creation of a space in which the companion can learn from experience and, hence, share doubts and needs in a dialogical space, which can positively influence the companion's integration into the hospital care context and enhance care continuity for clients in the home context.

REFERENCES

1. Silva AM. O acompanhante do paciente adulto hospitalizado: percepção dos enfermeiros [Dissertation]. Guarulhos (SP): Universidade Guarulhos; 2007.         [ Links ]

2. Szareski C, Beuter M, Brondani CM. O familiar acompanhante no cuidado ao adulto hospitalizado na visão da equipe de enfermagem. Rev Gaúcha Enferm. 2010; 31(4):715-22.         [ Links ]

3. Ministério da Saúde (BR). HumanizaSUS: Política Nacional de Humanização: a humanização como eixo norteador das práticas de atenção e gestão em todas as instâncias do SUS. Brasília (DF); 2004.         [ Links ]

4. Squassante ND, Alvim NAT. Relação equipe de enfermagem e acompanhantes de clientes hospitalizados: implicações para o cuidado. Rev Bras Enferm. 2009; 62(1):11-7.         [ Links ]

5. Ministério da Saúde (BR). Lei n° 8.069: dispõe sobre o Estatuto da criança e do adolescente e dá outras providências. (13^th Jun 1990).         [ Links ]

6. Ministério da Saúde (BR). Lei n° 10.741: dispõe sobre o Estatuto do Idoso e dá outras providências. (Oct 1^st 2003).         [ Links ]

7. Ministério da Saúde (BR). Lei n° 11.108: dispõe sobre a permissão de acompanhante para a mulher em trabalho de parto e no pós parto nos hospitais públicos e conveniados ao SUS. (2nd Dec 2005).         [ Links ]

8. Szareski C, Beuter M, Brondani CM. Situações de conforto e desconforto vivenciadas pelo acompanhante na hospitalização do familiar com doença crônica. Cienc Cuid Saúde. 2009; 8(3):378-84.         [ Links ]

9. Minayo MCS. O desafio do conhecimento: pesquisa qualitativa em saúde. 8^th ed. São Paulo: Hucitec; 2004.         [ Links ]

10. Neman F, Sousa MF. Experienciando a hospitalização com a presença da família: um cuidado que possibilita conforto. Rev Nursing. 2003; 6(56):28-31.         [ Links ]

11. Carvalho VA. Cuidados com o cuidador. Re. O mundo da saúde. 2003; 27(1):138-46.         [ Links ]

12. Pozebom NV. A comunicação entre a equipe de enfermagem e os familiares de pacientes hospitalizados: a visão dos agentes envolvidos [Dissertation]. Porto Alegre: Universidade Federal do Rio Grande do Sul; 2009.         [ Links ]

13. Hoga LAK, Pinto CMS. Assistência ao parto com a presença do acompanhante: experiência de profissionais. Invest Educ Enferm. 2007; (25) 1:74-81.         [ Links ]°