Report of the Experience

The following nursing situation, object of this article, which maintained the confidentiality of the original names of the individuals and their general information, complying with the privacy of information.

Upon entering the intensive care unit, I observed closely my service. There were five patients and one of them, Mr. José, was on life support and visibly he appeared not to be stable. He was a 40-year-old man, who had suffered a brain stroke over a week ago; now he was medically diagnosed with cerebral hypoxia. When observing him during the change of shift, I felt a sense of emptiness in my stomach, I can't explain why; his face looked different, in spite of his robust complexion he looked tired, with no desire to continue struggling, he was in a coma with Glasgow scale of 5 of 15, drips from infusion pumps had been increased above the normal, the mechanical ventilator was doing all the respiratory effort.

I met Mr. José three weeks ago in his daily routine, he sold me some cookies in the hospital cafeteria and now seeing his situation, makes me think of the paradox of life. After starting my shift, I decided to call the cafeteria to contact his family, made up of his young wife and three children, to let them know about Mr. José's health; seconds later, the eldest of them arrived. Before allowing him to go in and see his father, I spoke to him and explained his father's situation, it was not easy seeing his face of resignation, seeing his sad eyes. He embraced me and said - "Thanks"; now, can I go in and see him, can I speak to him, can he hear me, can I Kiss him? I said yes, that he could speak to him, we do not know if he can hear you, but you will not lose anything if you try, and - of course - you can touch him. I proceeded to leave the unit and left them alone; when seeing in the distance saying their last farewell, my heart shrunk and saw myself in the same situation some years ago, because as I have always said, I was first a family than nursing professional.

Suddenly, the doctors entered the unit, I asked his son to leave: the moment had come to remove the life support. Little by little, Mr. José started turning bluish all over his body and his temperature began to drop, he was dying before my eyes; carefully, we prepared his body for his family to remain for a moment with him before removing him from the unit, so I left them alone to express their feelings and after a while the wife called me; she wanted to give me a strong embrace and whispered in my ear - Thanks -, we broke apart while she held my hands tightly and again saying - Thanks. Thereafter, she turned around, took her children by the hand and walked away, I never saw her again. After that, I went to the garment room in the intensive care unit, I had held back my tears too much, I wanted to cry; after some time I went back to the other patients, they needed me, I had to continue with my role as nurse.

Knowledge Patterns in the Nursing Situation

Knowledge patterns in nursing refer to Barbara Carper, who proposed "four fundamental knowledge patterns that can be identified through the analysis of concepts and of the syntactic structure of nursing knowledge" ⁶ .

These patterns are distinguished according to the type of logical meaning: the empirical refers to the science of nursing; the aesthetic to the art of nursing; the personal to knowledge of oneself and of others; and the ethical permits the development of moral knowledge in nursing ^{2, 7} ; the sociopolitical speaks of policies and their actions; the emancipatory is that personal accomplishment.

Knowledge patterns have been examined as a complete expression, with internal adjustments among each other, that permits reflecting care and nursing therapy on the report of the experience exposed.

Pattern of personal knowledge. One of the most important patterns to guide holistic care, which is achieved when others are valued, their freedom respected, avoiding prejudice and, above all, accepting differences among people, thoughts, and individualities, supported on a disciplinary commitment ^{7 - 9} .

In the nursing situation, this pattern is reflected in listening, observation, identifying the need to keep the family informed, bearing in mind that Mr. José and his family; besides, the study identified the possibility, as nursing professional, of existing as a therapeutic being that upon knowing oneself, manages to know how to make decisions and carry out care assertively, besides expressions by the nurse made the family feel authentic and important. Hence, it is highlighted that the pattern of knowledge personal is made visible when sharing difficult situations that have been experienced, which makes nursing professionals sensitive to this particular situation.

Pattern of empirical knowledge or science of the discipline. Empirical knowledge is supported on scientific skill to conduct nursing practice based on the discipline's own theory, which, in turn, promotes investigative processes that reveal the nursing domain ⁸ . Each discipline has people who generate and communicate said knowledge; this "sharing" occurs in the field of the practice and of the research results ^{7, 9} .

In the nursing situation, knowledge was expressed through the care for Mr. José and his relative; in addition, it was expressed through the professional skill evidenced in the nurses' knowledge and academic formation in professional institutions that have favored its practice. These constitute the base to employing one of the theories of nursing, like the Theory of Caring by Kristen Swanson (Silva, Sorrel, & Sorrell, 2018) with its five processes to respond to the nursing situation analyzed:

Knowing. Understanding the meaning the experience of Mr. José's death for the family and the changes this generated in the family and personal dynamics.

Maintaining beliefs. Promoting an attitude of hope, allowing to approach his family and give them a space to say farewell (they prayed to the God of their belief), of accepting the change of roles.

Being with. Sharing the experience of the emotion felt, that is, of the feelings and the disposition to permanently listen to the situations, with an attitude of assertive, committed, and logical response.

Doing for. Guiding actions based on the needs of Mr. José and his family to provide care.

Enabling. Allowing the family to, in their own way, to go through the path of the experience lived, such as the loss of a relative, facilitating the elaboration and start of their grief.

Pattern of ethical knowledge. This pattern should make visible that the nursing professional act as morals dictate, adding elements, like virtue and its traits, which are empathy and compassion. In addition, individual deliberation by the professional's knowledge, supported on feelings of totality and integrity, and explained from the epistemological (what nurses should do) and the ontological (the morally accepted) ^{2, 9, 10} .

In the nursing situation, the ethical pattern was identified when establishing a relationship with the subject of care (the family); as nursing professional, what must be done was kept in mind. The situation of confronting an unknown event was understood (loss of a loved one). The nursing professional allowed each family member to weep and express feelings of sadness and despair, without limiting them or interrupting them; accompanying them in silence to guide them on the moment of grief committed to establishing communication.

Responses by nursing professionals in the nursing situation indicate they established their being and knowledge empathically with the family, which is why the study kept in mind the ethical values and principles of the deontological responsibility of Nursing in Colombia ¹¹, as with the respect, the dignity of human beings, and their right to information, to attentive listening, without regards to culture, sex, race, or creed; principles of integrality when providing nursing care with a vision that addresses the person's multidimensionality, upon developing an inter-relation with effective and symmetrical communication and participative dialogue, contemplated in the national norm ¹² .

Pattern of aesthetic knowledge. This is a pattern compared with art, and art is presented as an ingenious, creative, and novel way of caring with adequate technique, motivation, reason, and spirit filled with feelings and warmth ^{2, 13} ; these demonstrations characterize the moments of care of every nursing professional, when they can recognize themselves and involve themselves sentimentally in the experience lived by the other, and manage to evidence empathic response expressions that perceive their reality ^{7, 14} .

In the nursing situation during the approach, verbalization took place in delicate, attentive, and fine manner; in addition, gestures and support actions, like shoulder massaging, directed smile, posture of interest, and the response from the relatives manifested positive beauty in the interaction; each signal, gesture, word, or attitude reflects the art of nursing. In the nursing situation, the professionals evidenced their interest in the family, making them feel like persons.

Pattern of sociopolitical knowledge. This knowledge is made visible with the nurses' reciprocity with the environment surrounding the relations between them and their patients. Moreover, it includes an analysis of nursing professionals on the policies and their actions, from a nursing perspective toward and from the people, with cultural and historical elements to achieve becoming an agent of care ⁶ .

The nursing situation reveals different nursing professionals, who feel that their practice goes beyond the technique; they present what people expect of them: a professional with kind treatment, with defined goals tending to achieve closeness with the patient's relatives, avoiding cultural friction when providing nursing care.

Pattern of emancipatory knowledge. It is innovative and essential knowledge to develop the nursing epistemology and practice; it is defined as that personal accomplishment of identifying difficulties in society and its structure, and the political influence generated by situations of inequity and limited justice to propose changes, in order to generate improvement and wellbeing in the individuals ⁶ ; with this definition understood, this pattern invites to critical reflection and creative thought in the formulation of clear proposals that benefit the health and care of people.

In the nursing situation, although economic and geographic difficulties could not be transformed by the nurse, a problematic analysis was performed seeking to improve nursing care of people and caregivers who experience the phenomenon of amputation. The aforementioned, through a management proposal of equal and just nursing care for mothers who are heads of household who start living a process of grief.

Conclusion and Contribution to the Discipline

Nursing is an art, given that it is the means through which care is provided; it is understood as the intentional act by nursing professionals to provide wellbeing to the person seen from a comprehensive perspective, founded on the discipline's scientific knowledge. Nursing professionals view the person integrally, considering that they are not isolated, but in constant interaction with the environment, in addition to never leaving their family aside, which must be considered within the nursing care plan ^{15, 16} .

For the situation previously described of my fear upon again experimenting grief, when knowing the pain Mr. José's family could have been enduring, it helped me to have the adequate words and be able to encourage the family during the process of grief by using intentional silence, privacy, and direct contact.

Death and grief phenomena have been studied by nursing, where it has been verified that death is a unique and personal process, which is why it is not possible to generalize about it ^{17, 18} .

Due to this, nursing professionals, since their period as students, must prepare to provide care to patients and families, with scientific, ethical, and humanistic knowledge, aware that during their nursing work they will perform care more efficiently, while acquiring the tools to cope or reduce their own anxiety upon a patient's death ^{5, 19, 20} .

In spite of numerous reports on how to confront grief and which must be the guidelines to achieve an adequate nursing intervention in opportune accompaniment to the family in grief, the results obtained and experiences achieved indicate that preparation for said event is almost null. The challenge for nursing professionals is to have to leave aside their own emotional load when providing a good intervention to, thus, provide comprehensive care to patients and their families.

This study evidenced the importance of epistemology and ontology as support of professional care, as well as their use in professional praxis and nursing education.