Download the teaching of nursing care in a core of palliative care: case studies

ISSN: 1981-8963
DOI: 10.5205/reuol.6391-62431-2-ED.0902supl201528
Cordeiro FR, Roso CC.
The teaching of nursing care in a core of...
CASE REPORT ARTICLE
THE TEACHING OF NURSING CARE IN A CORE OF PALLIATIVE CARE: CASE
STUDIES
O ENSINO DO CUIDADO DE ENFERMAGEM EM UM NÚCLEO DE CUIDADOS PALIATIVOS:
RELATO DE EXPERIÊNCIA
LA ENSEÑANZA DE CUIDADOS DE ENFERMERÍA EN UN CENTRO DE CUIDADOS PALIATIVOS:
ESTUDIOS DE CASO
Franciele Roberta Cordeiro1, Camila Castro Roso2
ABSTRACT
Objective: reporting about the teaching of care for patients with disease outside of healing possibilities.
Method: a descriptive study of experience report type carried out from the teaching trainning admitted to a
Palliative Care Unit during the Master’s and Doctorate Courses with nursing graduate students, from April to
May 2012. Results: activities were developed on the body care, communication with patients in the process of
death and dying and their families as well as specific care techniques of palliative care. Conclusion: it is
concluded that the atmosphere on/in the field facilitated the process of teaching and learning for both
graduate students and for nurses who performed the teaching activities. Descriptors: Education; Education
Postgraduate Nursing; Death; Palliative Care.
RESUMO
Objetivo: relatar sobre o ensino do cuidado a pacientes com doença fora de possibilidades de cura. Método:
estudo descritivo, tipo relato de experiência, realizado a partir do estágio de docência em internados em um
Núcleo de Cuidados Paliativos durante os Cursos de Mestrado e Doutorado com alunas de graduação em
Enfermagem, no período de abril a maio de 2012. Resultados: foram desempenhadas atividades relativas à
higiene corporal, a comunicação com os pacientes em processo de morte e morrer e suas famílias, além de
técnicas de cuidado específicas dos Cuidados Paliativos. Conclusão: conclui-se que o ambiente proporcionado
pelo/no campo facilitou o processo de ensino e aprendizagem tanto para as alunas de graduação como para as
enfermeiras que desempenharam as atividades de docência. Descritores: Ensino; Educação de Pós-Graduação
em Enfermagem; Morte; Cuidados Paliativos.
RESUMEN
Objetivo: informe sobre la enseñanza de la atención a pacientes con enfermedad fuera de las posibilidades
de curación. Método: un estudio descriptivo del tipo de informe de experiencia realizado a partir de la etapa
de la enseñanza admitida en una Unidad de Cuidados Paliativos en el Máster y Doctorado con los estudiantes
de pregrado en Enfermería, de abril a mayo de 2012. Resultados: las actividades se llevaron a cabo en el
cuidado al cuerpo, la comunicación con los pacientes en el proceso de la muerte y del morir y sus familias,
así como las técnicas específicas de atención de cuidados paliativos. Conclusión: se concluye que la
atmósfera acerca/en el campo facilitó el proceso de enseñanza y aprendizaje para los estudiantes de
pregrado y para las enfermeras que realizan la actividad docente. Descriptores: Enseñanza; Educación de
Postgrado en Enfermería; Muerte; Cuidados Paliativos.
1
Nurse, Doctoral Student, Graduate Nursing Program, Federal University of Rio Grande do Sul/PPGENF/UFRGS. CAPES Scholarship Holder.
Porto Alegre (RS), Brazil. Email: [email protected]; 2Nurse, Doctoral Student, Graduate Nursing Program, Federal University of Rio
Grande do Sul/PPGENF/UFRGS. Porto Alegre (RS), Brazil. Email: [email protected]
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J Nurs UFPE on line., Recife, 9(Suppl. 1):1001-6, Feb., 2015
1001
ISSN: 1981-8963
DOI: 10.5205/reuol.6391-62431-2-ED.0902supl201528
Cordeiro FR, Roso CC.
INTRODUCTION
Care given to those who are at the end of
life is a major challenge for nursing
professionals, whether through the demands
raised by patients and families, is the
impact on physical and mental health of
these workers.1 Patient care requires these
professional technical knowledge, scientific,
ability to listen, observe and communicate
with patients and their families, as to the
effectiveness of the care process occurs, it
is necessary to link the skills of professionals
with the attitudes and expectations of the
subjects care.2
In teaching, educating for death is one of
the perspectives that emerge in the current
scenario. With the rise of Chronic
Noncommunicable Diseases (NCDs), due to
higher expected population life expectancy,
there are a number of diseases, and among
them, oncological diseases, which has been
responsible for the involvement and the
progressive degradation of the subject,
resulting in pictures fleeing healing
perspective, restricted to the alleviation of
pain and symptoms that result from this
chronic disease process.3
Although not in the health area courses,
a discipline directed to the care process in
the end of life, there was visualized the
inclusion of internships and practical classes
with patients about to die in curriculum
courses such as Nursing.4 These activities
are held in common clinical units or centers
that provide specific care for these
individuals.
Despite the fragility of the care network
for patients with no chance of cure and
their families, there is a movement,
especially since the 2000s, driven by the
National Humanization Policy (2004), the
Oncology Care Policy (2009) in addition to
the mobilization of institutions to draw
together teaching, research and attention
seeking for establishing and developing
strategies aimed at a comprehensive and
humane care to individuals who die and
those who are around.5 Thus, there is the
establishment of some units of attention to
them, with the preferred site the hospital.
Some nuclei were created for the attention
people about to die from the logic of
Palliative Care. This philosophy of care
promotes treating death as an inherent life
phenomenon, leading to its acceptance by
the provision of care aimed at comfort,
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The teaching of nursing care in a core of...
reducing pain and the family and multisupport at death.6 In Brazil some places we
have this philosophy in implementation and
development process are the public hospital
of São Paulo, the IV Hospital of the National
Cancer Institute (INCA) and the Clinical
Hospital of Porto Alegre.
The formation of these spaces represents
an advance in the care given to these
patients and their families, especially the
kind of attention that is given by the teams,
usually seeking to look and take care of the
individual as a totality, focusing less on the
disease and more in control of the signs and
symptoms prior to death, and the coming
together of family bonds and redemption.
Identifying these units, an enabling space
for the development of education beyond
life, also foster’s death, to care for the
body of the subjects in the process of dying
and the other elements that surround it,
such as family, spiritual, social, cultural
issues, among others. Using these spaces as
an environment that aims to break contact
and communication barriers between the
nursing students and the subjects in the
dying process appears as an interesting
strategy for the qualification of professional
nursing education at the same time
improves and assists in the formation of a
field of knowledge and care around the
dying process.
It sought from these scenarios, following
and experiencing in a Palliative Care Center
in southern Brazil, the teaching process of
care for people with disease with no chance
of cure for a teaching stage of the master
program and doctoral. Through the
experiences made possible by contact
between nurses, graduate student and
doctoral student, the guiding teacher of
stage and undergraduate students, the unit
staff as well as patients and their families
was possible to trace new perspectives for a
new proposal for education and closer
together the subjects who die. Thus
emerges, a large playing field for nurses,
which should be explored and allowed for
nursing students. Thus, this study aims to:
● Reporting about the experience of
teaching of care for patients with disease
outside of healing possibilities.
METHOD
This is a descriptive study including
experience report conducted from the
teaching training admitted to a Palliative
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Care Unit during the Master’s and Doctorate
with graduate students in Nursing, from
April to May 2012.
The teaching training is characterized as
an activity of the Master's and Doctoral
Degree, aimed at experience of students
within the academic setting, especially from
the approach to teaching fields, whether in
the
classroom
or
in
environments
professional practice.
The teaching training and the monitoring
of graduate students took place in the
month of April and May 2012. At first we
made a rapprochement with the Palliative
Care Center staff team of a public hospital
and teaching in southern Brazil in two
previous encounters the entrance of
undergraduate students in the field. This
moment was necessary for adaptation and
recognition of the unit, their routines,
patients admitted and professional joints
occurring in the field.
The nursing team was composed of a
nurse and two nursing techniques, the shifts
in the morning and afternoon. In the night
time activities have not been developed,
but the team has two nursing technicians
and a nurse who moves from another unit to
assist in the care and supervision of nursing
services.
The Center has six beds distributed as
follows: four single rooms and two beds in a
room together. Tolerance of oncology and
hematology patients above 18 years old and
it is necessary that the patient is aware of
his diagnosis and prognosis. Since its
founding in 2005, the core provides the
shelter of family, one of the conditions for
hospitalization, the presence of a family
during the admission process. Unlike other
hospital settings, there is free movement of
persons, without restricting the number of
visitors and time. Also, there is an adequate
diet by a multidisciplinary team with the
needs and desires of the patient.
It
avoids
unnecessary
invasive
procedures, such as the passage of
nasoenteric probe or obligations to food
intake as that prescribe team, not
acceptable by the subject in Palliative Care.
The unit has medical team for the
treatment of pain, one of the main
symptoms to be cared for and treated by
health professionals of the unit; professional
social work and psychology that articulate
forwarding and return of patients to home,
minimizing the limitations of care and
English/Portuguese
J Nurs UFPE on line., Recife, 9(Suppl. 1):1001-6, Feb., 2015
DOI: 10.5205/reuol.6391-62431-2-ED.0902supl201528
The teaching of nursing care in a core of...
logistical and emotional
patients and families.
difficulties
of
The monitoring of students took place
from six meetings, lasting an average of five
hours each, totaling 30 hours of internship.
The students studied the fifth semester of
the nursing program at a public university
and this was regarded as the second hospital
practical field of students, as part of the
nursing discipline in Adult Care I. It should
be noted that went through this field only
students who chose during the registration
the option for this place, seen that the
university concerned the options for
practical courses are conducted by students
after division in the classroom. All students
were female, aged between 20 and 24 years
old and none had any previous experience in
nursing, for example, in a technical course.
In relation to the authors who accompanied
the students, these had previous experience
in nursing acting as oncology clinic nurses
and unit ready adult help.
RESULTS AND DISCUSSION
When initiating activities in the practical
field, the students had previous exposure to
the theoretical content related to the
concept of palliative care, its philosophy
and its contingencies. Initially there was the
presentation unit and articulation of
students with the core nursing staff. This
first contact was essential, since it was
possible the monitoring of students by
professionals in the development of some
unit routines, such as making the
systematization of nursing care, as well as
specific procedures like body preparation
after death. Thus, it was noticed a positive
aspect to integrate students and staff so
that there was an enabling environment for
learning and the contacts inside the unit.
Among the features and themes used as
care education facilitators those with
disease with no chance of cure, we used the
consensus of nausea and vomiting, cachexia
and anorexia, fatigue and constipation
induced by opioids produced by the
Brazilian Association of Care palliative.
These consensuses have some routines and
suggestions of care and practices relating to
the control of the major signs and symptoms
observed in patients in palliative care. Are
developed by multidisciplinary team and
assisted in directing the practical classes, so
that at the end of the field activities was
provided a moment of discussion of clinical
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cases of patients and was made the clinical
and therapeutic correlations with the
proposed material.
In relation to care of the signs and
symptoms in patients with no chance of
cure, we highlight the central role of pain
control, one of the prevalent symptoms in
these patients. It was possible to
understanding and developing one of the
still restricted to patients in palliative care
units:
hypodermoclysis.
The
hypodermoclysis is characterized as a
subcutaneous puncture needle or catheter
over needle scalp type, fixed by dressing
type "transparent film". This technique is
intended for the infusion of drugs for
analgesia, sedation, treatment with certain
types of antibiotics and hydration up to
2,000 ml per day.7 This pathway is shown to
be an important feature in view of the
difficulties of punctures peripherally in
patients who are already debilitated due to
long chemotherapy treatment, dehydration,
loss of skin turgor and venous hardening,
resulting also in functional deterioration
caused by the organism disease.8 The
technique was applied in the unit,
especially for pain control having a good
therapeutic response to pain control while
minimizing the use of invasive procedures
and often unnecessary for the moment, as
the insertion of central venous catheters,
which would cause pain and discomfort to
the patient.
The
moments
of
contact
and
communication with patients and their
families were interesting moments of the
stage. There was some fear of the students
to approach and touch the subject, perhaps
insecurity, not knowing what to say in a
moment so delicate. Communication with
patients in the dying process has shown
many limitations in face to face contact. It
was possible to identify the role of
professional teaching in this field as an
organizer and facilitator of the learning
process and the relationship between
students and patients.
At times when you could see trouble on
the environment and the approach with
patients and their families, teaching
internship in nurses sought to hear the
students, trying to bring them closer to the
subjects through dialogue, observation or
just respecting the silence those patients
who so wished. It was identified as the
silence and dialogue can be therapeutic and
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J Nurs UFPE on line., Recife, 9(Suppl. 1):1001-6, Feb., 2015
DOI: 10.5205/reuol.6391-62431-2-ED.0902supl201528
The teaching of nursing care in a core of...
provide a more effective care and captive
those who run.9
Another important aspect was to follow
the process of imminent death, preparation
of the body and the family at the time of
mourning. In addition to the bath, the
completion of packing and procedures as
withdrawals from catheter and dressings, it
was possible to establish a time of
reflection on death itself, awakening in
some pupils feelings of malaise and other,
closer to this event. In the moments before
and after death the family was called to
attend the farewell rituals.
During the internship was able to resume
and apply the nursing process in some
patients from admission to the unit, in other
continuing what had already been assessed,
referred or directed. There was the practice
of history, physical examination of
subjective questions to patients regarding
their complaints and other aspects that they
believe is important. A care plan was drawn
for each patient and family during
hospitalization and later to the High,
through guidelines on care at home, on the
use of medications, changing diapers,
feeding schedules, among others.
It was also possible to rescue the ethical
and bioethical aspects of the dying process,
reporting the difficulties of implementing a
new philosophy as palliative care. For
several moments identified the limitation of
some families and patients to understand
the palliation purposes and is not to cure
the disease. Even though it is one of the
admission criteria in the unit, the patient
know his diagnosis and prognosis, there is
evidence of a denial process, rejection and
certain disgust when he realized the
terminally condition, meeting as described
in the literature.10
Questions like: "You are making
euthanasia with my family" emerged in the
field, making us reflecting on the way
people are thinking subjectivated the
events surrounding the dying process
leading to confusion around concepts as
euthanasia, medical futility, assisted suicide
and palliative care. View to increasing need
for disclosure about what are the Palliative
Care, differentiated it from other concepts
that are sometimes obscure for family,
patients and even for health professionals.
These conflicts may perhaps be minimized
from the reflection and dialogue between
health staff and those involved in the
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context of terminal illness, seeking fade
discomforting attitudes toward death, such
as the denial and investment in procedures
that will not get meaningful answers.
FINAL REMARKS
It appears that speaking of death and
care for the dying, despite numerous
discussions and developments around that
process, still appears as an instigating factor
and sometimes uncomfortable for health
professionals. Death is an inevitable event;
however, we are not and perhaps can never
be fully prepared to deal with its
repercussions. Through the training at the
Center of Palliative Care, it glimpsed up
new possibilities of care and relief of
suffering of departing and their families.
Similarly, we identified the break taboos
like approach and contact with the subject
in the process of dying.
The development by students, sensitivity,
and therapeutic touch with patients and
their families was noticeable. Learning
opportunities provided by the field showed
that education for death is possible,
provided that it has structure that provides
greater proximity to the subject and enable
them to achieve more smoothly procedure.
Thus, it is possible to reduce errors and the
greater effectiveness of care through the
nursing
process.
Perhaps
in
other
environments with more patients and fewer
resources were difficult to provide these
comforts.
The Palliative Care Center served as
learning field for both the nurses who
conducted the teaching stage, which
developed the practical skills of care
associated with teaching and for the
students who had contact with different
practices to the dying and their families,
making it the core, differentiated factor
that enabled a natural learning process. For
both parties involved in this scenario, the
environment had a positive effect seen the
possibility to take another direction, look
and care for those who many think that
there is nothing more to do.
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DOI: 10.5205/reuol.6391-62431-2-ED.0902supl201528
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DOI: 10.5205/reuol.6391-62431-2-ED.0902supl201528
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Submission: 2013/12/03
Accepted: 2015/01/12
Publishing: 2015/02/15
Corresponding Address
Franciele Roberta Cordeiro
Rua General Lima e Silva, 1185 / Ap. 206
Bairro Azenha
CEP 90050-103  Porto Alegre (RS), Brazil
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