ARTÍCULO ORIGINAL / ORIGINAL ARTICLE/ ARTIGO ORIGINAL

Perception of nursing students about behaviors and ethical aspects involved in patient data collection

Percepción de los estudiantes de enfermaría sobre los comportamientos y los aspectos éticos implicados en la recolección de datos de los pacientes

Juliana Dias Reis Pessalacia¹; Bruna Martins Tavares²; Fabiana Castro de Faria³; Samantha Oliveira⁴; Cristiane Chaves de Souza⁵

¹RN, Ph.D. Professor. Universidade Federal de São João del Rei (UFSJ), Brasil. email: juliana@pessalacia.com.br.

²Nursing student. UFSJ, Brasil. email: bruna-tavaresm@hotmail.com.

³Nursing student. UFSJ, Brasil. email: fabicastrofaria@yahoo.com.br.

⁴Nursing student. UFSJ, Brasil. email: sam.oliveira1@gmail.com.

⁵RN, Master. Professor, UFSJ, Brasil. email: souzac.cris@gmail.com.

Receipt date: April 14, 2012. Approval date: February 4, 2013.

Article linked to research:

Subventions: none.

Conflicts of interest: none.

ABSTRACT

Objective. To identify the perception of nursing students in relation to the behaviors and ethical issues involved in data collection from patients. Methodology. Descriptive and exploratory study with a qualitative approach, using the content analysis proposed by Bardin as the theoretical framework. Participants were students in the 7^th period of the nursing undergraduate course at a public university located in the state of Minas Gerais, Brazil, in 2011. Data were collected through interviews. Results. From the analysis of the results, the following categories emerged: preservation of patients' intimacy and privacy, respect for patients' autonomy, experiences and feelings of students and training strategies relating to the nursing process during the undergraduate course. Conclusion. The nursing students are concerned with the ethical approach during data collection from patients and the preservation of their rights. Pedagogical practices should be reinforced that take into consideration the technical aspects, as well as those related to behaviors and ethics.

Key words: nursery; teaching; nursing process; ethics, nursery.

RESUMEN

Objetivo. Identificar la percepción de los estudiantes de enfermería sobre los comportamientos y los aspectos éticos implicados en la recolección de datos de los pacientes. Metodología. Estudio descriptivo y exploratorio con abordaje cualitativo, que utilizó como referencial metodológico el análisis de contenido propuesto por Bardin. En el estudio participaron estudiantes de enfermería del séptimo período de una universidad pública de Minas Gerais, Brasil, en 2011. Los datos fueron recolectados por medio de entrevistas. Resultados. Emergieron del análisis de los resultados las siguientes categorías: preservación de la privacidad e intimidad del paciente, el respeto a la autonomía del paciente, experiencias y sentimientos de los estudiantes, y las estrategias de enseñanza del proceso de enfermería durante la formación del alumno. Conclusíon. Hay preocupación de los estudiantes de enfermería por el enfoque ético de la recolección de datos del paciente y por la preservación de sus derechos. Se deben reforzar prácticas pedagógicas que tengan en cuenta no solo los aspectos técnicos, sino también los relacionados con el comportamiento y la ética.

Palabras clave: enfermería; enseñanza; procesos de enfermería; ética en enfermería.

INTRODUCTION

Nursing has undergone several changes over the years, which are related to the political, economic and social model experienced in Brazil over time. The care primarily focused on remedial measures has progressed to the required holistic view of the human being, in order to deliver humanized care, which also involves the social context individuals are inserted in.¹ In the context of efforts to achieve holistic care, the systematization of nursing care is highlighted. This is a way to ensure holistic and individualized care to each patient, based on scientific knowledge. The nursing process is a method suggested to organize nursing care, that is, to implement the systematization of nursing care.² The Federal Nursing Council (COFEN) in Brazil, through resolution 358/2009, has recommended the nursing process, which is organized into five stages: clinical history, nursing diagnosis, nursing planning, implementation and evaluation.³

Studies show that gaps remain in undergraduate training about the nursing process. With regard to Brazilian Nursing education, a lack of interest and a concerning lack of motivation relating to systematic care have been noted, since undergraduate education is excessively focused on the development of technical skills during practical lectures. Students can see this weakness when they are inserted into practicum areas, showing that what they learn in the classroom is insufficient to meet the demands posed to the care delivered in their services.⁴ During the undergraduate program, the theoretical and practical instructions about the nursing process do not always provide students with understanding and perception of their relevance for nursing care.⁵

When starting their practical activities, nursing students begin to implement the nursing process, which must be dynamically applied, with systematized and interrelated actions.⁶ The first stage of the nursing process, the clinical history, is characterized as a deliberate, systematic and continuous process, which is implemented with the help of various methods and techniques to obtain information about the person, family or community, as well as their responses to the health and disease process.³ During this stage, ethical problems related to the invasion of patients' privacy and intimacy may occur if students are not appropriately prepared to address intimate issues during data collection and to the exposure of the body during physical examination. Patients may feel intimidated, awkward, embarrassed, or even unhappy in relation to some situations or techniques the nursing team performs. Such feelings may negatively affect patients, due to the fact that they are concerned with the manner in which they will be judged, and this can lead to the omission of relevant information to the nursing team.⁷

Based on these considerations, this study was developed to identify the perception of nursing undergraduates in relation to the behaviors and ethical issues involved in clinical data collection from patients. This study also proposes to identify the difficulties students experience during that stage, as well as training strategies to facilitate learning. The identification of these elements can help to reassess training about the nursing process, in order to contribute to improvements in the training process and show students the importance of care delivery based on ethical principles.

METHODOLOGY

This is a descriptive and exploratory study with a qualitative approach. The study sample was composed of 33 students in the 7^th period of an undergraduate nursing program at a federal public university located in the state of Minas Gerais, who were contacted in the first semester of 2011. The undergraduate nursing program at that university is structured based on subjects, with curricula divided into modules. Nursing undergraduates are included in the social and health-related reality of the town is performed since the first period of the course, thereby minimizing anxiety in the performance of procedures. The research participants were selected through a draw, using the class numbers on the call list. Inclusion criteria were: being enrolled in the nursing course in the first semester of 2011 and having regularly taken the undergraduate course until the 7^th period. Fourteen students participated in this research and were identified by the initials EE1, EE2, EE3 and so forth.

The sample size was defined based on the data saturation criteria, through the repetition of the study participants' statements. That is, the inclusion of new participants was suspended when the data obtained began to show, in the researcher's opinion, some redundancy or repetition. Data collection took place between May and July 2011, using the interview technique, with the following guiding questions: 1) In relation to the physical examination and data collection stages of the nursing process, which aspects do you believe should be considered to preserve the autonomy and privacy of patients? 2) Have you experienced any difficulty, conflicting or awkward situation when approaching patients during the clinical history? How did you feel? 3) In your opinion, what theoretical or practical training strategies could facilitate the clinical history training? The statements were recorded using an MP4 player and later transcribed for analysis. For data analysis, the theoretical framework of content analysis proposed by Bardin⁸ was used, aimed at studying the language. The different stages of content analysis are organized around three chronological stages: pre-analysis, exploration of the material and processing and interpretation of the outcomes. For data exploration, first, the transcribed material was fully read, followed by a pre-analysis to identify the participants' profile.

Subsequently, the data were cut, aggregated and listed, revealing clear signs of categories. Then, the categorization itself was performed, in which the information contained in the participants' statements constituted the analysis corpus, leading to the creation of indicators that were submitted to analytical procedures and subsequent inference, and compared to data in the literature.⁸ Subsequently, the units of analysis were selected, resulting in four categories and eight analytical subcategories that were quantified according to the number of times they were stated by the participants.

This study complied with the Brazilian ethical guidelines for research involving human beings and received approval from the Research Ethics Committee under registration number 52/2011. Before starting data collection, the objectives, risks and benefits of the research were explained to the participants, as well as the methods to be used, and those who accepted to participate in the research signed an Informed Consent Form.

RESULTS

From the analysis of the data collected during the interviews with the students, concerning the behavioral and ethical aspects involved in their experiences in the first stage of the nursing process, the following categories emerged:

Category 1. Preservation of patients' intimacy and privacy

The statements of eleven participants constituted this analysis category. In these statements, the nursing students pointed out aspects considered important to preserve patients' privacy during clinical data collection, from which two analytical subcategories were identified: the objects to preserve patients' intimacy (seven of eleven statements), and the behaviors to preserve patients' intimacy (also seven out of eleven statements).

As for the objects to preserve patients' intimacy, students emphasized the need to use screens during data collection: [...] maintaining patients' privacy is very important, for example, using screens to maintain this privacy (EE4).Concerning the behavior required to preserve the intimacy of patients, the statements refer to actions performed during data collection with the purpose of preserving the intimacy/privacy of patients: I think that also speaking softly with patients, you know... speaking loudly, whether you want it or not, exposes them to the other people around, in the nursing wards (EE5). [...] due to it being a collective room, I think that, during the performance of examinations or any other procedure, the others in the room should be asked to leave... (EE8).

Category 2. Respect for patients' autonomy

This analytical category was constituted by the statements of 12 of the 14 participants in this study, and by two subcategories of analysis: information required from patients (ten of 12 statements), and the right to free choice (six out of 12 statements). As for the information required from patients, prior to data collection, students stressed the need to inform patients before and during nursing care in order to guarantee their autonomy, as per the statement below [...] information must be provided to patients in relation to the treatment, explaining so that they really choose whether or not they want to participate in the procedure..., to be provided with very precise information in relation to this (EE2). The study participants also emphasized the need to ensure the patients' right to free choice in relation to refusing to participate in the data collection process. It is noteworthy that patients will only be able to make informed choices when they are well informed about the process. Firstly, we have to ask if patients accept to participate in this data collection process, identify ourselves and... show our objectives... (EE3).

Category 3. Experiences and feelings of students during data collection

In this category, students reported their experiences during the nursing practice, exposing awkward situations and feelings experienced while approaching the patients. This category was composed of 10 statements by the study participants, subdivided into two analytical subcategories: awkwardness (eight statements in the category) and feelings of discomfort, shame and powerlessness (six statements in the category). In relation to awkwardness, the statements suggest situations of awkwardness on the part of the students: Like, there are questions there such as the sexuality and income issues that I think are... a little difficult, not like that, I do not know if they are difficult, but I think they are awkward, both to professionals and patients...(EE6). The students also experienced feelings of discomfort, shame and powerlessness during data collection: There was an occasion during data collection [...] questioning about the patient's sexuality, involving an elderly patient... Like, I felt uncomfortable asking it, and the teacher sort of forced me to ask [...] (EE1).

Category 4. Training strategies related to the nursing process during the undergraduate program

In this category, the students' statements suggest strategies to improve the quality of training concerning the first stage of the nursing process. Statements of 11 of the 14 participants in the study constituted this category and were organized into two subcategories of analysis: the preparation of students for data collection (11 statements in the category) and the relationship between teachers and students (consisting of one statement in the category).

In relation to the preparation of students for data collection, the participants' statements indicate the need for teachers to previously demonstrate how data collection with patients is performed, which would better prepare students to approach patients, besides addressing theoretical concepts relating to data collection based on ethical principles during training and in the relationship student-patient: For me, in practice, one thing that makes a lot easier is when I see the teacher performing data collection and physical examination. Then, we accurately see how it is done... Yes, the way to approach, how you should approach. Then, I think it makes it a lot easier (EE7). [...] to implement curricular contents that contemplate the issue of clinical history and physical examination [...] how to approach patients... (EE12). Concerning the relationship between teachers and students, the need for teachers to use alternative ways of correcting students was highlighted, so as not to embarrass them in front of patients: [...] we could first have an agreement, here at the university [...] in situations where we are incorrectly performing the physical examination, maybe start singing, talking [...] (EE3).

DISCUSSION

It was observed in this study that, from the students' point of view, the exposure of patients during clinical data collection is one of the factors that cause feelings of awkwardness and discomfort, both for patients and students. This finding confirms the study, which points out feelings of shame, discomfort, annoyance, lack of privacy, even humiliation. Patients have already mentioned these, underlining the need to also understand how students experience these situations, by intervening and making them as less awkward as possible, both for patients and students.⁹ It is known that hospitalization changes the routine and habits of patients, as they are faced with an unusual environment, subject to pre-established rules and surrounded by strangers.¹⁰ Therefore, the need for the nursing team to take the necessary measures to maintain patient privacy is reinforced.

The invasion of privacy, whether territorial or personal, offends people. Ethical and legal issues should be taken into consideration in the nursing process, not only as a way of protecting patients, but also to guide professionals on how to proceed during the performance of the nursing process stages.¹¹ Situations like examining patients and touching them can be followed by objection and shyness on the part of students and patients, since they are considered strangers to each other.¹² In this study, students listed privacy as being related either to the physical body, emphasizing the importance of using 'screens', or to psychosocial issues, highlighting the need to speak softly and ask questions in a private environment, requiring any support people to leave. Thus, the environment is pointed out as an important factor which, if not controlled, can increase the chances of excessive exposure of patients, leading to feelings of awkwardness and invasion of privacy. This finding reinforces the literature data, in which the environment where data collection is performed is considered important to the development of bonding between patients and students. It is necessary that both parties feel safe during this time.¹³

Autonomy relates to the ability of patients to make informed choices, without having their dignity violated, being required that professionals respect their values, beliefs and wishes.¹⁴ In this study, students emphasized that obtaining the consent of patients to perform the first stage of the nursing process is essential. Patients need to be previously informed and explained about the objectives of the interview and physical examination, and should be free to refuse participating in this process, as well as to withdraw their consent at any time. It is noteworthy that informing patients prior to data collection contributes to reduce students and also patients' anxiety, who see themselves as objects of intervention. The performance of the interview and physical examination is essential to identify the health needs and the nursing problems requiring intervention.

However, touching patients can be followed by feelings of apprehension and insecurity. In relation to students, the fear of touching patients, of making them feel pain or of proceeding incorrectly may complicate this relationship. The moment to undress patients is, for many, the most awkward one. The looks attracted by the nursing student, the fear of being corrected by the teacher in front of the patient, and the lack of patients' trust in the student are some of the factors that can explain these difficulties. The word awkwardness can be defined as a condition or emotional experience caused by the possibility of evaluation by another person on a certain occasion. Such experience can be expressed by behaviors of anxiety, irritability and reduction of eye contact.¹⁵ In the present study, students pointed out inquiries about the healthcare needs/ clinical problems related to patients' sexuality as the main source of awkwardness. In this sense, the nursing process training should be based on ethical care related to autonomy, in which patients are previously informed about the kind of questions that will be addressed during data collection and about their freedom to refuse responding if they do not wish to. They also need to be informed about the confidentiality of the data collected. The awkwardness and the difficulty in dealing with questions involving the participants' sexuality, even for more advanced students, is a concern because it shows the need to better address this issue in the undergraduate course.¹²

Teachers play a crucial role in the education of nursing students, instructing and assisting them with decision-making and the development of skills. It should be taken into consideration that preparing a new nursing professional is a complex task, given that the practical field requires that skills and abilities are performed in real time, which can compromise the care delivered, given that students are not always prepared for this.¹⁶ In the present study, the attitude of teachers also have to be pointed out as a factor that can cause students to feel awkward during data collection, based on which it can be concluded that the pedagogical practice is related with ethical issues. The teacher supervising the practicum should provide a safe learning environment, in which students and patients do not feel exposed to awkward situations. The manner in which teachers deal with students and guide the activities in the practical field is crucial to ensure the quality of the training process. If teachers adopt an authoritarian and inflexible position when dealing with students, this can pose a threat and negatively affect the performance of procedures. A study indicates that a number of teachers do not know how to deal with students and do not give them confidence/security, causing them to suffer during the practicum.¹⁷

A study¹⁸ showed that some factors can make training about the nursing process easier or more difficult. Among the difficulties, the fact that the educational methods are not adopted in professional practice, the teachers' lack of trust in the methods used and the lack of interaction between nurse educators and clinicians were highlighted. Potential facilitators include teachers' renewed belief in the method, a view that is shared by students, who believe this to be the most appropriate way for the profession, besides providing them with a global and individualized view of the patients. It could be noted, from the statements of the students participating in the study, that the training process becomes easier when teachers perform a demonstration of the data collection process and the physical examination in the practical field, which eases the anxiety of students and helps with knowledge acquisition. The importance of student preparation prior to the application of the data collection instrument and to the physical examination was also highlighted. In this sense, teachers, as facilitators of the training process, will be able to review the instrument with students and perform practical laboratory activities that contribute to the memorization of the interview and the physical examination techniques. The ethical and behavioral issues related to care practice can also be discussed prior to the field activities.

Based on this study, it can be concluded that nursing students are concerned about the ethical approach of patients and the preservation of their rights, as well as that the difficulties faced in training practice regarding the clinical history may cause feelings of awkwardness among students and patients. Therefore, the importance of adopting more effective pedagogical practices is emphasized, which consider theoretical and technical, behavioral and ethical aspects in the approach of the clinical history. Such adoption is necessary, considering that the identified bottlenecks may negatively affect the nursing care delivered to patients, given that students show that they are not yet prepared to experience this process. Therefore, it is recommended that contents about how to approach the patients during the clinical history stage of the nursing process are shown to students before the start of the practicum and also after its start, because only then will the difficulties be expressed, minimized and overcome.

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