Introduction

This study refers to the feelings before death, experienced by nurses in their daily work, analyzed from the Dejourian perspective. Dejours studied the impact of work organization in relation to workers' mental health,¹⁾ Psychopathology of Work was build up through his ideas and research. However, from the understanding that people do not necessarily feel unbalanced before certain environmental conditions, Dejours proposes changing the Psychopathology of Work denomination to Psychodynamics of Work, because it seemed more appropriate for not having identified a causal relationship between certain psychological disorders and ways of laboral organization.² In the context of psychodynamics analysis the human being, the material world and the psychic are analyzed, as there is relation to these with the work activities that have great importance, because through it, human being relates and coexists with the environment and seeks to meet their needs, that is, seeks pleasure and avoids suffering.³

The practice of nursing is complex, which held in environments and organizations that promote occupational hazards and may be generator of suffering and pleasure. In this profession, workers face fears, conflicts, tensions, power struggle, anxiety, and living with life and death, among other factors inherent in their daily life.⁴ In this sense, the nursing team is exposed to physical and mental overload during the demands of their work, such as emergency situations, with multiple tasks. This situation is enhanced with extended working hours, duplicated and often with strenuous shifts.⁵ Suffering represents the worker's struggle to not get sick; it is a space between health and disease. Pleasure results from psychic discharge of energy, possible due to the freedom the employee has to decrease psychological stress.⁶

The physical well-being and pleasure constitute on the freedom highlighted on the desire of each one of them on the organization of their life and, consequently, their work, freedom over the work content, division of tasks and the relationship with themselves and with the others.⁴ Working should not be a misfortune, but should give people conditions to develop their potential and self-realization.⁵ In this sense, pleasure and suffering are not mutually exclusive, as in the same environment and work organization both positive and negative structural elements can be found in workers.⁶ In nursing, workers experience this duality in situations of pleasure when caring of the other, providing their healing; but in the course of work activities they face suffering, pain and death.

A study performed in Sweden aimed to describe the nurses’ experience in relation to their work day and showed that the work routine of these professionals was balanced between moments of tension/suffering and other stimulation/pleasure moments. Situations causing suffering were described as feeling insufficient, having to meet many demands, not providing security and having little contact with patients. Stimulant/pleasurable situations included having the situation under control, enriching meetings with patients and healthcare professionals and necessary skills to be independent.⁷ In Canada, a study investigated the relationship between working conditions and illness-absenteeism related to nurses and nursing assistants. It became evident that depression was an important determinant of absenteeism for both categories of workers. However, the workload and the lack of respect was an absenteeism significant determinant for nursing assistants, but not for nurses. Those people working in medical offices, private education and clinics, educational institutions and governments and associations had less absenteeism than those who worked in hospitals.⁸ It is important to improve working conditions, which would possibly decrease the absenteeism of these workers. Therefore, the nursing work shifts from pleasant to unpleasantness moments.

In addition, in this profession, even though it is understood that being born, growing up, getting old and dying are natural processes, nursing workers often have difficulty in dealing with death, which can cause problems when they assist patients without therapeutic possibilities in aggravated illnesses situation. Also, their biologicist training is highly focused on health-disease-healing. The finding of these professionals about the finitude of life has generated emotional distress and can even refer to the Burnout syndrome.⁹ The relationship between work and suffering involves a form of moral courage that could be a feature of caring.¹⁰

Suffering at work can also have social recognition as genesis. A socially recognized work allows efforts, anxieties, doubts, disappointments and discouragements to have a meaning. However, nursing presents the perceived lack of recognition, autonomy and professional power, issues that are usually maintained by the inadequate labor organization.¹¹ Therefore, the aim of this study was to analyze the feelings of nurses faced with death, according to the Dejourian psychodynamics.

Methods

This is a qualitative, exploratory study, because it was considered that the human being is the main object of the research, and this method allows searching and considering the existing subjective aspects in the study. Qualitative research has unique concerns, including the fact that the data collected, for the most part, is descriptive, including the interpretation of open questionnaires.¹² The research was conducted in 2010, in a public university, with stricto sensu graduate studies in Nursing. The sample was chosen due to convenience; participants consisted of students with Nurse training, enrolled in a compulsory subject to start graduate studies; 11 nurses participated in the study after freely accepting to be part of the research, after being introduced and reading the free and clarified term, highlighting the objectives and justification of the research in the classroom, with the consent of the teachers responsible for discipline.

Ethical procedures were obeyed and the research proposal was approved by the Research Ethics Committee of the university, protocol 1253/2010, in accordance with Resolution 466/2012. The subjects were contacted by researchers and if they agreed to participate they signed the Free and Clarified Consent Term. For data collection a self-administered instrument was used, developed by the authors, identifying issues (gender, civil status, ethnicity, religion, if the student was studying master's or doctorate, time in the profession) and open questions on the subject of study: 1) Have you ever experienced death situations in your professional life? It was used to identify if the participant had already faced death situations in the workplace; 2) What were your feelings regarding this? It was used to understand the feelings brought by this confrontation, with death situation at work.

Participants who had had explanation of the researchers in the classroom about the survey were approached and invited to participate in the study during discipline intervals and it was at these moments that they received the data collection instrument, in a sealed envelope. Later, day and time were scheduled for collection of the completed instruments, respecting filling time of each candidate, and the instruments were given back enveloped and without identifying the participants. There was saturation of data because it was possible to observe extremely converging, similar and equal responses in most of them. Data analysis, its interpretation and discussion occurred considering the theoretical framework of the Psychodynamics of Work, especially the suffering and pleasure, highlighting these feelings.¹³ The participants responses are presented with the consonant P (participant), then numbering from 1 to 11, according to the return of questionnaires. After completed and analyzed research, participants were informed that the data would be published so that the scientific populations become aware of the importance of the subject in question.

Results

Of the 11 participating nurses, nine were female, eight declared being single, nine were white, seven were catholic, eight were enrolled in master's, and had a professional practice time in the nursing profession ranging from 2-16 years. The analysis of responses allowed us to find driving and potentiate factors of pleasure and suffering feelings.

Discussion

In this investigation the nurses had feelings of pleasure and also suffering before death of patients under their responsibility, which corroborates findings in other studies.^4,5 The dynamics of work can lead to both pleasure and suffering because in the same environment and work organization there are positive and negative structural elements.⁷ However, some institutions ignore the suffering of their employees and remain away from reality, in addition to capitalize on the work of their employees, who start to present high levels of physical and emotional distress. Therefore, workers have to deal with the responsibility of spending not too much, serving well and bringing profits for employers, or ultimately, when the institution has not profit, at least economic.^4,5-14,15

Pleasure was identified when they reported that their duty had been fulfilled, when they have done the possible in caring for the sick, when they felt comfort and relief with death, because the patient was in an irreversible situation and the suffering was over. Pleasure originates from the realization of human potential, which provides the feeling of self-confidence, to be important, competent and kind, capable of handling situations as they arise, and using their own capabilities and be free to express what they feel. It requires self-satisfaction, productive relationships and satisfactory with others, and a successful relationship with society.¹⁶ However, if the employee cannot enjoy the benefits of recognition of their work, they do not reach their meaning, which can be deconstructive, capable of destabilizing their identity and personality, which may cause them mental disorder.³

Duplicity of feelings was identified, with which nurses can come across, feeling guilty if they feel relieved with the death of the patient. Suffering is the space of struggle that covers the well-being and mental disorder.¹⁷ It is a mediator subjective experience between mental disorder and psychic comfort.¹³ Some participants of the study also showed in their reports sadness, frustration, helplessness in the face of death, difficulties of dealing with grief and feelings of inadequacy. They experienced their own pressure and those who were around, as if they could control, avoid and prevent death; they have experienced suffering when they believed not having done enough to save the patient's life.

Suffering is inevitable to nurses who deal with the prospect of death and the human finitude.¹⁸ However, the Psychodynamics of Work tries to understand how workers can maintain mental balance, even when subjected to destabilizing conditions,¹⁹ which seems to have happened to the study participants. It was also found the presence of defense mechanisms to produce better coping of suffering at work, when patients die.

In suffering, the defense mechanisms are used, such as denial or trivialization of what is happening in order to minimize the odds and ensure their own survival,¹⁰ which is not represented as something negative, and also meaning a way the worker creates defensive ways to deal with the work organization.¹⁴

A previous study showed that one of the individual strategies used by intensive care nurses was finding strength in religiosity,¹⁸ corroborating the findings of this study. Such strategies are essential for protection against suffering; however, when used collectively they strengthen the team as a whole.¹⁸ In the context of Psychodynamics of Work, the work is not only seen in its negative context, but may be structural, and suffering can be directed towards pleasure and health,²⁰ even in death situations. Unfortunately, training in the health professions still tends to emphasize the technician training at the expense of humanistic values. The constant denial of the difficulties places the health team in a state of permanent stress, with no healthy way of expression, predisposing it to illness. However, acceptance and expression of feelings and emotions are part of the process of personal development also influencing the professional development.²¹ Seen from this perspective care is a practice that values the human being in its uniqueness.

However, the frustration of nursing workers before the patient's death was highlighted by a previous study, since their training is built up and focused to save lives. When this does not happen and the patient dies, the professionals see themselves unprepared and associate their own death to the patient, as well as to their loved ones. Thus, they experience the process of dying as loss, suffering, distress, requiring psychological counseling, which should be accessible to them.²²

It was concluded that nurses participating in this study, before the death of their patients, showed driving and improving factors of both pleasure and suffering feelings. Those relating to pleasure were identified as the feeling of duty fulfilled, comfort and relief; those relations to suffering were represented by sadness, frustration, difficulty with grief, impotence and incapacity. There were also defense mechanisms to avoid suffering, namely: praying after death and ask God to comfort the family; believing that death is a relief to the person and not thinking about the suffering and death, taking refuge in hard work.

If the employee presents biologicist training, dedicated exclusively to save and heal and, despite the efforts, the patients dies, he/she will have difficulties to address and overcome this situation. However, regardless of the suffering and defense mechanisms to face the coping feeling, nurses found pleasure in their work, even in situations of death of their patients. Nevertheless, it is necessary to include the issue of death and dying and human finitude in academic training, so there is an approximation of the nurse in this process, given the fundamental importance of understanding the finiteness of life. It is suggested to carry out new studies that address this complex subject in addition to create welcoming and reflecting strategies, and give them opportunities to talk about their feelings experienced in those moments, with focus groups to discuss these feelings to those professionals who live with the process of death and dying daily.

As constraints there were no many participants, making it unlikely to generalize the data, but this research is very important since it reports the pleasure and suffering experienced by professional Nurses in their harsh everyday and also reports the importance of checking the psychodynamics of work of this professional.