The meaning of care for operating room nursing

Objective: to understand the meaning of care for nursing technicians who work in the Surgical Center of a general hospital in the western border of Rio Grande do Sul/Brazil. Methods: this is a qualitative research, with an exploratory and descriptive approach. The technique used for data collection was a semi-structured interview and notes from the field diary were available for support. The respondents were eight nursing technicians of the Surgical Center. Results: it can be emphasized that participants value psychological, social and affective aspects of patients and their families, also expressing a holistic view in regards to caring for themselves or others. Conclusion: in the referred unit, care is an activity involving multiple aspects, patients, families and staff. The meanings valued by professionals reveal detachment from technical aspects to value psychological, social and emotional aspects of care. Descriptors: Nursing Care; Surgery Department, Hospital; Nursing, Team.


Introduction
A Surgical Center is characterized as a service that provides elements for the surgical practices, prioritizing quality customer support.The nursing and health teams are responsible for perioperative care to the client, from preoperative reception until recovery from anesthesia in the postoperative period (1) .
For nursing, care in this unit was created to meet the needs of clinical work, and has a dynamic of nursing care centered on the objectivity of the actions with emphasis on the intervention of a technical nature aimed at the recovery of clients/patients (2) .In view of these characteristics, psychosocial interaction in care is seen as restricted at various times.
In hospitals, the organizational structure often presents quantitatively reduced nursing professionals, inadequate compared to the demand imposed by the process of holistic and humanized care.This aspect can result in prioritizing some care; instrumental and mechanistic actions that, when added to the scarcity of material resources sometimes affect the dialogue, exchange of information and experience, and the development of supportive work, thereby weakening relations established between professionals, patients and families (2) .
It is essential to understand care as a moment of construction through the encounter between subjects; in this case, the nursing technicians who work in the Surgical Center and patients/families.On the other hand, although developed care does not always build face to face, there are a number of actions taken by the team of nursing technicians featuring their concern for them, and with the implementation of care to ensure the comfort and well-being of patients (2) .Nursing staff contact with the client helps to explain the surgical procedure and the recovery process, it minimizes fears, insecurities and apprehensions, meaning that it provides an established link through dialogic interaction (3)(4) .
Care is a subjective action universally understood because it is present in all cultures.However, it is also defined in each in diverse ways as it reflects the values and the specific socio-cultural practices of a particular social group and does not merely implement procedures and techniques or the trade as a profession.
Based on these assumptions and in order to identify the care meanings for these nursing professionals, the following research question arises: "What is the meaning of care for nursing technicians who work in the surgical room?"The intent of this research concerning care in the Surgical Center has emerged due to the observation of practices and procedures adopted by nursing technicians when we performed the surgical nursing traineeship in the Nursing Graduation Course.Monitoring of the routine/work process allowed us to perceive the existence of an assistentialist dynamic, focused on the implementation of techniques and procedures.
In this context, this study aimed to know the meaning of care for nursing technicians who work in the Surgical Center of a general hospital in the western border of Rio Grande do Sul/Brazil.

Method
A qualitative study of an exploratory and descriptive approach was carried out from March to August 2013 in the Surgical Center unit of a general hospital.This service has four operating rooms, postanesthesia recovery room with seven beds and a material and sterilization center, with daily demand of approximately 15 elective, urgent or emergency procedures per day.The nursing team is composed of 15 nursing technicians and a head nurse technician.Nursing technicians are spread over work shifts (morning, afternoon, evening I and II) according to the needs of the institution.All nursing technicians were invited to participate in the study according to the following inclusion criteria: having at least one year of experience in the Surgical Center Unit, and with the exclusion criteria being: participants who worked in the Material and Sterilization Center and those who were on vacation or health or maternity leave during the period of data collection.
Data collection gathered by the researcher during the period from March to May 2013 was done through a semi-structured interview script containing socio-demographic data (age, gender, religion) and work background information (training time, work experience as a nursing technician in the institution and on the unit), and ten open subjective questions, all recorded by a digital recorder.Also, field reports were used with the intention of registering comments on informal dialogues, behaviors, gestures, and expressions which related to the subject of research.
During the team's meeting the research was presented along with objective of the study and the staff was invited to participate in the research.Interviews were held in a private room in the Surgical Center, according to participant availability.Information was obtained after participants consent and signing of the Free and Informed Consent Terms.This study was approved by the Ethics Committee on Human Research of the Universidade Regional Integrada do Alto Uruguai e das Missões, under Presentation Certificate for Ethics Assessment 12371513.2.0000.5353,opinion number 219.297.
Data was qualitatively analyzed by Contents Analysis (5) , comprised by a corpus analysis of the following steps of organization: pre-analysis by a brief reading of empirical data; exploration of the material with encoding of raw data in order to reach the core of understanding of the texts; category classification (determined by phrases, words and discourses of the characteristics that elucidate the meaning of care in operating rooms); and finally, interpretation of results by the saturation of the data when it was possible to approach the theoretical references to the answers/ testimonies obtained from participants.
In this study, the nursing technician is understood as a caregiver in their daily practice, developing actions and relationships of care and affection with patients and families, and they were identified by the letter S (subject) followed by an ordinal number corresponding to the order of the interview, e.g., S1.

Results
As for the characterization of participants, two were males and six were females, between 26 and 65 years of age, five Roman Catholics and three Evangelican.Regarding the length of service in nursing, four had worked for over ten years in the institution.Regarding work experience in the Surgical Center, three had worked for over ten years in this service and the other five for lesser time.
Daily activities developed by nursing technicians in the Surgical Center followed the process based on job rotation where care environments are in accordance to monthly scale of the service, for example, all technicians sometimes worked as support for surgical room, at other times in the Post-Anesthetic Care Unit.This work process is adopted in the hospital to justify the deficit number of trained nursing technicians for the service.
Results presented below were obtained from a general analytical category entitled "Psychosocial-affective Patient/Family Dimension and the Technical Nursing Team," which originated the three subcategories as shown below.

Subcategory 1: technical nursing team in the dimension of family care
In this subcategory, occurrences and factors that indicate the importance that the family has on the care of the post-surgery period were evidenced, with emphasis on the special care that nursing technicians have with these characters.Such care is based on dialogue, receptivity/welcoming, respect, answering questions and information.
In this sense, nursing staff of the Surgical Center value the family's presence in the waiting room, as outlined in the speech fragments: we (the team) know what happens here, but they (the family) do not.They stay outside waiting.So, just like the patients, they are also concerned because hours go by in here....It is important to get outside and explain to them what will be done (S1).We must listen to them and take care of them (the family members), if they are in need of aid, or feeling down; … thinking of the sick person, imagining their condition(S8).Care extends from the psychological part all the way to the family; … giving explanations to family members who are awaiting (S1).
Some testimonies reveal care as meaning closer ties with the family, the importance of welcoming, bringing the family closer to the health-disease process of the patient.The approach between staff and family stirs feelings of appreciation, respect, unity, and humanity in the family, as well as gives them the opportunity to be heard, to have a voice in the treatment process of their family member.
In this context, technicians seize humanization concepts of care and incorporate them into their daily practices, allowing them to distance themselves from the technical model, a traditional characteristic of this unit.It is noticeable that the care is consolidating not only among patients, but also among the family unit.Under this approach, it is assumed that all those involved in the health/disease process are cared for.
Minimizing the anxiety of waiting through information, words of comfort, a simple gesture or facial expression becomes essential to the practice of nursing staff in any scenario, as shown by these lines: I always try to give information to them (the family), I go there (to the waiting room), I speak as if they are the patients, they ask if the patient is awake, if they are talking; …they (family members) calm down.I always try to talk to them... (S6).
From this perspective, the family is consolidated as an integral part of the care practice, valuing anxieties, doubts and expectations in order to develop consistent and quality care, starting from the preoperative to the postoperative period, with the support team, and in this particular case, the nursing technicians.

Subcategory 2: nursing technicians and patient care
This subcategory points to the meaning described by Surgical Center nursing technicians in the care of patients who are in the perioperative period and the immediate postoperative period.The concern of the team is to minimize most of the questions, concerns and anxieties brought up by patients during the surgical procedure submission period, through communication and explanation of procedures, in order to calm them and give them more security.
Knowledge, values, and skills that foster the potential of persons undergoing surgical procedures were demonstrated in the testimonies.The following statements express what it means for these workers to care for the patient: …explaining the procedures that will be done, trying to keep them calm, ...working with information ... giving it your best, bringing new things ... giving them affection, understanding, talking to the patient... (S3); ... I always try to ask and guide the patients so they don't get lost and feel too nervous, as many are (S1); I always try to be as honest as possible, never lying, always trying to be clear with them, telling the truth, trying to calm them down, talking a lot (S6); ... They are human beings, our goal is to treat them well ... They feel good and so do we (S8).
The answers value assistance to the patient undergoing surgery, and intrinsically clarify how important it is to humanize patient care, using holistic assistance as a care instrument, in view of the fragile situation subjects are facing, valuing the psychological approach of the patient, giving them directions.Identifying the concerns, commitment and the passion with which the nursing technicians provide nursing care in the Surgical Center; caring in talking, by showing affection, paying attention to the patient/ family, and seeing them as human beings.
This subcategory reveals the feelings that are involved in the relationship between the technician and the patient.It is from the psycho-socio-affective dimension of the performers involved that forms the link of the care provided by the team of nursing technicians who work in the Surgical Center.

Subcategory 3: Health and care of surgical center workers
Work is an inter-subjective phenomenon that occurs when individuals establish a direct relationship with their social, organizational and technical contexts of their work.The meaning of work transcends socioeconomic and cultural composition, needs, values and the subjectivity of workers.
Promoting discussion and reflection about the health of nursing professionals is key to understanding the relationship between working in health care and its implications on quality of life, revealed by the reflections of the care provided to clients.Therefore, 4 issues related to the health of the nursing technician worker of the Surgical Center emerged, with respect to their own care, self-appreciation and care for others (the working team): ...providing comprehensive and qualified health assistance to patients, but also us taking care of ourselves (S2); We worry too much sometimes (about our colleagues), we try to help them (S7); ... I also have to take care of myself, take care of ourselves, because just like I might be transferring something to the patient, he (the patient) may also be transferring something to me... the most emphasized thing in the course (Nursing Technician Course) was the use of gloves, regardless of who the person is (S2).
The workers' interviews show that care goes beyond the health-illness process of customers/ patients.They point out that the professional must be aware of self-care and recognize that they deserve to take care and be cared for, either in their work context or in their social and family environment.Respondents referred to the importance of workers being co-responsible regarding Personal Protective Equipment use, thus reducing biological risks, in addition to care among staff.
Nursing workers are exposed to several risks that may affect their physical and moral integrity.The risk factors are characteristics or conditions whose presence is associated with an increased likelihood that damage will occur, despite considering if the factor in question is or is not the cause of the damage.
Embedded in this scenario is the team of nursing technicians.The Surgical Center has its own characteristics, consisting of a closed unit with strict aseptic techniques.These particularities of the service require worker`s attention, responsibility and organization, as they play important roles in the acquisition, handling and maintenance of specific materials and equipment for patient care in the pre-, intra-and post-operative periods.
Given the complexity of care in this environment, it is worth noting the importance of nursing staff identifying aggravations to their health produced by these conditions and work organization.In order to minimize the harmful effects of this work, it is necessary for workers to be aware to take care of themselves, noting that the workers' healthcare goes beyond the occupational hazards, also reflecting on psychosocial aspects involved in the work which were not mentioned by respondents.The main factors considered in "self-care" are related to biological and ergonomic risks.Considering this, describing self-care in the biological risk perspective: I take care of myself!With the use of personal protective equipment, gloves, goggles, apron.
Depending on the type of surgery, if it is infected, contaminated, ...each surgery encompasses specific protective equipment (S1); Self-care is much more complicated ...when I started working we bathed babies (newborns), we took the babies (from normal delivery or c-section) and bathed them without gloves, the babies were all bloody, gloves were not used for hygiene, for dressings (S5); .. being careful with the sharp piercing objects in the operating room, always wearing gloves for prevention ... Puncturing the patient with gloves, we know it's difficult (S3); ... being careful with colleagues, especially when it comes to sharp piercing equipment, because sometimes in the middle of the chaos, the worst can happen!I`ve pierced myself once (S5).
It is possible to highlight the evolution of care and working conditions in this service from the speeches.Some subjects expressed their care manner, while others mentioned the development of work processes over the years, and the importance and appreciation of the improvement of procedures, thus implying that obtaining achieved results occurs in relation to improvements in care provided.In this perspective, the workers reinforce their concerns of biological risk, in relation to self-care and caring for others.

Discussion
Care relationships involve attributes such as love, awareness, care, solidarity and ethics, allowing mutual growth between care and caregiver.In this sense, consciousness is considered as a result of existing knowledge into action, enabling change and transformation from systematized nursing knowledge (6) .In this manner, it can be emphasized that the care needs consciousness as knowledge, but should also be founded on affection, so sensitive care can be provided based on attention, listening, welcoming and affection.
The perioperative period is surrounded by feelings such as fear of the unknown and fear of death, among others.Thus, the subjectivity of the surgical experience for patient/family requires qualified, safe and humanized nursing care based on actions, behaviors and attitudes.Humanized care in nursing directs to the affection and emotional well-being of the other, providing security, confidence, communication and displaying affection (7)(8) .Care encompasses acts, behaviors and attitudes.Acts performed in the care may vary according to the conditions in which it occurs, the situation and the type of relationship established.
In this context of nursing care, the family has a reference role in the care process for the patient and also for the health team.It also must be understood that the family assumes the condition of mutual suffering of the patient and, in a sense, the condition of the patient is shared by the family that are there, supporting and sharing these moments (1) .
By keeping the family informed about conditions under which the patient undergoing surgery is experiencing, the Surgical Center nursing staff reinforces the thought of humanized and comprehensive care (9) .Families in the waiting room waiting for information should be seen by the nursing team as a unit of care, as well as the patient.It is essential to observe this manner in order to enhance the nursing work, clarifying their doubts, watching their reactions, behaviors, and trying to understand their feelings and emotions (10) .For this reason, care professionals need to be aware and conscious that performing a task or procedure means relating and interacting with each other, and therefore experiencing the care experience.They should be able to perceive and understand the characteristics and uniqueness of each person carefully, respecting their values and beliefs, as well as considering their own responsibility in this act (11) .
This process characterized by communicating with each other (patient/family), and is considered an effective method to minimize fears that can destabilize those involved.Studies have shown the efficiency of this sensitive care in a complex hospital; that explaining about surgical procedures and recovery can reduce fears, insecurities and apprehensions, especially when there is availability for interactive dialogue (3)(4) .
Another important issue in this care hospital is expressed in risk exposure, as mentioned in the interviews.Nursing professionals in hospital organizations are generally exposed to unhealthy work environments with risk of diseases (12) , characterizing the highest percentage of the accident group with biological material because they are exposed longer and are in direct contact with patients during care, due to their routines (13)(14) .
Personal protective equipment is considered a facilitator in accident prevention.However, professional resistance to using them due to the lack of adherence and inappropriate use are usually the main barriers to accident prevention.Protective equipment such as gloves, goggles, mask, closed shoes and aprons are essential measures to avoid or reduce the risk of exposure.However, even with the availability of such equipment in the workplace, professionals often choose to not use them due to factors such as discomfort, annoyance, carelessness, forgetfulness, lack of habit, inadequate equipment, insufficient quantity or not using them because they are considered unnecessary (15)(16) .
It is noteworthy to mention that professional practices reveal that the three main actors directly or indirectly involved in the surgical center routine are patients, family and the nursing staff.This highlights the care involved in respect to each other, self-care and caring for others surrounding them.

Final Considerations
Results presented in the study show that for Nursing Technicians, care in the Surgical Center is anchored in a universe of meanings, coming from the psychological, social and emotional recovery of patients and families, to a holistic view of these same aspects, but also related to self-care and caring for others.Results highlight the fact that all participants, when answering research questions, held to factors related to respecting each other and their singularities, concerned in providing effective comprehensive nursing care.
This study contributes to demystify the Surgical Center as a closed and highly technological unit that nursing provides merely technical care through the implementation of procedures and techniques.It reveals the participant`s sensitivity to present testimonies that value dialogue, respect, affection, reciprocity, care, ethics and the commitment of these professionals to patients and their families.
As a possible limitation, the rotation of nursing technicians inside the unit can be pointed out, as they sometimes worked in the operating room and other times in the recovery room.It is understood that the actions in the operating room mostly involve specifically technical behaviors, while in the recovery room the actions involve a broader socio-affective and effective attention.
It is believed that new research in the future may be carried out in this scenario, brought from the need to know the perception of patients and families about the care provided by Surgical Center nursing technicians.This would clarify the meaning of care described by the professionals in this research to be perceived in the same way by their patients/clients.

Collaborations
Salbego C developed the field of research and participated in all stages of production of the article.Dornelles CS and Greco PBT participated in directing research and the final production of the article to be published.Pradebon VM and Alberti GF participated in the final production of the text and critical review.