Feelings experienced by the nursing team at a burns treatment center

Objective: Unveiling the feelings experienced by the nursing staff in care delivery to burns patients. Methods: Qualitative. Results: Seven categories: Work harder than professionally developed, putting yourself in the place of the patient and the family, powerlessness towards the situation and compassion and pity in the child's care, suffering due to parents' neglect in view of the child's vulnerability, suffering in care delivery to suicide patients and feeling of happiness in caring for the patient and seeing their recovery. Conclusion: There are experiences of feelings of pleasure and pain and, therefore, strategies need to be implemented by the managers and the nursing team for health promotion, disease prevention and health recovery.


INTRODUCTION
Health workers are subject to the daily experience of extreme situations that can cause stress in care delivery to critical and high-complexity patients, which is the case for most patients hospitalized at Intensive Care Units and Burns Treatment Centers (BTC).
In general, hospitalization due to burns happens rapid and unpredictably, as an urgency that requires immediate help.Hence, healthy individuals suddenly move to a complete or partial disequilibrium and face the hospitalization, pain and commitment of their vital functions.That happens to patients and their relatives, who are confronted with unexpected and new situations 1 .
In care delivery to burns patients, the nursing team is confronted with a routine of great work, pain and suffering, depression, disturbed sleep pattern, impaired mobility, uncertainties due to the burns sequelae, among that many other factors, not just related to the patients, but also to their relatives.Therefore, nursing care to burns patients is considered extremely exhausting and capable of causing changes to the health of health workers, as they are responsible for direct care delivery to individuals, families and communities.These same workers, however, need to have their health needs attended to with a view to the physical, mental and emotional balance needed for the execution of their professional activities 2 .
Is is emphasized that nursing figures among the most stressful professions, due to the responsibility for the human beings' life and the proximity with patients and their relatives, in which suffering is almost always a reality, demanding great dedication in the development of their activities, increasing the possibility of health problems and the development of physical and mental illnesses 3 .
In view of these considerations, the researchers felt the need to develop this study, aimed at unveiling the feelings experienced in the nursing team in care delivery to burns patients at a BTC.
It is highlighted that the study is fundamentally relevant because of the incipient nature of studies on this theme, and can contribute for managers and professionals to plan health promotion actions, reduce problems and recover the health of these workers, with a view to a better quality of life.

METHOD
An exploratory and descriptive study with a qualitative approach was undertaken.This type of design was chosen as its main characteristic is to understand the universe of meanings, motives, aspirations, attitudes, beliefs and values, permitting the description of the experience of reality and phenomena that cannot be reduced to the operation of variables 4 .
This study involved the Nursing team from a BTC (nurses, technicians and auxiliary nurses) working morning, afternoon and night shifts at a university hospital in the North of the State of Paraná.The inclusion criterion used was: working at the unit for at least one year and male and female.The exclusion criterion was: being on holiday or leave.
To determine the number of participants, the data saturation criterion was used.Hence, the sample size was not define, that is, the interviews were held until the statements about the study phenomenon converged or were repeated, which was the case after 20 professionals 5 .
The data were collected through interviews, held in a private room at the workplace, between July and September 2012.To guarantee the quality and reliability of the data, the interviews, with a mean duration of 40 minutes, were audio-recorded with the participants' consent.To preserve the anonymity, the interviewees were identified with the letter E1, E2, E3 and so forth.A semistructured form was used in the interview and, to unveil the study objective, the following guiding question was used: Tell me what feelings you experience when you take care of patients with burns.It was emphasized that, at the moment of the interview, a questionnaire was also applied with questions for the interviewees' sociodemographic characterization (gender, age, marital status, religion, workload in hours, activity time at the BTC and time since graduation).
To analyze the results, thematic content analysis was used, with the following steps: reading, determination of the recording units and meanings, coding and classification: and the treatment and interpretation of the obtained results.Through floating reading, the registration units were marked, organizing them per themes.By means of approximations and distancing, the categories were constructed 4 .
The study development complied with the Brazilian and international ethical standards for research involving human beings and received approval from the Ethics Committee at Universidade Estadual de Londrina (UEL) under Nº 0166.0.268.00-09.

RESULTS
All 20 nursing team professionals (auxiliary nurse, technician and baccalaureate nurse) interviewed were female, over 30 years of age, married and Catholic.The hour load was 36 hours, more than two years of work at the BTC and more than three years since graduation.
The analysis of the testimonies led to the construction of seven thematic categories as presented next, with the interviewees' respective statements.
Category 1: The most difficult work the professional developed, the statements show that: The burned patient is the most difficult patient I have taken care of in my professional life, they are the most complex, honestly the most difficult in fact, they are difficult in all senses, I think there is no work more difficult than this (E1).

I have never worked in such a difficult place, it's the most difficult I have faced so far (E10).
Category 2: Putting oneself in the patients and families' place, the testimonies reveal that: I suffer together with the patients because I put myself in their place (13).

I try, but I am unable to and I am almost always putting myself in the patients, the family members' place and I end up feeling the same as them, that is, sadness, anger and rage (E15). I put myself in their place and I often feel what they are feeling and even what the family feels I end up feeling (E20).
Category 3: Feeling of powerlessness towards the situation.The interviewees expressed themselves as follows:

Our work is difficult because we never know to what point we will be able to help, to what point we will be able to intervene, we get kind of powerless (E4).
We experience the feeling of powerlessness towards many situations, that is, ranging from care to the dialogue with the family members (E5).

We live a feeling of powerlessness towards many situations and then I suffer (E6).
Category 4: Feeling of compassion and pain in taking care of the child, the statements reveal that: I get sad and feel great "pity" when I take care of children (E9).

I am very compassionate with the children, pity really, because they are hospitalized and do not even know how they ended up here (E12). I feel pity of all patients, but even more of the children, I feel compassion, great pity really (E14).
Category 5: Feeling of suffering due to patients' neglect in view of the child's vulnerability.The interviewees stated the following: I suffer a lot when I take care of children because they're here almost always due to the neglect of the person they were with and because they did not pay attention to the dangers surrounding them, it's neglect and lack of attention really (E7).
They're children who did not know about the consequences of their acts and who were victims of bad care, because the mother or responsible caregiver did not take care at home as they should, it seems that the parents do not pay attention and that revolts us and makes us suffer a lot because of this situation (E16).
When I see the children, the babies who do not even know what happened to them are victims of lack of attention by the mothers, the fathers or whoever was taking care, it's very sad.I honestly feel angry with the parents, or whoever was taking care because they don't take care and then it are the children who suffer (E19).
Category 6: Feeling of suffering in care for suicide patients, the statements identify that: I suffer a lot to take care of suicide patients because they wanted to die and did not manage and then I have to take care of who does not want to live and I was prepared to save lives and there is suffering because I am still not able to understand people who want to die before it is the time (E8).
It is difficult to take care of patients who tried to commit suicide by burning themselves with fire.These people tried to end their own life in such a cruel way and did not measure the consequences.I suffer a lot because I do not accept this behavior.I end up feeling anger and even suffer because I feel that angry (E17).I confess that I don't like to take care of people who tried to commit suicide because God gave life and they want to take it away and are not even able to, and then we have to take care of them, that's why I don't like to take care of people who tried to kill themselves (E18).
Category 7: Feeling of happiness in taking care of patients and seeing their recovery.The discourse indicates that:

It's a source of huge satisfaction, to take care of the patient, watch his recovery and when he is discharged and tells us: your care was really important, the attention you paid to me and I'll never forget you (E11).
A moment of great happiness, pleasure, satisfaction is when I deliver care to the patients, when I am able to relieve their physical and even mental pain, when I perceive that they are recovering, that they want to get discharged and see their family (E3).

I get very happy to relieve the patients' pain a bit, to stay at their bedside, give them kindness, understanding, lending
Feelings of workers at a burns center Martins JT, Bobroff MCC, Ribeiro RP, Soares MH, Robazzi MLCC, Marziale MHP a hand since they enter the hospital and it's good when we see the patient being discharged (E9).

DISCUSSION
The suffering causes physical and mental exhaustion in the health professionals and is directly related with the stressful situations of work, as these professionals deliver complex, repetitive care and deal with the pain and often with the death of burned patients.Due to these factors and when these workers perceive the impossibility to solve all of the patients' problems, frustrations and feelings of powerlessness emerge, causing mental exhaustion 6 .
In a study undertaken in Australia with nurses from a burns treatment unit, four categories of powerlessness were found: inappropriateness, apprehension, vulnerability and frustration 7 .The feeling of inappropriateness referred to the professional's feeling of powerlessness in taking care of the patient, due to the pain and because they are unable to do what they would like to grant the patient comfort; apprehension was related to the fear of what could happen to the patient after discharge, without professional team support; they found they were vulnerable because someone in their own family, or themselves could be the future patients, which they would not like, as they knew the real situation; and they felt great frustration in furthering the patient's independence in the slow recovery process 7 .
These feelings happen constantly in the daily life of the nursing team due to the confrontation with the patient's suffering and pain.These workers often put themselves in the patient's and the family members' place, also suffering because of this 8,9 .
Taking care of patients in critical conditions, whose clinical situations re constantly unstable, grants the professionals feelings of powerlessness and insecurity about care or decision making, factors that trigger exhaustion and stress and, consequently, cause suffering for the nursing team 5 .
In a study involving nursing professionals from a burns unit, it was observed that these professionals pity the patients, especially the children, which favors the stress, makes them vulnerable and causes difficulties to take care of these patients.In that context, delivering care to children is considered much more stressful than taking care of adults 10 .
In the abovementioned study, difficulties were revealed in the relationship between the nursing team and the family members of the child burn victims, as the professionals consider that the families were negligent or careless 10 .
It is known that children are vulnerable beings and, therefore, are more probable victims of unintentional injuries.Negligence, lack of care, lack of "malice" or incorrect supervision by the parents and/or the caregivers cooperate towards this type of accidents.In general, there is a lack of information about burns prevention in childhood at home 11,12 .
In that sense, educative actions should be a priority, mainly in Collective Health services, due to the clear costs of treatment and recovery, mainly when the patients are children.
Guilt was also the most important event cited in a study based on the premises of Symbolic Interactionism, involving parents of child burn victims attended at a tertiary hospital in Southern India.The parents were criticized and censured because they did not protect the children against the event that led to the burn and, thus, their own competency was questioned by themselves, other family members, strangers and health professionals.The blame the health professionals put on them was more devastating for the parents, as they did not expect this attitude from care professionals.The parents referred that these professionals were insensitive to their feelings and emotions, considering that errors and accidents can happen with any human being and that, because they are health professionals, they should also deliver care to the family members, as they are experiencing feelings of extreme suffering 13 .
As regards the patients who tried to commit suicide by setting fire to themselves, it is highlighted that the way some health professionals who deal with these patients think and manifest the prejudices deriving from this attitude, or even have but do not express these feelings, is a source of concern.It is a view of disrespect for the personal and social importance of the suicide attempt.These personal and cultural difficulties still exist in society and should be considered in the care context 14 .
It is emphasized that burns in adults due to a suicide attempt, in the large majority of cases, are considered as unacceptable behaviors in the Brazilian culture and can provoke reactions of rejection by some professionals.Therefore, the job environment favors stress, dissatisfaction, suffering, anguish, among other feelings 10 .
In a study involving the nursing team at a municipal hospital in Rio de Janeiro, it was identified that the health professionals do not accept the burns due to a suicide attempt or violence of any kind.The research participants also affirm that these clients try to give up on life, as opposed to their own convictions to save lives 15 .
Concerning the feelings of pleasure, satisfaction to take care of burns patients, a study involving nurses from Teheran obtained data analogous to the present study, demonstrating that, in delivering care to the patients, witnessing their recovery and the moment of their discharge were factors that contributed to experiences of feelings of pleasure at work 16 .
In another study involving nursing technician from the emergency care unit of a public teaching hospital in the North of the State of Paraná, it was identified that feeling of pleasure, contentment and gratification arise when these professionals perceive that the patient's health condition improved as a result of the nursing actions and the care the team delivered that day, or even after some days in hospital 17 .
Similarly, in another study involving a nursing team at a municipal hospital in Rio de Janeiro, it was identified that the care act is perceived at the time of discharge as the team's success, which causes feelings of joy, satisfaction and mission accomplished 15 .

Feelings of workers at a burns center
Martins JT, Bobroff MCC, Ribeiro RP, Soares MH, Robazzi MLCC, Marziale MHP Finally, it is highlighted that the nursing team needs to perceive that taking care of patients or family members is a process with a relation between one or more people, that is, professionals with technical-scientific and humanistic preparation and available for effective care and for other people who need help and care.Thus, the feelings of satisfaction with the care delivered and with the kindness received will positively affect both 18 .

CONCLUSION
Based on the results, it can be affirmed that the nursing team experiences feelings of suffering, affirming: that it was the most difficult work they developed professionally, by putting themselves in the patients and family members' place, due to the powerlessness in view of some situations, compassion and pity when taking care of children, the parents' neglect in view of the child's vulnerability and suffering when taking care of suicide patients.
Nevertheless, the nursing team also experiences feelings of pleasure when taking care of the patients and perceiving that this care was important for their recovery.
In view of the feelings of suffering these workers experience in daily work, the managers, together with these professionals, need to seek solutions that are discussed and implemented to promote health, reduce problems and recover these workers' health, improving the quality of life in the work environment and, consequently, in professional life.
Although the study objectives were achieved, this study comes with a limitation, as investigating meanings involves the singularity, the abstract, the subjectivity, with influence from the time, the space and individual characteristics of each nursing team professional.Therefore, the results need to be considered in their particularity, as they picture the reality of the nursing team working at a BTC of a teaching hospital in the North of the State of Paraná.