Experiences of hospitalized patients with the venipuncture process

Objective: To understand the representational components, the origins of the participants' experiences with venipuncture process, their perceptions and (im)explicit markers of care demands according to Neuman. Methods: Social Procedural Representation research, conducted with hospitalized adults with punctured veins in a hospital in Minas Gerais. Sample of 149 people with full selection. Individual interviews recorded using clipping and collage of comic books' technique. Content analysis applied NVivo and Neuman's theory. Results: Most participants were female age ≥ 50 years. Experiences contemplated own accounts, with third parties, families and professionals, perceived as dialogic, expressing feelings/behaviours, values, information/knowledge and representational objects, with those with families less significant due to the focus on care. Conclusion: Selected comic books' speech fragments and images demonstrate exposure to stressors (intrapersonal, interpersonal and extra personal), presenting gaps in the demands of nursing care when integrating relational, cognitive/specialized and instrumental technologies.


INTRODUCTION
The venipuncture process has multiple purposes, including antineoplastic, pharmacological, haematological, analgesic, sedative, blood volume replacement and renal replacement therapies, as well as the control of biochemical and electrolytic parameters and diagnostic purposes 1 .
The use of peripheral veins in the hospital environment articulates the work performance of nurses and their team, doctors and pharmacists.Rereading the nursing work to reconcile technological levels, specificities, distinct cultures and users' concepts 2 in the light of philosophical references enables reflections for a comprehensive care 3 and guiding the practice of the nursing team.
Regardless of the nursing team's multiple or simplified composition in the Brazilian and international realities respectively 1,2 , it was possible to identify gaps in the literature, such as the lack of dialogue and interaction on nursing care shared with its subjects that can represent what is their understanding about the venipuncture process.
These gaps have arisen through the absence of content about how the actions and forms of professional approach by the nursing staff performing venipuncture empowered users on the decision-making process about the way the drug treatment was operationalized, and whether these professionals guaranteed that their needs were met, acting in a humanized and individualized way, and allowing them to express themselves about their feelings on having their blood vessels 1,2 punctured.This is the challenge to be considered by the nurses for a quality care 1,2 .In order to overcome this limitation, this study seeks to redeem the meeting and the prominent place in which the needs of those who have their vessels punctured are identified, targeting the binomial professional that punctures and the punctured user; enhancing compliance, competencies, skills and interpersonal, communication and therapeutic relationships from the social perspective 2 .Social representations built from the experiences that occur in the encounter of the individual with the collective dimension will be used for this purpose.
The skills and competencies required by those performing vein puncture, when confronted with a variety of user characteristics and how the phenomenon is realized, perceived and interpreted, enable us to affirm that it is a complex and multifactorial procedure.Therefore, it is appropriate to carry out a rereading of its occurrence in the perspective of those who have their vessels punctured, in order to identify their needs, whether there are stressors components and what would be the perceived human responses as to be reported by them 4,5 .
Given the above, this study aimed to understand what are the representational components, the origin of the patients' experiences with the venipuncture process, their perceptions and the (in)explicit evidences that could shed light on the care demands.
As the care provided during the venipuncture process should not only consider the technical dimension, it should be analysed under the singularity in which it is developed, comprising the form in which the encounter and interaction between professional and punctured person happens, in a rational interactionist and humanistic perspective 6 .
This research is based on the following argument: the need to raise funds to team up health technologies with skills related to the content and user profiles, with the intention of being a guide for nurses in order to contextualize their work performance on the venipuncture process.

LITERATURE REVIEW
In this study, the theoretical-philosophical foundation of Betty Neuman's theory was used by providing an understanding of the individuals' responses to the venipuncture process and what are their feelings, behaviours and experiences regarding this procedure.
The metaparadigms were designed as follows: 1) subject containing an open energetic structure composed of normal, flexible lines of defence, and resistance lines that can be influenced by physiological, psychological, socio-cultural, spiritual and development variables; 2) nurses who can act on the (re) stabilization of the patient's energy system, helping them to eliminate, reduce or cope with the stressors; 3) health-disease process directly influenced by the (in)stability of the defence lines of the subject's energy system 5 .
Stressors are classified as intrapersonal (subject's feelings, principles and doctrines), interpersonal (relationship between people) and extra personal (from the environment) 5 .
The ways to approach the health-disease process from the modern era's perspective bring hospitalization and medicalization of bodies as core elements of the health professionals working practices, which, when combined with the use of technologies, justify the frequency at which blood vessels are used to facilitate therapeutic interventions 3,7 .
The health technologies include, in addition to the technological apparatus, professional knowledge, skills, practical experience and interactions with the care subjects.They are classified as: light (referring to behaviour, interaction between assistance and reception), light-hard (expertise) and hard (instrumental) 3 .
The fragmented biomedical model that prioritizes the use of hard technologies at the expense of others, when applied to the venipuncture process and in the prospect of individualized care and quality, requires paradigmatic changes in order to reconcile the use of the three technologies and achieve the approach which includes body, soul and spirit 2,3,8,9 .
From the professional practice point of view, the challenge that arises is the reconciliation of the technical and relational dimensions, that should characterize the meeting between the Patients' experiences with venipuncuture Campos LB, Martins JR, Arreguy-Sena C, Alves MS, Teixeira CV, Souza LC caregiver and the cared for, from the perspective of a dialogical relationship as not to hide, nor neglect the human responses that arise when this procedure is performed 9,10 .
If, on one hand, when one refers to an institution and a health professional, what they want is the success of the procedure (technicist approach), on the other, the risk is to neglect both the legitimacy of solidarity relations 10 and the use of health technologies that create opportunities for participation and for the rescue of the user autonomy.The hospitalized person needs to stop being naive, i.e. a passive-patient, and to became a critical/ participatory person in their care 11 so as to avoid this risk.
The aforementioned ideas imply a conception of a professional who is able to rescue the solidarity dimension within themselves, and overcome the gap that reduces the venipuncture process to a temporal event that is reproduced in their labour activity without reflection and neglecting the existential perspective of their profession and their relationship with the users.
Given the above, the venipuncture process, regardless of its therapeutic purpose, is being designed as a complex activity that exceeds the central focus -the installation of the intravascular catheter -and transfers this focus for its dialogical relationship with the user, as to ensure both therapeutic action and technical implementation accuracy.
By reconciling care dimensions 2 with the justifications underpinning the complexity of the venipuncture process, it's possible to identify professional skills and abilities, as follows: 1) technical/assistential, to enable the successfully introduction of the catheter in persons having different blood vessels characteristics, clinical situations, therapeutic needs and individual responses to the procedure; 2) relational and communicational, to see how each individual faces "the prick" in order to assist them in the resilience process; 3) managerial/ administrative, to use the available material/equipment in the institution, adapting it to users' individualities and consequently adapting it to the clientele profile; 4) educational, in order to make a complex and widely-used procedure in nursing practice be understood and accepted by people who need it for recovery, treatment, diagnosis or stabilization and 5) political participation, which involves the pursuit of articulation between care and philosophy, resources, workload and number of workers for the quality of care.
In addition to the skills mentioned above, the importance of integrating them with health technologies 3 should be added, when a multidimensional approach of nursing care and the exercise of a less fragmented practice 8 are the goals.

METHODS
This is a study bounded by the Theory of Social Representations by Moscovici 12 and founded on the Betty Newman's theory, held in the surgical hospital sectors (general, neurosurgery, plastic surgery, cardiac and hemodynamic) and clinic (neurology, gynaecology, infectious diseases and orthopaedics) of a Philanthropic Hospital in Minas Gerais.
Complete selection sample.Eligibility criteria were: 1) people hospitalized in clinical and surgical sectors; 2) both genders, ages ≥ 18 years who had undergone venipuncture for diagnosis, pharmacological and/or haemotherapeutic treatment, during hospitalization; 4) people who could express themselves coherently and 5) people who agreed to participate as unpaid volunteers, expressing acquiescence of their participation by signing the post-informed Free and Clarified Consent Form (ICF).
Exclusion criteria were the people who required privacy for recovery from clinical situations (such pain, discomfort or discomfort in progress) or were discharged during the data collection period.
Recruitment was carried out in the wards through individual invitation.149 people participated, with 30 reset losses (refusal; desire to stop, interview interruption due to supportive care, discharge, recovery after procedure, being or considering themselves unable to attend and not accompanied by a guardian).
Information on the participants' socio-demographic characteristics was obtained and methods and techniques (interview with audio recording, the cut and collage technique with comic books and field diary) of data collection were triangulated.Guiding questions were: Why did you choose this figure to represent venipuncture?How do you interpret it?Describe a key moment of the "puncturing the vein".
Using the cut and collage technique with comic books, participants handled 12 pages of images (front/back) from three comic books written by Maurício de Souza and one by Disney, whose protagonists were: Cebolinha, Mônica, Penadinho, Marina, Zé Luiz, Mickey and Goofy, totalling 202 figures 13,14 .
Data collection occurred at the bedside from May 2014 to February 2015, during afternoon shifts and early evening hours to be reconcilable with the assistance activities, with an average duration of 20 minutes.Each participant received a code containing letters and numbers.
Data collection took place in two stages as it was a cut from a wider project.It was preceded by the participation of interviewers in a workshop, conducted by Masters students, which addressed the application of communication techniques in the scientific research data collection process.
The purpose of the workshop was to approximate graduation and post-graduation; enhance the appropriation of verbal/ non-verbal evidences (quoted in the speeches); favour the identification of the subjectivity contained in each participant's expression; capture their experiences from the discursive content; and enable the analysis of speeches to subsidize a consistent analysis on this investigation object.
Other objectives were to identify the limits of the reported experiences and the relations of power/submission/help/ resilience implied to the venipuncture process.Such possibilities attributed internal validity to the research.

Patients' experiences with venipuncuture
Campos LB, Martins JR, Arreguy-Sena C, Alves MS, Teixeira CV, Souza LC Participants chose the figures, using as a criterion that which would best portray their perceptions of "puncturing the vein".In order to capture the explanations and interpretations of imagistic content, thematic perception and former experiences, an audio was recorded.
The data were entered into Word for Windows, treated in the program NVivo version 10 and concomitantly analysed with the communicational messages evidenced by tone of voice, pauses, word repetition and unfinished sentences, among others, registered in the field diary and in recordings.
The quantitative sociodemographic variables were consolidated in the Statistical Package for the Social Sciences (SPSS) programme version 23, and analysed by descriptive statistics.
The Minayo 15 benchmark was used for categorization (default, exploration and categorization) of the contents, looking for answers regarding to whom the participants attributed the origin of their significant experiences, and whom the speeches were about.The result of the categorical trajectory (the "we" denomination in the program used) enabled the identification of the origin of the participants' experiences which were categorized into clusters according to similarity of contents, confirmed by Pearson correlation using binary analysis.This correlation ranged from 0.507419 to 0.864717, confirming the saturation of information.The existence of anchoring (proximity of the participants with the research object) and objectification (transposition of the research object to a form of concreteness) were used as a criterion of scientific approach to identify the social representations.
All ethical/legal requirements for research involving human subjects were met.The project was approved by opinion number 522/853 on 6 February 2014.

RESULTS
Participants were characterized as follows (Table 1).The imagistic content and the interpretations given by participants about their own experiences, with family members, others and professionals who portrayed their perceptions about the venipuncture process contemplated four dimensions, namely: 1) behavioural/attitudinal: pain, fear, sensation of being shot, consternation, scream, nervousness and position of vein puncture; 2) cognitive/informative: knowing that the institution has a formative role, so learning is part of the actions developed in this scenario; 3) evaluative: boring, tedious, bad and like and 4) representational: needle, tourniquet, equipment, patient and arm (reified content) (Figure 1).
There was a variety of the participants' approaches with their own situations and circumstances, with others, families and health professionals who performed vein puncture.
The origin of representational content from their own experiences and those experienced with family members is shown in Figure 2.
The categories that depict the origin of social representations arising from the experiences identified with others and health professionals are listed in Figure 3.

DISCUSSION
The analysis of reports, corroborated by its contents about the needle puncturing the skin, justifies the reporting behaviour of pain, discomfort and fear (fear, pain, scream, nervousness) whose tolerance and acceptance vary with the form of coping, prior experiences, the age of those who have their vessels punctured and the behaviour that they consider appropriate for showing their discomfort 4,16 .It is noteworthy that such behaviour is a reflection of the subjectivity of the subjects, who have diversified human responses to the same stimulus.
Behaviours and feelings described above were corroborated by empirical data from other research that portrayed how participants braved the venipuncture process, with fear and anxiety in the days leading up to the procedure, and pain and discomfort during the needle insertion stage 4 .
The fact that there are objects among the dimensions of the representations indicates that the venipuncture process, although being a technical procedure (reified), was incorporated into the common sense by participants through the instruments used to perform it and the conditions/body areas where the procedure occurs (patients and arm structure).
These identified objects were corroborated with the contents that describe how to perform a puncture 17 , which foundations subsidize the realization of the process, the people who need a punctured vein and the material used to ensure access to the vein 1,17 .
The place where this procedure is performed depends on the type of solution that will be infused, the condition of the vein, the patient age, their preference, appearance of the vessel, morbidity conditions, duration of therapy and the institutional policy of materials 1,18 .
The anatomical sites for performing peripheral venipuncture are the arm (axillary, basilica and cephalic veins); forearm (basilica, intermediate basilica, cephalic, intermediate cephalic, intermediate brachial, radial and ulnar veins); hand (veins of the superficial palmar arch) and fingers (lateral and medial superficial fingers veins) 1,4 .
The fact that the investigated institution is a place for nursing technical training was perceived by users, who saw the presence of students as a threat.The way they captured that presence was characterized by a lack of consolidated skills/competencies for the venipuncture process.This supported the interpretation of the vein puncture time as a possibility of failure and led to a negative evaluation, considering it a threat: "I'm traumatized by those girls who are learning there (school site).I don't like to have blood sampling there" LD150.

Patients' experiences with venipuncuture
Campos LB, Martins JR, Arreguy-Sena C, Alves MS, Teixeira CV, Souza LC  The presence of people in vocational training, if they're not prepared to be inserted in practical scenarios by their teachers/ tutors, causes their exposure to the evaluative judgment of users, as the patients realise inconsistencies in their behaviour, lack of technical skills in their area and use of inappropriate vocabulary 19 .
The evidence mentioned above allow users to conclude on the inability of future professionals to deal with situations of clinical practice, which justifies their feeling unsafe or threatened.These factors can be characterized as interpersonal stressors (between client and students).Another type of identified stressor is the environmental, demonstrated by the fact that it is an educational institution 5 .
Whereas all health institution should be the scene of continuing education of its work team and or future professionals in the health area 19 , there is need for reconciliation between technology and vocational training.One strategy is the use of  laboratory teaching, using technological models adapted to this purpose.They aim to promote the familiarity of students with equipment and technical steps to acquire manual dexterity.Such conditions are key to prepare future professionals and supplement their training, without exposing both the professional and patients to unnecessary risks and discomforts 18,19 .
The diversity of ways in which people respond to the venipuncture process, even under the appearance of adequate social behaviour, requires the professional to be able to capture the users' reactions individually and enhance their participation in the process, as to favour their coping and empowerment in facing this situation 10 .

Individual experiences
It was possible to capture the participants' experiences and approaches to the venipuncture process from their speeches, in a (non) explicit form, from which representational components triggered by the inducing term "puncturing the vein" were identified.
The diversity of situations and circumstances mentioned include "feeling the arm burning" and "sweating", "fear" and "can't move my arm".These expressions depict the act of "puncturing the vein" as something capable of causing suffering and discomfort that worsens when the venipuncture process is extended or the vessel's characteristics make the puncture or maintenance in the therapeutically recommended time 1,4 difficult (such as veins that are not prominent, or thin, with small gauge and tortuous).
In this study, observed as intrapersonal stressors were: their own experiences; personality; the person's condition; their reactions; characteristics of the disease; the drugs used and the duration of treatment.It should be added that the report "can't move the arm" set up in a functional stressor due to the influence of the equipment used in intravenous infusion on the participant's mobility and therefore, according to the types of stressors ranked by Neuman, this was considered as of environmental origin 5 .
The venipuncture process was seen as a cause of suffering in the present investigation and corroborated by other  research 4 , especially when its occurrence was associated with successive punctures and failure in the first attempt.However, even in these cases the act of puncture was tolerated, as the participants mentioned acquiescence to the fact, either by recognizing the need for its realization or by fearing that their reactions would worsen the situation; or wanting the benefit of treatment/improvement/healing at the expense of their discomfort/pain.Some reports demonstrated familiarity with the procedure, as mentioned by the LD035 participant, who claimed that if they moved their arm, the needle could come out of the vein and then a new puncture would be necessary.
Repeating individual experiences described by participants brought inlaid details of behaviours, attitudes, knowledge/ information relevant to this source of experience for the anchoring and objectification of the contents related to the inducing term "puncturing the vein".

Experiences with family situations
Participants who accompanied their families in the experience of this process witnessed situations such as: not finding the vein searching for it with the needle, not being able to perform the puncture and leaving the family member with bruises, which allowed for a negative representation from an evaluative point of view concerning the venipuncture process.
Despite the above situations, the experience in family situations had little influence on the construction of social representation of "puncturing the vein" in this investigation.
The reason for consistent reports to be insufficient for the construction of social representation is justified by the fact that the participants' focus was their family member, at the expense of the technique performed.The person who accompanies a family member in a hospital stay offers affective/emotional support for them in dealing with situations considered difficult and unpleasant, expressing solidarity with them in those moments 20 .
Based on this emotional context, the relationship identified in this investigation between family member and companion was characterized as an interpersonal stressor 5 , since the family member's presence was an influence, helping and encouraging the person who has their vessels punctured to overcome this moment and to deal with venipuncture in the quest for obtaining the treatment benefits.It is worth mentioning the possibility of the same influence having the opposite effect, with family presence generating unbalanced behaviour in the individual's power system.

Experiences with professionals performing venipuncture
The reports of the participants relate whether the content of the representations were negative or positive regarding the influence of the professional puncturing veins.

Patients' experiences with venipuncuture
Campos LB, Martins JR, Arreguy-Sena C, Alves MS, Teixeira CV, Souza LC It was observed in this study, as interpersonal stressors, the relationship and perceptions exchanged between being the patient and the professional puncturing the vein 5 , exemplified by professional insecurity, lack of preparation and skill, inexperience, and the influence of temperament, causing the persistence in making multiple punctures until obtaining success.
The triad consisting of the personal characteristics of the patient having their vein punctured, the ability of professionals performing the venipuncture, and user peculiarities portrayed by the type of venous network and therapeutic motivation justifies the complexity that characterizes this process and the success or failure of its realization.
Among the occurrences of vascular trauma that could be identified are: vessel transfixion with blood extravasation, irritation of the vessel layer(s), pain at the site of insertion of the intravascular catheter or venous route, venous spasm 1,4,21 and human suffering.In this conception, the risk approach to vascular trauma can be considered a nursing diagnosis 16 and care quality measurement parameter.
To comparatively analyse the impact of vascular trauma events with systemic complications (air embolism, allergic reaction, systemic infection and circulatory overload) 18 , the first may seem harmless and do not justify a professional concern.However, because preventive and palliative actions are needed, they call for the individualization of treatment/care and they generate human suffering 4,21 , thus deserving to be the focus of a new reading on how the professional practice is being carried out as to allow its restructuring in the light of technical, theoretical, taxonomic and philosophical paradigms 5 that allow practical actions in order to minimize them.
Another conception identified among the participants was that they expressed affection for the profession and appreciated the nursing professional.The way they express this appreciation includes calling them "little angels" in order to express how they made them feel calm, cared for, how they treated their illness and benefitted from their presence.An example was mentioned by participant LD048: -"Symbolizes an angel (figure) coming to calm the person (representing the professional) (laughs).The person with fear and a little angel coming to reassure them (laughs)".
The fragment of the aforementioned report shows remnants of the nursing concept as a profession linked to pious deeds, charity and compassion, in the analogy proposed by Caponi to use the image/symbol of consecrated women to portray the profession's historical origin, as opposed to the solidarity behaviour that should guide professional action 10 .
In this conception, the "little angel" can be understood as an image representation of the professional nurse, and for this representation to be modified, there is a need for this professional to build a relationship with the users based on solidarity, dialogue, ethics, and humanised actions, recovering user participation and autonomy to empower them with the responsibility that they bear concerning their health and treatment.Thus, the nurse will be able make the person having their veins punctured the protagonist of the care, instead of being a mere spectator [9][10][11] .That is to say that users should be seen as active subjects of their history, searching for a more critical awareness of their reality 11 .

Experiences with other's situations
In this category, the frequency with which the peripheral vessels were punctured and kept in people and in the closest environments caused the presence of this procedure to favour its anchoring for participants.
It was situations witnessed by them with known and/or unknown persons that allowed us to suppose that in carrying out this procedure, the privacy of those who had their vessels punctured wasn't maintained.
It became clear that the participants had already accompanied and seen other people experiencing the venipuncture process, in which they observed behaviours, feelings and attitudes that portrayed or allowed them to notice: the act of screaming, anxiety, disgust, concern for the procedure's success, loneliness and inevitable circumstances coming from this time.Such experiences led participants to assign a "negative" value to this process, characterizing it as bad and painful.
This fact was corroborated in data from other research, in which third parties reported having witnessed the realization of this procedure 4,16,17 and stated that it influenced their behaviour, reflecting on the representational components identified for the venipuncture process.
The venipuncture process was perceived as a source of interpersonal, intrapersonal and extra-personal 5 stress for themselves and those who had a vein punctured, although admittedly a component that favours morbidity recovery.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE
The types of experiences of the participants originated from their own situations, with their family, with others and the relationship with the professionals who punctured their veins were considered remarkable enough to justify the presence of representational elements obtained for the theme, whose predominantly technical origin may be learned by laypeople.
Events and circumstances that involve the daily venipuncture process were portrayed as generators of suffering and difficulty in coping.These were translated into reports and images, whose negative content reflected intrapersonal, interpersonal and extra-personal stressors, although participants recognize their need and accept its realisation in the search for their recovery.
These stressors are (non)explicit markers, characterising gaps in the demands of nursing care in relation to the integration of relational, cognitive/specialised and instrumental technologies that could guide the work of nurses and their team.

Patients' experiences with venipuncuture
Campos LB, Martins JR, Arreguy-Sena C, Alves MS, Teixeira CV, Souza LC This investigation brought as a contribution the necessity of relativizing values, concepts and knowledges that should permeate existentially the venipuncture procedures in order to generate a practice with the possibility of inter-human intervention.This so that the actors involved are benefited and can grow on a continuum that characterizes a situation in which care is the intermediary path to human perfection.In this context, the focus of professional care is transferred from the result to the process.
The limit of this study is the impossibility of the transposition to another reality and is justified by the choice of the adopted design.

Figure 1 .
Figure 1.Images and exemplifier discursive contents of representational elements of the venipuncture process.

Figure 2 .
Figure 2. Images and reports of participants exemplifying their association to the venipuncture process with themselves and with family Patients' experiences with venipuncuture Campos LB, Martins JR, Arreguy-Sena C, Alves MS, Teixeira CV, Souza LC

Figure 3 .
Figure 3. Images and reports of participants exemplifying their association to the venipuncture process with health professionals and others.

Table 1 .
Characterization of 149 participants according to sociodemographic data