ORIGINAL ARTICLES

 

Emotional preparedness of health professionals in family interviews: a hermeneutic study

 

Paula Isabella Marujo Nunes da Fonseca1, Cláudia Mara de Melo Tavares1

1Fluminense Federal University

 

ABSTRACT
Approaching families in order to convince them to donate organs is always a conversation filled with a heavy emotional load, and it is performed by experienced transplant coordinators.
Aim: to understand the emotional preparedness of experienced transplant coordinators when approaching families of possible donors.
Method: This study has a qualitative approach, in a hermeneutic method; the Committee of Ethics at UFF/HUAP approved it of under protocol #321/11. The data was obtained through semi-structured interviews, with eight open questions and 24 individuals, between January and May 2012.
Results: The majority of the interviewees do not prepare themselves before approaching families and they also recognize the necessity to implement a support system to assist the emotional demands generated by their workload.
Conclusion: Despite the fact they do not prepare themselves emotionally, professionals see the relevance of support to promote their own self-understanding and that makes them feel safer and prepared to approach families at such a sensitive moment. 
Descriptors: Expressed Emotion; Health Personnel; Transplants; Psychiatric Nursing.

 

INTRODUCTION

The process of organ donation, which will lead to a transplant, is composed of a few essential stages: first, the notification of brain death to the Center of Notification, Harvesting and Distribution of Organs (CNCDO, in Portuguese) after the medical evaluation, which requires agility in the process(1); then, communication to the family of the final diagnosis of brain death; third, the approach to the family to donate organs; and finally, the final authorization from the family to harvest organs.  

The focus of this study is on the third stage, namely that of approaching the families, which is performed by an experienced transplant coordinator. This is the moment that the professional explains what brain death is to the people who have just lost their relative, and who are the ones to decide for or against the donations of the organs of their loved one. This stage is defined as a meeting between the relatives of the potential donor and one or more professionals of the harvesting team, and another trained professional. The approach to the family aims to achieve the consent of the relatives in donating and has a great emotional and subjective complexity(2).

As a consequence, the Donation Coordinator Manual states that the goal of the approach moment with the family is:
“[...] to guarantee that relatives and friends understand what is brain death, trying to identify the will of the deceased person, clearing doubts about the processes that involve donation and transplant, evaluating simultaneously the biological risk of the donation and providing emotional and psychological support”(3:118).

Emotional and psychological support is justified according to literature, as the family approach is a delicate and considerably difficult moment during the process of donation. It is the point when the relatives of the potential donor react and express their discontent in many different forms(4), as it is a moment that is characterized by death, the distancing from the loved one, and the feeling of impotency(5). When dealing with relatives who are either aware of, or understand, the donation process, the coordinators usually meet with positive reactions. However, the majority of relatives have negative reactions regarding brain death as they are more attached to their personal beliefs and hope for a miracle, thus becoming passive or aggressive regarding organ harvesting. It is based on this scenario that it is necessary to have a better understanding of brain death and the option for organ donation.  The health professionals need to understand the caring demands of relatives during this moment, from a more holistic perspective , which is respectful to the singularity of all people involved in this project(6).

The creation of an emotional support leads us to believe that every serious communication from the health professional (here represented by the expert transplant coordinator) must have some sort of previous planning, due to the distinct possible emotional outcomes to be dealt with. Because of this, some studies regarding the communication of death in health institutions affirm that professionals do not have proper theoretical training, and in particular, they need emotional support to deal with the suffering and the death of their patients(7-9). This research reinforces the idea that these workers would like to learn how to better deal with the difficult moments of communication, based on real-life situations, acquiring methods of behavior when facing the same situation in their professional practices, not getting involved emotionally, better accepting the moment of death, and having psychological support(10). Hence, it is important that the caring practices of those who face death must be discussed, in order to not let the current lack of emotional support present in hospitals grow, which denies death as a process, employs silence as a method and is built on the illusion of omnipotence. This support is needed urgently so that professionals do not see themselves as alone and unsupported, and that they do not need to bury their afflictions within their ego(10).

Consequently, this study aims to understand the emotional preparation of the expert transplant coordinators when dealing with the family approach to organ harvesting. To discuss the information gathered, two theoretical references were used: one, proposed by Daniel Goleman, refers to the importance of emotional intelligence, which is ‘[...] the capacity to identify our own feelings and of the others, to motivate ourselves and to well manage the emotions inside us and in our relationships’(11:337). The second approach, proposed by Juan Casassus, regards emotional education(12) as “[...] a set of abilities that an individual needs to acquire in order to support the develop of one’s emotions and feelings, learning to manifest those expressions in a better format, guiding the individual to achieve self-control regarding his own emotional behavior”(13:67).

 

METHOD

This is a qualitative study, with an interpretative hermeneutic approach, based on the perspectives described by Hans-Georg Gadamer, who perceives that interpretation leads to knowing the conditions at which the level of comprehension is, or in other words, it tries to understand language the way it is, and through it, the man himself, his own history and existence, as language is the key of access to the world and to the things in it(14).

The methodological approach selected, using interpretative hermeneutics, allows us to know the tradition of the emotional preparation of the professionals that deal with the families during the harvesting of organs. This practice is highlighted when observing the language used by the expert transplant coordinators. The tradition is the whole set of conceptions transmitted time after time, which unconsciously condition the actions of the professionals, also manifested in the language. Human beings are the living language, and with it, they name the world. Language is characterized as a relationship between the being and the world, which makes humans different from every other living being on the planet. With this instrument, the being is detached from the world around it, as the possibility to interpret the environment is opened, thus demonstrating the ontological dimension to all humans(14).

The scenario chosen for this study was the Center of Notification, Harvesting and Distribution of Organs (CNCDO, in Portuguese) of the Brazilian state of Rio de Janeiro. The data was collected from January to May 2012; the subjects that composed the sample were twenty-four transplant coordinators, who consisted of 17 nurses, two social workers, two physicians, and three psychologists – who belong to a team that is or was part of the group of teams that coordinate the process of organ donation in the state. The criteria for inclusion were as follows: that the professionals approach or approached families about organ donation, and that they were working during the period of the data collection at the Transplant Center. The criteria for exclusion were that the professionals had never approached families regarding organ donation, or that despite having this experience they were not working at the CNCDO under research during the period of data collection.

A semi-structured interview was used, with questions related to their emotions and their handling during the situations when approaching the families. Questions included were as follows:

The subjects’ discourse was analyzed in accordance with the philosophical hermeneutics of Gadamer, in order to organize and understand the information recorded; it was later fully transcribed. From other readings, the researchers aimed to unveil the ideas behind the testimonies and their singular way of building their language, which was analyzed under the theory of emotional intelligence, such as in Goleman(10), and of emotional education, as described by Casassus(11).

This research was approved by the Committee of Ethics in Research, from the Antônio Pedro College Hospital/UFF, under protocol 321/11 CAAE 0336.0.258.000-11, in November/2011. It follows all ethical requirements described in the Resolution 466/2012.

 

RESULTS

With regards to the emotional preparedness in approaching the families during the harvesting stage of the organ donation process, the coordinators were asked if they had any sort of previous planning. Hence, the categories generated were: “the prevalent ‘no’”; “preparation method”; and “the (re)admission of the importance of emotional preparedness”. The “prevailing ‘no’” was found in the testimonies, which referred to the fact there was no type of planning prior to the moment of approaching the families. Some testimonies developed the connection between emotional preparedness to a pre-acknowledgement of the situation that the professionals will have to face. Based on that, the coordinators indicate the preference to know the situation at the moment it will occur, thus justifying the lack of previous preparation. Other interviewed professionals declared that they do not get emotionally involved during the approaching moment and that any type of emotional preparation is unnecessary. In the testimony transcribed below, the authors of this study highlight the line of thought that supports the decision to not have any emotional preparation before approaching the families, based on the views of the subjects of this study.

“No, I never had any… Those who are part of the process sometimes think the person is self-sufficient enough, that they are capable of keeping the balance, and in fact, we know we see daily that these capacities don’t work that way, and in fact, people simply don’t care about it. And since the beginning, since the first team [of professionals] there was a team before us – they were temporarily hired, and than we came, the gazetted professionals… In our group, we had two psychologists, and because of that there was no preoccupation on our part… There was a moment at which we drew a draft idea of support for the technical team, those who were on call – the ones who really were in charge of approaching the families, but that wasn’t put into practice.” (Overseas Blue)

With regard to the “preparation method”, it was found that this refers to the means the subjects use to perform what they refer as preparation for family approach, which can be a direct or an indirect contact. Despite reporting that they did not have any preparation, their testimonies demonstrated a certain movement that can be interpreted as a means to better accept the situation or to support the rebalance of the individuals to better face the difficult moment. Therefore, the belief that one is doing a greater good, praying, visiting a therapist in order to feel prepared, knowing that the organ to be donated will save another person, believing in the diagnose of brain death, and performing the Course of Bad News, were some of the strategies mentioned. It is possible to understand that the preparation considered by the professionals involves the technical appropriation of the process, going through the positive subjectivities of the stages, and it even touches upon some external jobs (such as therapies), thus leading to self-understanding. Hence, there are some testimonies that confirm such findings:

“No, today I don’t do it anymore. Like, when I have to approach a family that I think will involve a difficult conversation, when the donor is a child, a young adult… I think that the way I get prepared is by trying to be calm, believing that what I am doing is to serve a greater good, and when I’m done, I say to myself “wow, it was cool, a positive outcome” or “well, it didn’t work out”… Well, that’s it.” (Magenta)

“I pray.” (Turquoise Blue)

“No… Emotional preparation… Not really. I do something with myself, but not as a professional […] Only with my own strength, the understanding you have, the strength given by the idea that the organ donated will go to another person and improve the life conditions of the receiver. And I do believe in brain death.” (Olive Green)

The last category of this stage was called “the (re)admission of the importance of emotional preparedness”, in which the reports of subjects that perceive emotional preparedness as an important element emerged. Their arguments revealed that some emotional preparation was necessary, such as learning to get prepared as part of their professional experience while approaching the families, recognizing that at a certain moment the lack of emotional preparedness was missed, and to recognize that an academic education merged with clinical practice and allied with the aforementioned preparation, helps to deal with difficult moments. Moments such as these were mentioned in the following testimonies:

“I do believe it’s necessary, but I have never done it.” (Carmine)
“No, I have never done any emotional preparation, but sometimes I miss it [...]” (Grys Paine)
“In college, no one says anything about [emotional preparedness]. At no time during our undergraduate program is there a course, or part of one, related to the approach to the families during the specific process of organ donation. What we discuss during the undergraduate program is to know how to give the right answer; and many times, we know how to inform the patients about the issues related to death.” (Cadmium Orange)

Through the following inquiry, which was designed to understand the opinion of the professionals as to the necessity of emotional support for those who approach the families, it was possible to observe that the majority highlighted the category “yes” stating the necessity of the mentioned service and building some arguments that could justify the incorporation of this type of support at the studied health unit. In fact, only one single subject disagreed with this position. From those issues, the categories that arose were “yes”, “justifications for yes” and “no”.

In regards to the “justifications for yes”, some aspects of emotional support were unveiled:

 

 

“[...] a support, more than one, so we learn how to deal better and focus more in a common goal...”(Green Land)

“I think it’s important to have support, especially good preparation, because I see that it’s not only at work, but today in our relationships, as people are more and more distant from each other… modern life, technologies… So the more people don’t talk face-to-face, the more we need to deal with resistance to organ donation and deception We are too far away from our emotions, so I think we need to have some preparation, a support to make things better, because the habit of having a problem with one person and sitting down to discuss and solve it is becoming rarer today. We are losing the ability to listen to others, to speak calmly, to know what the other has to say.” (Burnt Sienna Earth)

 

 

 

 

One subject has found that emotional support would be important beyond the technical team and would benefit the administrative team as well as the coordinators. Another professional suggested the participation of professionals from outside the unit to offer this support; hence they would be able to suggest ways that the team should behave.

Regarding the category “no”, one subject reported that the emotional support provided at the unit would not be necessary for those who approach the families:

“So, I can tell for myself: no. I don’t think so. I can’t see any improvement in my life because of that, you know? It’s as I told you: I go in and come out of the conversations with the families, and I see no change. So I don’t feel there’s any need for it. So, for me, it’s a ‘no’.” (Ochre Yellow)

 

DISCUSSION

In the category “no”, the majority of the subjects reported no emotional preparation before approaching the families. With regards to such ideas, in some cases, the allegation of a lack of preparedness can be a psychological defense so as not have to face the task, which is seen as really difficult for some. It can also reveal some gaps in the education of these professionals(7).

Some coordinators recognize that previously understanding the situation would make them suffer in advance; one professional states that not knowing beforehand, and learning about the case as it happens is enough, thus explaining that emotional preparedness is unnecessary. Such arguments reiterate a lack of understanding about the topic of emotional preparedness, as it does not mean these subjects need to learn the situation prior to facing it, but in fact, to be emotionally balanced enough to communicate the difficult news, being aware or not with the situation. The alternatives that are proposed for such practices are found in the main aspects on which emotional intelligence is based, and in the knowledge produced regarding emotional education. With emotional intelligence it is necessary to build self-consciousness, which is a fundamental element to the psychological intuition. At this moment, it is important to remember that the limits of consciousness of feelings are not always transposable. First, there are the psychological signs of an emotion, which normally occur before the person is fully conscious of their own feelings. When paying attention to the signs (as for example, those related to the anxiety seen prior to the approach), the professional will be able to gain consciousness of the fact that they are becoming anxious. Therefore, self-consciousness means recognition of a feeling when it happens, which is fundamental to emotional awareness and self-comprehension. It is considered the first domain, among the five proposed ones, to expand emotional intelligence (11).

The arguments of Casassus(12) reinforce the ideas of Goleman(11), which state that to have a successful emotional education (seen as a possibility for emotional preparedness), it is necessary to achieve emotional consciousness, as it is closer to the concept of self-consciousness, proposed by Goleman. Therefore, emotional cycles are consciously and unconsciously experienced in a pre-conscious space and because of this it is necessary to understand each one of them. Hence, the first step is to have emotional consciousness. This means to be aware of one’s emotional world(12). To learn one’s own emotions is a step into self-awareness, which results from observing how the expressions of the one’s body are developed. To feel is an emotional experience; the sensible body is the one that  is able to support the emotions. It is necessary to have the confluence of feeling and knowing in the same instant to achieve such consciousness (12).

When there is no full understanding of the emotions, there is a distancing from the other. If there is no perception and recognition of one’s own emotions, they will not be perceived and recognized in the other. Thus, the subject is limited due to their incomprehension of what is happening to the people he is relating to, which keeps the professional on the emotional incomprehensive spectrum, locked inside the rational space, and blind sighted about the opportunities the emotional world can offer(12). This lack of emotional consciousness makes it difficult to build proper emotional preparedness, as the individual is unaware of his or her own emotions. And as explained above, the lack of recognition leads to difficulties in dealing with the emotions of the other, making the approach an even more complex moment. This scenario could be changed if the professional was conscious of their feelings while preparing to face the approach moment.

In the category “preparation method”, the report demonstrates initially a denial of any emotional preparation, but shortly after it describes elements that give strength to the interviewed subject when facing the approach to the relative. These include being calm, believing they are doing a greater good, being b, and imagining that they are doing something useful to improve the life conditions of another person. Projections of the possible positive outcomes from the actions performed by the individual also bring about security and reduce the anxiety that is typically found in fear. Based on the last discussion, the individual feels he or she was successful depending on the level of motivation of enthusiastic feelings, on the satisfaction in doing the tasks, or even based on an ideal measurement of anxiety. This is the way in which emotional intelligence deeply affects all capacities, facilitating or interfering with them (11).

Another issue to highlight is the presence of spirituality to prepare one self emotionally. Religion is the field of subjective elaboration on which most of Latin America people base the symbols that translate into the meaning of life when searching to overcome the existential crisis imposed by illness. It is also a reference to organize the largest amount of community mobilizations. It is also the space in which the significant majority of the health professionals base and find motivation to do their work. Hence, “to valorize this dimension of reality is not a question have faith in God or not, but to consider the process of subjective and social reality in which there is a clear objective existence.”(15:9)
For the Association of American Medical Colleges:

“Spirituality is recognized as a factor that contributes to the health state of many people. The idea of spirituality is found in all cultures and societies. It is expressed on the individual searches in an ultimate meaning through the participation in an organized religion of the belief in God, in family, in nature, in rationalism, in humanism, and in arts in general. All these factors can influence in the way how patients and professional health caregivers interact among one another.” (16:352-7)

Such affirmation reiterates the importance of spirituality as a powerful mean to emotional preparedness, which is directly reflected in maintaining the professional’s mental health.

On the other hand, with regard to the category “(re)admission of the importance of emotional preparedness”, according to the testimonies it is possible to see that some subjects believe that emotional preparation is necessary and that not being prepared generates consequences for their roles. There is also a report from one of the subjects, a social worker, who understands that their educational background, which was focused in the social area, would help them to be more prepared to deal with the other party. According to this subject, this does not occur with the other professionals, who have biomedical backgrounds. It is possible to confirm these ideas in the testimony of a nurse, who affirms that they have never had any sort of preparation in dealing with the matters involved in organ donation and family approach during their undergraduate program; this is an argument that is demonstrated by other previous studies(7-9).

Overall, only one professional declared that an emotional support service was not important whereas the other twenty-three interviewed professionals stated that it was. Such recognition reiterates the vulnerability of professionals when dealing with frequent moral dilemmas. An emotional support means to generate a welcoming and comfortable environment for the other, maintaining a relationship of trust and respect with them, as many times the hospital, the place with many health professionals, is the only place that emotional support can occur(17). Hence, from the installation of emotional support, the subjects are able to visualize the possible results to be achieved, and all of them are brought to self-understanding, as depicted in Image 1 below. 

 

Image 1 – Subjects’ justifications for emotional support and the intermediation to self-understanding, Rio de Janeiro, Brazil, 2014.

Source: Proposed by the author.

 

Image 1 demonstrates that it is possible to achieve self-understanding through emotional support. Self-understanding represents the necessary means/steps to achieve the established goals and to better face the situations that involve difficult communications.
It is relevant to mention that the five domains that belong to the construction of emotional intelligence are present:
1. To know one’s own emotions (to learn how to deal with them);
2. To deal with these emotions (to focus on a target);
3. To motivate one’s self (professionals would have better approaches and would not suffer so much);
4. To recognize the emotions of the other (to deal with the other/to help during specific situations);
5. To deal with relationships (to withstand the hard situations, not falling ill)(11).
Coherent with the data observed, some studies affirm the importance of establishing emotional support for professionals that experience the routine of approaching and communicating difficult news(7,18). Therefore, positive outcomes are far more likely if patients feel better welcomed, safe and b enough to face up to a delicate situation.

 

CONCLUSION

The data demonstrated here matches those identified in previous analysis, mostly observed in literature. Steps that generate effective changes in the mental health care of experienced transplant coordinators are serious and must take place some time in the near future. It was possible to demonstrate that, in order to face the reality of difficult communications, the coordinators use their personal skills; despite that they are not completely ready to face such issues. Nevertheless, the subjects also recognized the relevance of a service that could bring them some emotional support.

The activity would work to assist them to find self-understanding, so each one would find their steps to emotional education, which would be effective, as it would not come from either fixed models or from other generalizations. Aware of the possibilities that could be offered together with emotional support, the subjects’ previous objectives could be fulfilled if there was an emotional support service available. This would involve knowing how to deal better with oneself in order to not fall ill, to better deal with the emotions of the other and to improve the quality in the communication of difficult news. Based on all of this, we call attention to the relevance of emotional preparedness and support for the healthy mental life of the professionals who work and frequently deal with moral dilemmas, such as the expert transplant coordinators, thus urging the implementation of provisions to fill that blank.

 

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All authors participated in the phases of this publication in one or more of the following steps, in According to the recommendations of the International Committee of Medical Journal Editors (ICMJE, 2013): (a) substantial involvement in the planning or preparation of the manuscript or in the collection, analysis or interpretation of data; (b) preparation of the manuscript or conducting critical revision of intellectual content; (c) approval of the versión submitted of this manuscript. All authors declare for the appropriate purposes that the responsibilities related to all aspects of the manuscript submitted to OBJN are yours. They ensure that issues related to the accuracy or integrity of any part of the article were properly investigated and resolved. Therefore, they exempt the OBJN of any participation whatsoever in any imbroglios concerning the content under consideration. All authors declare that they have no conflict of interest of financial or personal nature concerning this manuscript which may influence the writing and/or interpretation of the findings. This statement has been digitally signed by all authors as recommended by the ICMJE, whose model is available in http://www.objnursing.uff.br/normas/DUDE_eng_13-06-2013.pdf

 

 

Received: 02/24/2014
Revised:09/10/2014
Approved: 09/10/2014