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INTRODUCTION
The critical care units are characterized as being environments prepared to patients care who have a death potential risk.1 Under this approach, organizational support must be complex, requiring technological and human resources trained to meet the care demands for patients and their families.2-5 However, the Intensive Care Unit (ICU) of "Dr. Abel Gilbert Pontoon "in Guayaquil, has limitations in the human talent endowment, especially nursing staff, which affects in one way or another the care quality provided to patient.
In this context, nursing constantly seeks conditions to maintain and improve to service offered quality, as a work mystique, ethics and humanism, values attributed to professional ethics code,6,7 that is, the ethical conscience reinforcing is a professional obligation. However, this staff complains of fatigue, stress and is even accused of a disinterested practice and poor understanding of the patient's vulnerability. In that sense, the ICU patient is characterized by being dependent on nursing care, that is, it requires 24 hours of attention to achieve their health needs; in such a way that the care of these critical patients becomes the existence central axis of critical care units. For the professionals of these units, care is considered beyond biologic care, to become a reflection on the protecting action or helping the other in a meaningful way in nurse-patient therapeutic relationship.8,9
Under this approach, we cite Sandman, Molander, & Benkel10 who see reflection as a nursing care basis, linked to bioethical postulates; that is to say, of the theoretical abstraction that implies a morally acceptable behavior. In the critical patient, their ability to express their thoughts, feelings and, of course, the suffering due to their health state is diminished. However, the bioethical care of nursing in these patients allows to integrity recognize of human response to pathological processes that they live, as well as the interrelation of this with their physical environment. In this sense, nursing reflects its performance in a way that seeks to provide a humanized care that reflects a bioethical conduct, guaranteeing the satisfaction of critical patient from an integral and holistic perspective.11
The foregoing can be corroborated with the Cantos12 proposals on bioethical care, the person integral care, the family, the community and their environment, helping to maximum develop the individual and collective potentials that allow to state optimal health safeguard in all life stages. In this sense, Nursing experiences in its daily life the phenomenon of overcoming its limitations and work stress, above the bioethical care of the critical patient.
In the case of the Abel Gilbert Pontón Hospital, nurses refer to a preliminary diagnosis that their performance is generally based on medication administration and biologic care based only on the pathological, leaving out the biopsychosocial relationship, which implies unsatisfactory care and deficient bioethics.13
As stated by Rosero; Ibarra; Silver; Mena, & González,14 as well as Collado Quezada, & Parra,15 the vulnerability degree of health personnel facing the conditions of hospital environment is high, facing technological, physical and human environments of complex and vulnerable management , which has a direct impact on ethically satisfactory care. Technology in care should be seen as a support; However, this technology can compromise a rationality based on care, it takes an effort in bioethical care not to get lost in technological environment and away from a humanized care.16 Under this approach, the study nurses allude that limitations situation and work stress is given by the work overload that complexity generates of a critical patient, and a hospital environment, coupled with a marked shortage of nursing personnel. This situation demonstrates the organizational support lack to manage ethical problems in a consistent manner.17
Given the above, and as a preliminary step to design solutions, the research purpose is describe of nursing bioethical behavior in patient care for intensive care unit of Guayaquil Specialty Hospital of "Dr. Abel Gilbert Pontoon. "
METHODS
The study uses a qualitative approach, under the localized clinical ethnography methodology.18 The paradigmatic approach is interpretive and hermeneutic, trying to give meaning to experiences lived by the nurses themselves to daily life within the studied ICU, without losing the hermeneutical perspective. In this sense, it was a study in the critical care unit, paying attention to bioethical behavior in nursing for patient care, in such a way that it is considered a clinical ethnography.
The key informants of this study are 4 nurses working in the Critical Care Unit of Abel Gilbert Pontón Hospital, with more than 3 years of experience who expressed their interest in study participating, providing all the necessary ethical considerations. Key informants are people who can provide information about the study element. In the present research a data saturation was achieved as the findings are interpreted, reaching the fulfillment of study objectives. The data collection was carried out after an extensive explanation to the study subjects about the ethical considerations, especially the informed consent.
The technique used in this research was the open interview, focused on research objectives, allowing direct interaction with the research subject, and therefore knowing the experiences as they are lived by informants as established by Morse.19 The interviews were conducted individually to four Nurses of the Critical Care Unit, with prior agreement of time and place, using audio recorders, which allowed to collect the experiences opinions and then organize and analyze the results obtained. The chronology used in data collection, was based on a first time to conduct a ICU survey in the Hospital studied, conducted by a doorman, who also works in the critical care unit under study, voluntarily accessing being part of the investigation and contacting the other informants, the interviews were conducted within a 4 months period, according to available time of nurses in their hospital daily life.
The authors of the present study consider the credibility criterion to determine the truth value of data collected as established by Taylor, & Bogdan,20 to confirm the findings and review some particular data. The researchers reevaluated the informants during the information collection. In this sense, most of informants were able to errors correct of facts interpretation, and for that they took care to give more examples that help to researchers interpretations clarify.
RESULTS
Table 1 represents Phase 1 of the findings organization, which consists in data meanings assignment and transformation into categories. In Phase 2 (Table 2) the data process categorizing was carried out.
DISCUSSION
The discussion was made based on 3 relevant categories during the analysis phase, which are presented below:
The commitment and attitude in the Nurse-Patient relationship when providing care in critical units that reflect a moral quality of bioethical and humanistic care.
The moral quality in Nursing care from a bioethical and humanizing perspective, is understood as the commitment and attitude in Nurse-Patient relationship at the moment of providing care to critical patients; this relationship has a bioethical and humanistic perception. Under this approach, we bring up the results obtained in the interview with informants, who say that "nursing care expresses life, with warmth and quality" referring to welcome feeling and comfort that occurs in nurse care to patient. This sensation is interpreted according to their own perception of warmth and quality, evidencing themselves when they express that "care is life" with moral qualities of bioethics and humanization.
The aforementioned can be corroborated with what the literature expresses "... the warmth is implicit in the patient's satisfaction, focused on treatment that is provided, willingness to listen to him, understand him and make him feel attended and comfortable".21,22
On the other hand, quality is understood as the patients' expectations scope; Although in this study it is a critical patient, who may be unconscious, the nurses assure that they must satisfy the quality care expectations to patient and see it reflected in their prompt recovery.23
The bioethical and humanizing perspectives of care are based on a moral quality, since they allow to establish a link with the patient person to person, strengthening the human integrating potentials, present in both the nurse and patient, impregnated with a series of moral and bioethical values that lead to satisfaction of the care need.24-26) This moral quality of care is behavior evidenced of study nurses. There is interest in showing care that can be perceived as comfortable, pleasurable and protective, that is, translated into warm care reflecting behaviors that guarantee quality care, by caring to comply with the scientific principles and patient safety, understood as protectors of critical patient's life and based on bioethical and humanistic principles.
In relation to commitment moral quality, it was indicated that "the commitment is great because despite the fact that human resources are little we do it with a love lot." The moral and ethical agreement of patient care can be observed, since nurses feel responsible (according to their conscience and human condition) to patient consider as a vulnerable being that needs understanding and care with quality and warmth.
For the nurses studied, the patient in a vulnerable and unconscious state is as important as any other patient, indicating an ethical point that provides care with justice and autonomy. The foregoing, corroborated with the statement by Waldow27 "Nursing is a profession that has the privilege of being together with the patient, offering comfort, not only physical, but emotional, regardless of their condition."
Regarding communication and interaction, expressed by subjects "one is going to treat it in some way to help them, that is, everything is based on patient empathy, in nurse-patient relationship". This is confirmed by Muñoz28 when he states that "... Nursing is a profession based on relationship between the nurse and the person who requires their care". However, this nurse-user relationship is decisive in quality terms and satisfaction of care provided, and in turn in person well-being, with the help relationship being an accompaniment that goes beyond the biological, through of empathy and dialogue. The help relationship is expressed is not only an intervention in Nursing, but it is the essence of this, from which the rest of care is initiated.
The study nurses reflect in the expression indicated that communication is valuable in critical patient care, taking into account that even without being conscious, the patient establishes levels of communication and interaction that allow to provide a satisfactory care. The study nurses consider that patient's responses to care, such as vital signs alteration, stimuli responses, treatment and others, are a form of communication and interaction that must be taken into account with a bioethical and humanizing perspective.
Nursing care includes effective communication involving a nurse-patient interaction"29 Care as a moral value represents the nursing ideal to maintain respect for dignity of the person requesting care. The Watson approach30 emphasizes that ideal and care value is a starting point, a posture, an attitude that has to become: desire, an intention, a commitment, and a conscious judgment that manifests itself in acts concrete. As an interpersonal relationship, care favors the meaningful interaction between the person being cared for and the caretaker, in which knowledge and feelings are incorporated, together with the skills, and safety in the technical procedures execution.
Attitudes of empathy and acceptance of patient as a care recipient that recognizes bioethical and humanistic values.
A humanized accompaniment of critical condition patient is reflected by the empathy attitudes, the patient acceptance as subject receiving the care, and the nurse's reflection on the humanistic and bioethical values of a therapeutic relationship in an unconscious patient.
The empathy identified as the a code result was considered as humanistic competence par excellence of nursing care. The caring experience is based in need identification of the other, nursing being a discipline based on empathy to ensure satisfactory care. In this line Watson, & Smith,30 define care as the moral idea in the profession, ensuring that caring is not a procedure or an action, it is a process of shared feelings between nurse-patient.
The values and care practical aspects take into account the patient human nature, the critical patient is not in all their cognitive capacities, being more vulnerable in unfamiliar surroundings such as the ICU, considering the patient as a person with limited behaviors. The study nurses assure that sometimes decisions must be made about the progress and patient care, even if it is with a negative prognosis, consulting the relatives who sometimes are not in a position to decide. However, nursing assumes a consideration role and respect in decision making.31
As the nurses of study show, "Their refusal is seen for different religious reasons or they can be of any personal nature, and we emphatically try to reach a mutual agreement, but without disrespecting their decision". In this sense, the role of relative related to patient helps in the decision.
The moral behavior that nurse reflects in care perception is the training received result, being responsible for providing comprehensive care to vulnerable subject. Jover, & col32 express the same idea when they conclude that "Professional competencies, human care (...) produce security feelings, tranquility, feeling person allowing the patient a close and trusting relationship with the nurse who performs individualized care ". The study nurses assure that they are responsible for bioethical and humanistic care of critical patient and show that the care quality is a moral commitment as caregivers. Responsibility for care is valued as awareness of caring consequences for a critical patient.
The responsibility expressed by nurses investigated was related to recognition as a bioethical and humanistic value in critical care. Care is related to an intersubjective relationship, the nurse abstracts from personal reality, making a self-perception to objectify their needs. From this interaction are derived qualitative actions based on love, respect for person dignity. "Nursing builds its own action culture based on their daily life",29) this is how the study nurses show "the daily support to patient in their environment during their stay is our responsibility until their last stay at the Institution", evidenced the support for integral care and its environment.
Emotional, social and cultural understanding of what it means to be in a critical care situation according to patient perspective and his family.
In the approach of globalization and technification, nursing is no exception. Without a human understanding of care, this technological advancement could lead to a biologicist reductionism of nursing care.
The critical units care allows maintaining the patient life support in conditions of death risk. However, care goes beyond life support. This care includes the emotional, social and cultural understanding that for patient and their family means being in a critical care situation. The human nature of nursing leads its professionals to be aware of need to understand a critical situation, expressing the study participants that "the most difficult thing is to see when a family member wants the patient to be disconnected from assisted ventilation", interpreted as a painful decision.
In this sense, the nurse lives the experience of accepting that care can be seen as fatal, that does not cover the family members expectations of a healing, this feeling of impotence present before care has bioethical implications, both the patient and his family, expressing physical, mental and social exhaustion before the uncertain prognosis of critical patient. Likewise, the subjects investigated expressed that "making a critical decision in nursing is related when there is a patient's refusal to receive certain care.
FINAL CONSIDERATIONS
It is possible to bioethical behaviors describe of ICU nurses in the critical patient care, obtaining as a result that the commitment and attitude in nurse-patient relationship when providing care in critical units reflect a moral quality of care bioethical and humanist. The care bioethics is based on moral quality that allows establishing human links between patient-nurse.
In relation to objective, it is concluded that the care takes into account the human nature of nurse-patient relationship; evidencing the meaning of respect and responsibility in critical patient care. However, the results show different feelings or divergent behavioral reactions such as face impotence of reality experienced in the ICU, where on occasions it does not achieve the goals of satisfactory care, due to implications of hospital's administrative management, both the material as in human talent.
On the other hand, the critical patient bioethical care of the Abel Gilbert Pontón Hospital: is a response to relationship between the nurse-patient in a situation of critical patient vulnerability, demonstrating that nursing has been incorporating into their daily practice the reflection on the caring action, taking into account the patient rights, based on an effort considered superhuman; that is, beyond the personality limits in nurse, emphasizing the bioethical and moral principles that humanize nursing care.
