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Temas em Psicologia

Print version ISSN 1413-389X

Temas psicol. vol.25 no.3 Ribeirão Preto Sept. 2017 



Intensive care psychologist: reflections about professional insertion, professional qualification and practice at the hospital



Amanda Mom berger SchneiderI; Mariana Calesso MoreiraII

IUniversidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, RS, Brasil
IIDepartamento de Psicologia da Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, RS, Brasil

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This research aimed to investigate the specifities of the work of intensive care psychologists, analyzing aspects of their professional routines, difficulties and potential, major interventions with patients, families and healthcare teams, and also investigate their training and how it affects the professional actions that have been explored nowadays. The data was collected through a sociodemographic questionnaire and a semistructured interview. Seven intensive care psychologists were interviewed, active in two hospitals in Porto Alegre-RS, both in care units to adult patients, and in areas such as pediatric and neonatal. Information obtained from the interviews was subjected to content analysis from which emerged some topics for the subsequent interpretation of the results. From this analysis, a shortage in Psychology courses that enables students to the specifics of performance in healthcare and its role in multi-professional teams in the current Brazilian context was perceived. In addition, the survey also highlighted the need to adapt the techniques that these pofessionals already used in clinical care, both in terms of psychological assessment as in the care to patients and family and group interventions. The lack of studies on Intensive Psychology was overt, highlighting the need for more research in this area.

Keywords: Hospital psychology, intensive care, multidisciplinary teams, Psychology graduation, ICU.



In Brazil, the hospital as acting scenario of psychologists, related to care and health practices is still recent, especially when compared to the 53 years of regulation of the profession in the country. Approximately, in the 70s, it emerged the need and relevance of restricted activities of the psychologist related to a different target public, environment and social context, which gradually led to an adequacy of the clinical practice and its theoretical and technical tools (Maia, Silva, Martins & Sebastiani, 2005).

As occurred in other professional areas, this approach has a direct impact on the work of psychologists in the hospital environment, which requires specific skills and abilities for the development of activities that effectively contribute to health practices in this context (Tonetto & Gomes, 2007).

Another aspect relates to a historical moment in the country and its reverberations in the insertion of health professionals in general. In the case of Psychology, the labor market was saturated with independent professionals and the private clinic model was no longer enough. This situation impacted on the trajectory of psychologists, who sought other fields of work, among them, hospitals and their needs related to psychology. The first interventions conducted in this context were related to the functioning of the institution, seeking to create new services and qualify it, investigating the needs and establishing objectives. Thus, it can be said that in the hospital both the clinical and organizational practices of the psychologist were expanded, although clinic has been the milestone of the professional establishment of psychologists in the hospital field, forming what later appears as one of their specialties (Fossi & Guareschi, 2004).

The implementation of this new professional area, called nationwide Hospital Psychology, raised the use of technical and methodological resources of different areas of the psychological knowledge, not being only restricted to the clinic, but also to organizational, social and educational aspects (Fongaro & Sebastiani, 1996). Hospital Psychology seeks to engage with issues linked to the quality of life of users and health professionals, therefore, not limited to the clinical care, even this being a central practice of hospital psychologists.

The same occurs with the necessary technical framework, since the idea is not to define practices that are restrictive of a professional field, dividing psychology by acting areas and understanding that they are the responsible for the definition of their specialties, but be able to select and expand those that relate to specific contexts. In the case of the hospitals, a good example of this are the intensive care units, focus of attention of this research.

The Intensive Care Unit (ICU) is defined as "critical area intended for the admission of critically ill patients, who require specialized professional attention continuously, specific materials and technologies necessary for the diagnosis, monitoring and therapy", according to the Resolution No. 7 (2010) of the Ministry of Health.

The insertion of psychologists in the health team active in the ICUs is recent. In 2004 it was regulated the Department of Applied Psychology to Intensive Care Medicine of Associação de Medicina Intensiva Brasileira - AMIB ( The Ministerial Ordinance No. 1071 of 2005 recognized the obligation that each ICU must have a psychologist. The psychologist who works in Intensive Care is called intensivist and some of his functions together the patient consist of psychological assistance, considering the factors that may influence his emotional stability and the evaluation of the patient's adaptation to the hospitalization, considering his mental state and his understanding of the diagnosis, as well as his emotional reactions before the disease. The psychologist also works with the family welcoming, guiding and informing the ICU routines to the family members and visitors, offering them space for expression of their feelings and questionings about the patient's admission process. Together with the multi-professional team, it is a psychologist's task to respond requests of professional related to the psychological aspects involved in the hospitalization of the patient, and to encourage the contact between patient-staff and family-staff, seeking to promote adherence and understanding of the treatment by those involved in the hospitalization process (Santos, Santos, Rossi, Lélis & Vasconcellos, 2011).

The most commonly used psychological interventions can be of support, guidance or psychotherapy. In addition to the functions mentioned above, some other objectives may exist depending on the case and the ICU specialty. Psychological interventions can be performed with the patient, family and healthcare team, but always for the benefit of the patient. For his action to be performed satisfactorily, the psychologist should know the bases of Developmental Psychology, Psychopathology, the grieving process, the psychological processes involved in becoming ill, in addition to psychoprophylactic, psychotherapeutic or psychopedagogic interventions (Silva & Andreolli, 2005).

Considering these aspects, it is clear that the specialization in Intensive Care Psychology is a relatively new field of work, which requires different efforts and preparation different from those acquired in the professional training and involving a significant emotional, mental and physical effort (Smoermaker, 1992 in Gusmão, 2012). The psychologist must be prepared to deal with several situations, such as the frequent requests of patient and family, the intense working day, the contact with the pain and the death process, be subjected to pressures on the decision-making in critical moments, among other factors (Silva, 2010). The care of critically ill patients can either bring psychological rewards as well as the need to confront several frustrations. It is often observed in the professionals who work there the excessive use of defense mechanisms and that they may also suffer by having to be faced with an intense emotional distress, responsibility, fear of making mistakes, fatigue and difficult relationships established in multidisciplinary teams (Lucchesi, Macedo & De Marco, 2008).

The role of the psychologist in the ICU is due to the psychotherapeutic support that the patient needs because of the possibility to present a number of psychological disorders/disturbances, whether or not related to the process of illness and ICU hospitalization. The psychologist allows, thus, the patient to have a free expression of his feelings, fears and desires, providing him an elaboration of the illness process. Dealing with suffering, pain, with the change in behavior due to the invasive treatments and with the interventions that increase survival is an example of a situation that requires guidance of the Intensive Psychology (Gusmão, 2012).

Thus, this research seeks to analyze the profile of the hospital psychologist that operates in Intensive Care Units (ICU) in public and private hospitals in the city of Porto Alegre. To that end, we count on professionals with a consolidated presence in this professional field (ICU), seeking to understand aspects of their professional routines, difficulties and potentialities, major interventions conducted with patients, families and health teams, and also investigate about their professional training and how it affects the professional actions that they have been exploring today. This task is a challenge due to the little amount of scientific and academic productions about this specialty not only in Brazil but also in other scenarios.


Methodological Procedures

This research is a qualitative study of an exploratory nature.


The participants were seven psychologists active in adult, neonatal and pediatric Intensive Care Units (ICU) for at least 3 months until the moment of the interview, in public and private hospitals in the city of Porto Alegre, State of Rio Grande do Sul. The selection of the participants was, for convenience, through personal contacts of the researchers in the hospitals participating in the study. The participants are inserted in the ICU approximately 30 hours a week. Of all the respondents, only one is dedicated to other area of psychology, the private practice, and two of them also conduct care of patients hospitalized in areas of the hospital other than the ICU. Regarding the theoretical orientation of the interviewees in their clinical practice, five consider their services of psychoanalytic orientation, one systemic and one based on the cognitive-behavioral theories. For a better viewing of information about the participants, check Table 1.


The data collection occurred as follows: we first applied a sociodemographic questionnaire that sought to collect information about the training and professional activities of the participants. Then, a semistructured interview was conducted, which covered topics such as the choice for the specialty, activities and interventions conducted with the critical ill patient, the training in Psychology, activities together with the multidisciplinary team, as well as the challenges faced by the psychologist who works in ICU. The researchers seeking to know the realities of the respondent group created both the instruments.

Data Collection

The participants were contacted by telephone and invited to participate in the study. In the initial contact, the research objectives were clarified, as well as its procedures and approximate duration of the interview. After, the meetings were scheduled on a date and place of choice of the participants. On the scheduled date, the researcher moved to the location for the interview. After the presentation of the research, the Informed Consent Form (ICF) was handed over to the participants, so that the collection could continue. Then, the sociodemographic Questionnaire was applied and, finally, the semistructured interview. All interviews were recorded with the consent of the participants, so that the transcription could be performed later. The average time of the meetings to perform the interviews was forty minutes. All participants responded individually the interviews, being four carried out in the hospitals in which they were working and three on the dependencies of the Federal University of Health Sciences of Porto Alegre.

Data Analysis

It was conducted a thematic content analysis, focused on the development of categories aimed at the interaction of the content of the interviews with the theoretical support found (Hsieh & Shannon, 2005) was performed. According to the research objectives, the thematic categories were defined a posteriori, respecting the steps suggested by authors who have developed methodological frameworks for such qualitative analysis (Braun & Clarke, 2006; Campos, 2004; Hsieh & Shannon, 2005). Four emerging categories were defined, namely: Psychological interventions in intensive care, Peculiarities of the professional action together with the critically ill patient, Psychologist's insertion in multidisciplinary teams - opportunities and challenges and Needs in the professional training of the psychologist who works in intensive care. The contents encompassed in each category are presented below together with the results of the research.

Ethical Procedures

The present research was reviewed and approved by the Committee on Ethics of the Federal University of Health Sciences of Porto Alegre and follows the Resolution 466/12 of the National Health Council.



From the content analysis of the interviews conducted with the participants about their activity in the Care Units, emerged four a posteriori categories. The first category is called Psychological interventions in intensive care and refers to the psychological interventions used in the professional practice of the interviewees. In this category, two thematic axes have emerged, namely: interventions together with patient and family and group interventions. The second category was named Peculiarities of the professional activity together with the critically ill patient, in which the specificities of the everyday actions provided by the psychologist in the ICU environment were considered. This category comprises two thematic axes, namely the contact with terminality and adaptation and inclusion of new techniques and parameters of assistance and psychological evaluation. The third category was named Insertion of the psychologist in multidisciplinary teams - opportunities and challenges, and it was considered the exchange between professionals of the multidisciplinary team and psychologists, the space of the professional of Psychology in these teams, as well as the difficulties faced for the action together the team. The fourth and last category refers to the Needs in the professional training of the psychologist who works in intensive care, and these refer to the characteristics of the professional training of the participants, considering the demands faced in the daily life of the profession in the hospital environment.

Following are the emerging categories, illustrated with speeches of the participants to better systematize the contents placed. In order to preserve the identity of the professionals and at the same time differentiate them, we chose to use the letter "P" of participant together the number of the interview.

Psychological Interventions in Intensive Care

Regarding the patient, it is important to note the possible psychological actions to be applied in the environment of intensive care, considering that it is a stressful environment, with high movement of persons and restricted visiting hours. Similarly, it is sought to report interventions conducted with the family of the patient, who undergo an interruption in their routine, given the uncertainty of the diagnosis, the confrontation of the unknown, and often, they leave to care of themselves to devote full attention to the family member hospitalized. As stated by one of the participants: "... we begin with an evaluation of the patient, evaluation of the families, monitoring of these families, and many as sistances in crisis moments ..." (P1). Another participant pointed out that:

... the focus is clinical, it is the assistance to the patient and family. Basically this is it, it is the monitoring, an initial evaluation of the patient, an evaluation of mental condition, and even to evaluate his condition to receive the service at that moment... . whenever we can, we also seek to assist the family, to understand a little more of the patient, his context, his history. (P2)

The second theme addressed constitutes the interventions accomplished in groups. Although only three respondents conducted group interventions, the others also highlighted the importance of this strategy. However, for several difficulties they cannot implement it into their routine. The groups formed by the interviewed psychologists have psychoeducational character, seeking to guide families and caregivers about the routine of the unit, the rules, clarification of doubts and presentation of the team, as reported by the participant:

It is an operating group, psychoeducational. The aim is to present the routines of the ICC for the family. This is diary. There is an agenda for each family of patients who ingress so that they can pass through this group and learn about the ICC. We talk about the routines, the staff, talks a little about the equipment, the support that they will find. We also guide with regard to the visit in the ICU and all the recommendations for infection control, the care that they need to have. Always there are a doctor, the psychologist and the nurse. (P4)

Besides the interventions mentioned above, the practices of the psychologists suffer some adjustments to be accomplished satisfactorily. Next, the peculiarities of this action in the context of ICU will be cited.

Peculiarities of the Professional Action Together with the Critically ill Patient

Considering the ICU environment as very dynamic, where the psychologist needs to use the technique in a different way than that used in conventional clinic, the participants brought the adaptations of the psychological techniques, as well as the inclusion of new strategies and parameters of assistance and evaluation.

One of the emerging focus concerns the psychologist as a professional who follows extremely delicate moments; of deaths, bad news, and welcomes the pain and feelings of hopelessness of the patient and his family:

It is a heavy and intense environment that puts you there in reflection about the threshold of death. You recognize it, as if you had running into situations there, often you see as if it is a mirror. You are going to deal with the suffering of others, and then you have to know that this is what you want to do. (P6)

In addition, it was addressed the importance of the psychologist to take time to preserve his health, whether physical or emotional. As reported by one of the participants,

It is a tense environment, when we realize, we are also always tense, and having contact with very complicated situations that affect us... . this is positive, because I think we can be more empathic, but we also need more time to take care of ourselves to be able to be present with quality. Moreover, when we are many hours in helping people, there is not enough time to take care of our health, and then, sometimes we are not as totally good as we could and should... . This is part of our training, so to say, the self-care is as important as the technique. Because feeling well with ourselves, being there in full, being able to study, with fresh head to study things that we do not know to be able to better assist the families. Thus, for us to be in this way, we have to feel well with ourselves, even in our personal life, I think this is the starting point. (P7)

The second topic addressed in this category refers to the adaptation and inclusion of new techniques and parameters of assistance and psychological evaluation, and concerns to what the participants regard as psychological practices that they had to adapt or modify to work in the hospital environment, specifically in the ICU. One of the examples cited was the following:

... regarding the very urgency of things. Sometimes it is a little difficult this issue of the assistances, anything involving the organic treatment has to be prioritized; it is a life risk many times. So sometimes, this is a difficulty, being on duty and having many interruptions. (P2)

Other examples were also cited by the participants as those referring to the necessary adjustments mainly regarding the therapeutic setting, the priorities and focus of assistance, presence of the family or team members during the session, length of the assistance, etc., such as in the passage mentioned by one of the interviewees:

Inside the hospital we have a lot of the practice, but it is a very specific context, a lot of shorter assistances, with a very different therapeutic setting that is we who have to form, we have to find a way, whether in the hallway or in the bed, where there are many interventions, many professionals entering. They are assistances in which you do not know if you will see those persons in the next day, so they are assistances that you have to be able to make a start, give support and make a closing always. (P7)

In addition to the necessary adaptations to their practice in the ICU, the psychologists, in some cases, are challenged to be added to a team formed by different health professionals, seeking to add and share knowledge. Next, it will be addressed the insertion of the psychologist in these teams.

Insertion of the Psychologist in the Multidisciplinary Teams - Opportunities and Challenges

In this category is exposed the perception of the respondents about their integration into the multidisciplinary team, the difficulties in team work and what the participants think that are achievements in the joint practice. Moreover, their considerations about what should be happening as a practice and it is not yet being accomplished, emerged. Bringing an example, the participant reports:

The team discussions in the round are very valid, so that we can understand the context of the diseases, because the family will ask you. So I think it is important that we understand together with the medical team, studying hard these questions we do not have much in our training, both for us also put our perception, our view, which is different ... We have increasingly to put our look at the staff, place ourselves, knowing the time, the place to place ourselves, to let people to understand more and more. I think that knowing more and more, they realize how this can contribute for the treatment. (P7)

Turning to another point, some of the difficulties mentioned by the participants were the followings:

It did not come to me in exact term, but I think that it is still the issue of doctors. Feeling the most, thinking the most, I do not know but too sovereign in relation to other specialties, other formations, still has much of this. It is difficult to reach them, I would not say that it is to all but some, there is a difficulty to reach them. (P3)

Team performance requires a daily exercise of interaction between professionals, which could be better worked on during the professional training. Next, the perceptions of the participants about the inclusion of these abilities in their educational path will be addressed.

Needs in the Professional Training of the Psychologist who Works in Intensive Care

This category covers the reports of the participants about what could be implemented in their training, since their graduation until the quest for their specialties, considering what is required of them in their daily practices. The first point to be cited is the following:

Thinking about these issues involving Hospital Psychology in a more direct way, death, illness, I think these issues that are more related to death itself we do not see much. At graduation, we see some things, but I think that maybe to be able to think a little more about these processes, end of life. I think that is a little defective, but I think that one graduation would not be able to cover these issues. (P2)

In a context more focused on the preparation of the psychologist to interact with other professionals, members of the professional team, it was raised that:

... what has been lacking much is this interface with other professions. You really lacked to have something more of integrated work indeed, multidisciplinary work, be able to learn some more theoretical things, but in fact you can exercise this, not only in the internship, I think internship is a proposal, but I could be a little more, It is a little stronger this issue of interface with other professions, and integrated work even on health. (P4)



Regarding the interventions performed by intensive care psychologists, Torres (2008) mentions that the psychologist plays the role of stimulating the patient to receive information about their clinical condition, treatment to be performed and his prognosis, and providing a space for the patient to elaborate the experiences arising from this process. Accordingly, Caiuby and Andreoli (2005) still believe that the role of the hospital psychologist is to actively participate in the care, reinforcing adaptive functions of the ego, reassuring the good perception of reality and clarifying the characteristics of the patient, or episodes of his life, which may be involved in the current conflicts. Thus, the psychologist seeks to reduce distress and anxiety, helping the patient to increase his knowledge about his psychological condition and face his current life situation. Another role of the psychologist in this context, according to Andreoli (1996) would be putting himself as mediator between patient, family and multidisciplinary team, seeking to stimulate dialogue and undoing the knots of communication. According to the author, brief therapies are resources widely used by the psychologist in the hospital context. The psychologists interviewed in this research report practices similar with those found in the literature. They highlight the importance of the psychologist to identify the positive characteristics of the patient, who may function, in some way, as an attempt to protection in the face of crisis for promoting adaptive defense mechanisms of the patient at this moment in which they become essential. Besides, they mention the importance to identify the patients at greater suffering due to an exacerbated anxiety and/or distress, and offer them a moment of listening and support for the relief of negative feelings. The participants did not raise experiences relating to assistance of patients sedated, intubated or in coma. It is thought that, at the time of the interview, when questioned about what interventions they use, the participants may have understood that the researcher referred to those patients in conditions to express themselves verbally.

As for the role as mediator between patients and families and multidisciplinary team, the participants reported some difficulties in assuming this role. Despite believing that the psychologist can aggregate to his practice the mediation between patient and staff, or family and staff, this type of intervention seems to be impaired by issues relating to the context. It is understood that this occurs due to the reality experienced by the psychologists in the hospitals where the interviews were conducted. The places of practice refer to psychologists a marked number of assistances to patients and their families, however the workforce of active psychologists in the hospitals is not enough for contemplating, often, the dynamics involved in the complexity of the cases treated, making some aspects of the activity of the psychologist to be predominant. The participants believe that it should be accomplished a work with the professionals of the multidisciplinary teams that could reinforce the importance of the communication with family members and patients, as well as the subjective issues involved in the process of hospitalization of a person. Thus, the cases in which it is necessary an intervention on the part of the psychologist concerning patient/staff and family/staff communication, would not need to occupy such a significant space in the assistances that the psychologists provide to patients and families. Although the literature mentions brief psychotherapy as one of the main strategies, the report of participants denotes the priority use of supportive care and interventions in crisis, being brief psychotherapy rarely used. Brief psychotherapy, according to the participants, is used in the case of the patient to stay for a longer time hospitalized in the ICU and demonstrate need and conditions to go through this process. It is believed that this difference is given due to the rapid evolution of the conditions of patients and, consequently, the assistance is usually done in a punctual manner, both in terms of dynamics and need of cases treated. Besides, possibly such strategies are selected by the respondents because of their activity to be predominant in the ICU, since, as reported by them, it is not usual to actuate in areas of the hospital other than the intensive care.

Lazzaretti (2007) states that it is the psychologist's role to guide the family about the best way to deal with this stressful situation. Torres (2008) believes that the intervention of the psychologist can facilitate the families to review their roles and adapt to the new requirements arising from the illness, as well as occupy the position of caregivers. In this regard, the activity of the psychologists interviewed meets the mentioned in the literature. What they carry out with the family of the patient is a work of welcome, support to tackle the crisis they are going through. Besides, they help the family members to place themselves in a position of caregivers, however, without neglecting their needs as well as to adapt in relation to the new roles in the family structure and identify the possible complicating factors of a loss process - not only mourning for the death of the family member who fell ill, but for the loss, whether of the health, a condition, or a reality. The reports of the psychologists about their practice together with the family corroborates the findings of the literature, understanding that the monitoring of the family is part of the psychologist's work in the ICU. The interventions are aimed at helping the family to go through this time of crisis in a less traumatic way as possible, and it is a practice that brings benefits to everyone involved.

Besides acting with intervention to the patient and family, the psychologist may also perform group intervention that allows to reach a greater number of people, which becomes extremely important in context of the hospital, considering the high demand (Scannavino et al, 2013). The psychoeducational group aims to clarify, guide and inform about the clinical characteristics of the disease and hospital routines, seeking to offer higher subsidies to the families in confronting the disease, enabling better adherence to the treatment and prevent the recurrence (Nicoletti, Gonzaga, Modesto & Cobelo, 2010). In the group, the work of psychology is to minimize the anxiety of the family, as well as observe the reports and behaviors regarding the situation faced and the hospitalized family member that the participants can bring and can assist in the aftercare (Baptista & Dias, 2010). The objectives of the group interventions brought by the interviewed are in accordance with the findings of the literature. Groups of psychoeducational character are conducted as an alternative to cover a larger number of people, in order to inform the routine of the ICU and clarify doubts about procedures, treatments, to the family. The group aims to guide the accompanying persons for visits and clarify questions that may arise, in addition to seek identifying the family members who need individualized attention. Despite all the participants to affirm the importance of group intervention in the hospital practice, only three perform this type of intervention. It is assumed that probably this is due to lack of physical space for conducting groups in some hospitals, as well as other difficulties of the professionals to discontinue their practice due to the large number of patients assisted individually. Besides, it has to be considered the poor adherence of other professionals of the multidisciplinary team in activities focused exclusively to promote health and that escape their ordinary and traditional practices of assistance.

Considering the intensity of the work with intensive therapy, different feelings can be awakened in the psychologist in the face of the delicate situations experienced in ICU. Therefore, it is highlighted the need of the personal care of the psychologist. Torres (2008) believes that the psychologist can experience paradoxical feelings before critically ill patients, since the work with them does not correspond to the traditional model of a psychological assistance. Silva (2010) states that the work of the psychologist in ICUs requires great physical and emotional involvement, whereas the professional deals with pain, suffering, anguish, demands and requests for attendance of different orders, which favors the development of stress and other diseases of occupational character. Veiga (2005) suggests possible sources of stress associated with the practice of the psychologist in the hospital, for instance, the constant contact with pain, death and suffering, problems of insertion in the health team, submission to the rules of the institution, emotional involvement with patients, works with patients unwilling to the care, crises, lack of training in the hospital area. Sanzovo and Coelho (2007) highlight the importance of the psychologist to create strategies to cope with situations that generate stress in the day-to-day, and, in addition, the knowledge and abilities acquired through experience can help to tackle such situations. The authors highlight the importance of the self-care of the psychologist, so that his interventions can be appropriate, and that his mental and physical health are not compromised.

The participants corroborate what affirms the literature, because they consider that the ICU environment is heavy, influencing personal emotions and that requires from the professional a differentiated preparation to not be emotionally affected, but also not to distance to the point of being indifferent to the patients. They highlight the need for the professional to receive psychological counseling, considering the situations they face and the possibility of identifying or mobilize excessively with their patients, which also occurs in other areas of the clinic. It is believed that the need for personal care, both physical and psychological, is very important in the face of the daily practice of the intensive care professionals. Besides, the psychologist has to face a different working reality from which he was prepared in his training, and the search for the continuous knowledge, as well as the exchange of experiences with other colleagues generate better conditions to confront complex situations.

Among the many difficulties faced by the psychologist in the ICU, the need to adapt his action is one of them. The treatment is objectifying and the psychological and social aspects, which are important parts of the subject and that influence his survival, are generally neglected or viewed as less important (Palavicini, 1995 in Torres, 2008). To Simonetti (2004) the psychological assistance in the ICU presents challenges besides being inserted in the team and deal with the objectivity of the environment. Some challenges cited by the author would be the fact that most of the patients hospitalized there have difficulty to speak, either because they were sedated, unconscious, confused, intubated or even depressed. The author suggests that the psychologist should create new forms of language to communicate with these patients. Caiuby and Andreoli (2005) consider that the psychologist should not stick only to the psychological problems of the patient, considering also the interfaces of the psychological and physical. Meeting what brings the literature, the psychologists interviewed emphasize the need to adapt to the objectivity of the ICU, especially the by the speed with which the situations are changed in this context. Always closing the open questions during the assistance is one of the biggest challenges of this activity for the participants, because in the next day it may not be possible to assist the patient. Another issue cited by the participants is always to seek information about the disease and treatments and how these can affect the mental health of the patient and also to assist the family, who often seek all information possible about the disease. Finally, the issue of the psychological language being differentiated, because there is much talk about the subjective and the issues that, often, differentiate from what discusses the rest of the team. It is considered that the need of the adjustments above comes from a discrepancy still experienced between the preparation of the professional of Psychology and the requirement for the practice in the environment of the ICU. The theoretical and technical training in psychology degrees generally is focused on an activity in which the psychologist will have more time to work subjective questions of the patient, as well as a greater facility to communicate with the patient, in a setting without interruptions and with determined time, similar to the conventional practice. However, it is believed that the professional who decides to enter this area is concerned with the integrity of the patient, and focuses on studying the interaction between physical and psychological, being more inclined to deal with the adaptations required by the hospital environment. Besides, among the participants it is evident the search for a training at postgraduate level aimed at handling deficiencies in their training and that they understand as requirements for the action in the area.

Another characteristic required in practice is the teamwork, and not in an isolated way as in the psychological clinic. Torres (2008) talks about two possibilities of assistance to hospitalized patients involving the team. The first would be the assistances by request, which can serve as a stimulus for the exchange of information between professionals, seeing as object of intervention the doctor-patient relationship and not only the patient. The second would be a model where routine interviews are conducted, and the psychologist comes to know all patients hospitalized, being able to actively participate in the medical visits and case discussions. The focus of the discussion becomes the aspects perceived in the patient, while not excluding the possibility that the patient-physician, patient-staff relationship is object of intervention. However, for the request to happen it is necessary that the team knows the objectives of the psychologist's action in the ICU.

Chiattone (2000) highlights that, often, the psychologist himself is not aware of what their tasks and role within the institution are, while the hospital also has doubts as to what to expect of this professional. By having clear his objectives of action, the psychologist insertion in the team is facilitated. An important aspect in the interaction with the staff is the psychologist to help the rest of the team in observing emotional aspects of the patient and their body language, in order to quickly identify needs of attention and demands (Lucchesi et al., 2008). The participants emphasize the difficulty of other professionals to understand the role of the psychologist within the multidisciplinary team, as well as the importance of preventing psychological trauma resulting from the hospitalization in the ICU. It is understood that, due to Psychology having entered the hospital environment recently, when compared with other professions that compose the team, the role of the psychologist in this place can still be exploited, both by other professionals and by psychologists. In practice, the psychologists interviewed report to act either by inter-consultation, or by routine. Sometimes it turns out they can intervene in some specific situation of the staff-patient relationship, especially working directly with the team, by believing to be an important part of their work, because it has a direct consequence in the recovery of the patient.

Participants also point to the importance of teamwork, which can indeed be a challenge to the psychologist, but all reported to be a positive experience, even reflecting that their training has been focused on individual practices and somewhat fragmented within the area of health. Meeting what brings the literature, the psychologists interviewed argue that the rest of the team needs to better understand the importance of treating and preventing subjective aspects with the patients of the ICU. As for the team work, it is believed that currently it is sought a greater integration between health courses already during the graduation, either in elective disciplines, in scientific events or extension projects. The courses have gradually turned to a greater preparation for action in public health and team, providing a more complete view for the joint action of those who are dedicated to the area of psychology in health care. For the action to be more effective, it is necessary to meet a demand that is the lack of available professionals, especially in public health. The participants brought that the amount of assistances is higher than the availability of time, and that possibly, with a larger number of contracting of psychologists the demand would be better met. Not only assistances to patients and families, but also the staff, which is often in intense suffering and cannot find the necessary support to continue their work. The action of the psychologist may be more comprehensive, when inserted in a team, conducting groups, assisting in the staff-patient relationship, among others. It is believed that with the strengthening of the specialty, other practices of the psychologist in the ICU can be implemented and developed, which generates benefit to the teams, patients and their families.

The trend is that the better the preparation of professionals, the more will be noted the importance of the insertion of the psychologist in the hospital. According to Castro and Bornholdt (2004), the psychologist, to be able to work in health, should consider whether his training gives him the necessary foundations for the practice, that is, the learning has to prepare other than theory and technique, but also the importance of social commitment, dealing with the health problems of his region and be able to act as a team. Some authors believe that, in Brazil, training in psychology is deficient when analyzed for the knowledge it provides about sanitary reality of the country, participation in research and health policies (Dimenstein, 2000; Sebastiani, 2003 in Castro & Bornholdt, 2004). The formation of the psychologist should consider issues involving increasingly, discussions on Public Health, Promotion and Health Education, Epidemiology, and Health Policy (Maia et al., 2005). The psychologists interviewed believe that there were gaps in their training, mainly in relation to the teamwork, regarding the reality that they would face in the ICU environment and the public policies that span the hospital. Besides, they think that their formation was focused on the clinical work, having been presented few alternatives to meet these demands. One alternative thought could be the expansion of the studies in Health Psychology through the reflection on the origin of certain diseases and the role of behaviors, risk and protective factors, associated with the health/disease process.

With the exception of one of the interviewees, who claims to have studied public policies during his training, the other three respondents who work in public hospitals affirm to judge this an important gap, since public policies intersect their practice. It is thought that the fact of the graduations in Psychology to value the clinical area is due also to the historical roots of the courses. However, the reality of the courses in Psychology seems to be updating itself in the face of the current context, focusing increasingly on health, research and the different contexts of the psychologist's action, forming more complete professionals and better prepared for different areas in which psychology is inserted.

It is understood that the courses in psychology have no condition to cover all the different specialties of the profession in their deepness. A possibility is to offer contents transversely and provide moments in which the students engage with professionals acting in different areas and that present properly the everyday of the profession in that context. Encouraging more students to conduct researches in the health area are also alternatives to complement the formation.



The present research aimed to provide a field of reflection on the insertion of the psychologists in the intensive care. From the interviews conducted, it was perceived a lack that is still present in the Psychology courses, in general, of contents that enable the students to the specificities of the activity on health in the current Brazilian context, both with regard to the public and private sector. Some gaps still exist when examining the knowledge in public policies, action in multidisciplinary teams and researches in the area.

Regarding the action in Health Psychology, specifically the Intensive Care Psychology, it is necessary that the psychologist be in constant update, seeking to equip himself with all the knowledge possible to feel increasingly integrated into the ICU practices. It is also emphasized the importance of personal care for the psychologist in this field, considering the intense emotional charge, the demand for assistances and the particularities of these, in the sense of working in a charged environment, with different situations of losses and the need to act in situations of emergency and often traumatic.

The research also highlighted the need to adapt the techniques already used in the clinical care of these professionals. The particularities of the ICU require adaptation and search for theoretical subsidy for conducting both assistances to patients and families as with regard to the psychological evaluation and group interventions in these contexts.

However, even in the case of an exploratory study, it is assumed that the results of this research may have been influenced by the fact that psychologists from only two hospitals in Porto Alegre were interviewed, which allowed to examine only two specific professional fields, although it has been attempted to select one in the public and another in the private sector, seeking to understand the two contexts. Another aspect that was not explored in depth in the interviews, but that during the content analysis was relevant is that concerning the ethical issues involved in the daily practices, both with regard to situations of terminality or prolongation of life, and those relating for example, professional secrecy of the psychologist versus sharing of information together with the multidisciplinary team.

It is believed that one of the limitations of the present study may be the disparity in the time of activity of the participants interviewed, being possible to think for future studies to evaluate experiences and reflections of professionals with similar time of activity in ICU.

With respect to new researches, it would be interesting to address the reality of this professional field in other states of Brazil, or also analyze the perception of other professionals that compose the multidisciplinary team about the insertion of the psychologist in the ICU, their potentialities, challenges and intersection with other areas of health. Complementary to this, it is believed in the relevance of the researches that could analyze the political pedagogical projects and curricular bases of the undergraduate courses in Psychology, seeking to analyze how are inserted contents that subsidize the actions of the psychologist in health.

Finally, the research highlights the lack of studies on Intensive Care Psychology, showing the need for more researches in this area, including publications that report assistances of cases and other experiences in the area, showing the reality of its practice and the technical adaptations necessary, so that it serves as a theoretical subsidy to professionals who wish to enter the area.



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Mailing address:
Amanda Mom berger Schneider
Federal University of Health Sciences of Porto Alegre, Department of Psychology
Rua Sarmento Leite, 245, Prédio Principal, sala 208
Porto Alegre, RS, Brazil 90050-170

Recebido: 29/01/2016
1ª revisão: 12/04/2016
2ª revisão: 25/05/2016
3ª revisão: 24/06/2016
Aceite final: 29/06/2016

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