Emotional Meanings of Clinical Practice with Head and Neck Cancer Patients: a qualitative study with Brazilian professionals

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Method A qualitative study was carried out using semi-directed interviews with open-ended questions in-depth. The sample was closed by the saturation strategy. Data treatment was conducted by Clinical-Qualitative Content Analysis technique under theoretical framework of psychodynamic concepts from Medical Psychology, and validation by peers from a research group. Results Ten clinical professionals were interviewed: four physicians and six nurses. From the analysis of the interviews, three categories are constructed for this article: (01) – An Instituted Stigmatization; (02) Wide-Open Reality; (03) Naturalization without Trivialization. The aggressivity of these tumours, the association with harmful lifestyle habits, and the great concern of family members call for clinical-psychological management, in which subjective mechanisms such as denial or other more primitive psychological defences have no sufficient resolution. Conclusions The stigma is a symbolic entity that takes distress for the clinicians, but also seems to highlight a higher level of awareness and reflection. This awareness can be a starting point for the development of healthier strategies for emotional coping, contributing to a more balanced work and personal harmonic relationship of care. healthcare personnel head and neck cancer qualitative research lived experiences clinical practice Introduction The relationship between clinical team and patients is dynamically established in objective and subjective contexts, where social, individual, and interpersonal aspects interface with scientific, political, and cultural factors [ 1 ]. These complexities are seen in the clinical and therapeutic environment, where psychological processes play a crucial role and are not always noticeable, but shape the clinical relationship and, consequently, the decision-making process. Two key elements in this context are the phenomena of transference and countertransference [ 2 ]. Transference refers to the emotions and attitudes of the patient concerning the healthcare professional, often reproducing patterns from previous relationships. On the other hand, countertransference refers to the emotions and reactions that healthcare professionals may experience in response to patients, often unaware, especially when challenges arise when managing this relationship. It may happen due to the characteristics of the disease, and the individual particularities of the patient or the family [ 2 , 3 ]. Therefore, transference originates in the patient, while countertransference is recognized and managed by the healthcare professional. However, these emotions are not always managed by healthcare professionals, exposing them to distress when they experience situations that go beyond the disease, challenging them in the context of the healthcare professional-patient relationship [ 3 ]. Therefore, the relationship between health professionals and patients involves emotions and feelings that, depending on the disease and the patient profile, can have a negative emotional impact on both. This way, health professionals experience an emotional burden with several patients, each with their unique way of handling the disease [ 4 ]. In the case of professionals who treat patients with Head and Neck Cancer (HNC), these are recurring experiences. HNC is a disease that has grown in Brazil, both in prevalence and mortality. It predominantly affects male individuals over 50 years of age with a history of high tobacco and alcohol consumption [ 5 , 6 ]. This context follows international statistics, which list HNC as the sixth most common cancer worldwide, with 878,348 new cases and 444,347 deaths estimated in 2020 [ 7 , 8 ]. Most patients with HNC present locally advanced disease at diagnosis, and the standard therapy for these cases involves surgical resection and/or chemoradiation, which are commonly accompanied by physical and functional abnormalities. The treatment is complex and involves several specialists in a therapeutic proposal to minimize the impacts of interventions and improve the quality of life [ 5 , 9 ]. Therefore, these professionals must have interpersonal skills for the clinical management of these patients due to certain emotional and psychosocial demands observed since the beginning of treatment. The analysis of these complex emotional processes of healthcare professionals in the relationship with HNC patients can provide important insights into the underlying perceptions and attitudes of these patients [ 10 , 11 ]. It allows healthcare professionals to improve their understanding of the patient’s individual needs and emotional reactions to diagnosis and treatment. This in-depth understanding can support the formulation of personalized therapeutic strategies, contributing to more appropriate and effective clinical decisions [ 11 ]. Studies show that investing in support for the healthcare team can enrich the quality of therapeutic relationships, promoting a more empathetic and collaborative environment between healthcare professionals and patients [ 12 , 13 ]. Consequently, it may reduce the psychological stress associated with HNC treatment, contributing to improved patient engagement, which may have a positive impact on clinical outcomes. By recognizing and appropriately managing the personal emotions involved in the relationship with the patient, healthcare professionals and institutions can promote a more compassionate and sensitive approach to care, resulting in a more humanized experience for the patient during the treatment process [ 12 ]. In this context, to suppress distress resulting from the patient’s situation of fragility and vulnerability, health professionals end up facing some emotional disorganization when treating patients with HNC [ 4 ]. By not understanding this phenomenon, these healthcare teams feel emotional exhaustion, mainly influencing clinical decisions and the process of building therapeutic relationships for humanized care [ 4 – 6 ]. Therefore, this study was based on the hypothesis that a conscious understanding of the emotions of healthcare professionals in the clinical relationship with patients can be perceived as better management of emotional exhaustion, contributing to a healthier work setting and humanization of care. So, this study aimed to interpret the perceptions reported and meanings attributed by health professionals to the clinical management of patients with HNC in a specialised clinical service at a general hospital of a Brazilian public university. Methods Setting This is a humanistic study using the Clinical-Qualitative Method (CQM) by Turato [ 14 ], which interprets psychodynamically the reports of study subjects about their experiences in clinical settings. Data collection Data were collected using semi-directed interviews with open-ended questions in-depth, in the clinical oncology service of a public university hospital. This service has a multidisciplinary team for oncology patients. The interviews were conducted by the first author of this article, a female nurse, trained through the rolling-play technique. The speeches were audio-recorded and transcribed in full by a scholarship student. Additional observations, perceptions, and reactions of the participants and the researcher during the interviews were written in Field Notes, such as paraverbal and nonverbal languages, which were used when required to complement relevant information. Analysis Data processing was conducted according to the Seven Steps of Clinical-Qualitative Content Analysis by Faria-Schützer and collaborators [ 16 ]: (1) Editing of the material for analysis – transcription of whole interviews made by the researcher; (2) Free-floating reading – search for cores of sense; (3) Construction of units of analysis – identification of meanings, selection of speech excerpts, reflections on each fragment; (4) construction of meaning codes – a grouping of similar units of analysis to structure the first meaning codes; (5) construction of categories – organization of materials for analysis of all interviewees to group the meaning codes; (6) discussion – a dialogue with literature; and (7) validity – critical reflection on the processes conducted in each stage – it is performed by all authors using the Standards for Reporting Qualitative Research (SRQR) [ 10 ]. The theoretical framework used as support was the Balintian British Medical Psychology, which explores psychodynamic concepts of the professional-patient emotional relationship [ 2 ]. The final validation occurred in meetings of the Lab. of Clinical-Qualitative Research (LCQR) with peers who also conduct investigations with the CQM. Data saturation Sample selection was intentional and used the information saturation criterion by Fontanella and collaborators [ 15 ] to close the group of persons from the staff, who are responsible for the routine with cancer patients. The inclusion criteria were: 1) resident physician in the third year of residency at the University Hospital; 2) nurse in the clinical oncology outpatient service for more than 6 months; 3) provide care to HNC patients in all wards of the clinical oncology outpatient service of the university hospital. Ethical aspects The study was approved by the Research Ethics Committee of the State University of Campinas and Brazil’s National Health Council under nº 09048919.7.0000.5404. Healthcare professionals who agreed to participate in this study signed an informed consent form, within an empathetic relationship in a private room. Participants Ten professionals were interviewed, four physicians and six nurses, with a minimum professional experience of 5 years and a maximum professional experience of 32 years. Also, they had a minimum professional experience with HNC patients of 1 year and a maximum professional experience with HNC patients of 14 years (Table 1 ), from August 2019 to January 2020. Table 1 Biodemographic characteristics of participants, Campinas SP, 2019-20. Code Sex Occupation Experience in months Experience with HNC patients in months P1 F Nurse 16 14 P2 F Nurse 32 04 P3 F Nurse 09 07 P4 F Nurse 07 03 P5 F Nurse 30 03 P6 F Nurse 12 01 P7 M Physician 08 03 P8 F Physician 05 03 P9 F Physician 06 03 P10 F Physician 06 03 Results Data categorization From the analysis of the interviews, three categories were constructed for this paper: (01) An instituted stigmatization; (02) Wide-open reality; (03) Naturalization without trivialization. Table 2 summarizes these respective categories and themes analysed. Table 2 Summary of interview data categorization. Categories of analysis Subcategories Description 1) Instituted stigmatization • Self-destructive lifestyle habits • Damaged family relationship • Shameful disease Represents meanings of the univocal psychosocial characteristics of HNC patients. 2) Wide-open reality It refers to perceptions of how intriguing and disturbing it is to face a patient with HNC. 3) Naturalization without trivialization It refers to the need to “dehumanize” themselves by suppressing their natural feelings and reactions when they have a humanized attitude with HNC patients. An Instituted Stigmatization This category is based on the perspective of healthcare professionals regarding the behavioural factors that contribute to the patient’s disease. It covers observations and perceptions about the disease stage and the social interactions involved. Also, healthcare professionals identify and emphasize the situations they will have to handle, revealing the subjective elements and the challenges involved in the relationship with a 'difficult patient’. Self-destructive lifestyle habits This subcategory is based on the perspective of healthcare professionals regarding behavioural factors. “It is the classic profile of men, cigarettes and alcohol involved and sometimes drugs. […] Another thing we realize is that the patient is marginalized.” (P1) “He is a very stigmatized patient. I think he is stigmatized because of his lifestyle when compared to other tumours […]. A head and neck tumour sometimes doesn’t have that empathy and can even involve some contempt, let’s say.” (P8) The patient’s epidemiological profile is analyzed, together with the social implications of this profile and how such implications affect the dynamics of the relationship between the patient and healthcare professionals. Healthcare professionals act as observers, with the perception that patients may be subject to stigmatization and marginalization. However, this position seems to be an attempt to avoid labelling the patient, which generates emotional tension due to the conflict between this perception and the desire to adopt a less stigmatizing approach. This narrative is influenced by ethical considerations, with healthcare professionals seeking a neutral position when faced with moral judgments about the patient. However, it is important to recognize that these professionals are products of society and, therefore, are susceptible to influences from existing conceptions that shape their perception of patients. Given that underlying behaviours are often linked with addictions, they tend to see the patient in a one-dimensional way based on these habits. Healthcare professionals feel distressed when trying to avoid this marginalization. The simple perception that a patient is being marginalized can shape the attitudes of healthcare professionals towards the patient. Damaged family relationship Healthcare professionals feel the presence of fragile affective-family dynamics when interacting with patients and the lack of support from the patient’s immediate family members. This perception conflicts with the traditional concept of family as an essential support during the disease process, especially for patients with cancer. “[…] Usually disconnected from the family, they have a neighbor, an ex-wife, a son who, let’s say, supports the patient. They go there and help this patient. Then they disappear! Most of them, not all.” (P8) “Most of the time they are not accompanied by wives; they are cousins, uncles, friends, brothers-in-law, brothers.” (P7) “We see the caregiver is not even from the family, it’s a neighbor, a church friend, a friend from the bar.” (P1) The development of social dynamics associated with deep-rooted stigma is observed in clinical environments, that is, in microscopic contexts of practice. In these circumstances, there is an evident perception that the patient has irrevocably compromised family relationships. Healthcare professionals readily articulate a narrative of whether factual or symbolic nature that exposes the supposed transgression of moral values by patients with HNC, thus justifying the deterioration of family connections and fragile affectional bonds. “Head and neck cancer patients present a certain pattern. They are often patients who smoked a lot, drank a lot, and maybe because of that, they don’t have a strong family bond, then sometimes they come alone even with difficulties.” (P7) “The family tends to deny this patient due to the type of care, the dressing. Suddenly he was a guy who drank, he had a history of beating his wife, not giving money, spending the night drinking and using drugs. And there are families who say: ‘You see? Now he’s paying me back!’ And then the only thing you can do is listen to what they say and try to mediate it. And how can we heal this wound from the past? It’s not easy, it’s very difficult.” (P2) While recognizing the weakened family relationships in patients with HNC, healthcare professionals also realize they cannot fully count on family support. This scenario does not enable to creation of the vital triad of healthcare professionals, patients, and families, in which family support is recognized as crucial for both the patient and healthcare professionals during the treatment process. This undesirable situation becomes more relevant when considering the patient’s family issues are added to the disease demands that need to be managed. This dynamic also affects the relationship between the healthcare professionals and the patient, as these professionals will find themselves overwhelmed, handling complex subjective issues that involve their own family values. Shameful disease Stigmatization of patients with HNC assumes a particular dimension in the clinical context. The term “stigmatized” is used by healthcare professionals to support the narrative of the patient’s perception of the disease, including its aesthetic issues. This term is also used to express the embarrassment shared by healthcare professionals, as they are perplexed and faced with deep existential questions, given the deterioration of the human condition they witness. “He is strongly stigmatized. The patient feels embarrassed when he is around other people, because of the odour. Strong odour and a visual issue.” (P5) “The first impression is when you press to see the next patient in a queue, you often expect a patient with a physical deformity, sometimes with a strong odour, with devices such as a tracheal tube, a probe, wiping off drool with a towel […]. And we’ve already seen patients who came in with larvae, with myiasis.” (P7) “I think that everyone who’s going to treat a head and neck cancer patient is nervous about how they look. I think it makes a big impression, right?” (P3) This phenomenon is clearly illustrated in the statements of interviewees P7 and P3. Although they understand the characteristics of the disease and the patient’s profile, and can handle these aspects in their routine, they still experience a feeling of surprise and apprehension regarding what they are about to see. This feeling reflects an intrinsic distress of seeing the “grotesque.” The impressive presence of characteristics such as intense odour, visible injuries, and deformations of the patient is perceived by the senses without requiring cognitive efforts. Wide-open reality Providing care to patients with HNC places healthcare professionals in contact with the reality of cancer since this disease is visually impactful. The speeches of interviewees P7 and P1 indicate they prefer to treat patients with other milder types of cancer, particularly concerning the underlying aspects. In contrast, the patient’s coping with HNC is described as intricate and distressing. “These are patients who, I think, are the prototype of cancer, when you say it, cancer! In the case of breast cancer, there are bald women with mastectomies, and head and neck cancer patients are deformed guys, very ugly things, with face tumours.” (P7) “Sometimes it’s easier to treat patients with stomach cancer because most of the time they have a gastrostomy, or not, and they’re intact on the outside. But not the head and neck cancer patient, he often arrives with an apparent injury, with a probe, he arrives with a tracheal tube, he arrives with some external injury.” (P1) Naturalization without trivialization The speeches suggest that healthcare professionals use strategies and natural attitudes to address what they regularly find, but such exposure still has mobilized them. These professionals can resort to the distancing technique, denying what they see as a mode to protect themselves against certain emotional tension. “I kind of transcended that, I receive this patient and see beyond the injury, I worry a lot about the patient’s prognosis, but I’m not very impressed. I don’t take that with me. It’s his thing. It’s his! [...]. When you see beyond the injury, then comes the person, right? Then I treat him as a person who doesn’t have an injury and that will work out. [...] I talk as if the person doesn’t have that injury.” (P5) “And I try to prepare myself to show the patient that it doesn’t matter to me whether he has a tracheal tube, whether he uses a probe, whether he smells bad or good. I try to prepare myself to treat him in the most receptive way, right? I try to prepare myself and be calm.” (P7) It is important to highlight that “I try” is present in the speeches of all interviewees, particularly when they say how they handle aspects of the disease that cause aversion, perplexity, and psychological discomfort. They also discuss how they try not to express these emotions. It requires considerable effort and mental energy to maintain constant control over their reactions. In this context, health professionals adopt a “dehumanization” approach, repressing their feelings and instinctive reactions to maintain a humanized stance both in terms of mental processes of perception and behaviours adopted when interacting with HNC patients. Discussion This study promoted a reflective analysis of the dynamic between healthcare professionals and patients in the field of clinical oncology. It is largely known that healthcare professionals who treat cancer patients face challenges due to the complexity of the disease [ 17 ]. These challenges may vary with the type of cancer, the influence of the patient’s social conception, and perception of the disease in the clinical context [ 2 ]. An important aspect highlighted in this study is the stigma associated with patients with HNC. This phenomenon is observed in the speeches of interviewees when discussing the particularities of these patients, constituting a central issue. Stigma was a social construct, shaped by beliefs and perceptions that are influenced by the culture and historical context of society. It refers to a negative or derogatory attribute that differentiates and diminishes the subject, which constitutes a disadvantage to this subject [ 18 ]. The perception of stigma by health professionals regarding HNC patients in clinical settings has an impact on the professional-patient relationship. Concretization of the symbolic meanings related to the patient’s status contributes to the distress of healthcare professionals, who strive to dissociate their patient perceptions from existing social conceptions. However, this relationship ends up generating a system of meanings arising from the social interaction itself [ 18 , 19 ]. By building narratives based on the behaviours and lifestyle of HNC patients, healthcare professionals reinforce the stigma, even if involuntarily, creating thought models that justify or even understand family attitudes and behaviours that devalue the patient. These narratives, which can be critical or moralistic, can be influenced by individual beliefs and unconscious fantasies, leading to a punitive and judgmental attitude towards the patient. Such reactions would occur unconsciously to help healthcare professionals handle internal conflicts and personal values [ 12 , 20 ]. The attitude of family members often coincides with the marginalization of HNC patients, as perceived and mentioned by physicians and nurses. This context generates challenges since care practice is affected by ethical-moral issues, resulting in a conflict of emotional demands. The identification mechanism can occur more strongly with the patient’s family than with the patient himself, despite his condition of being affected by the disease. This process of non-perceived identification causes the person to project elements of their psychic structure onto another person, seeing this person as someone who can receive affection [ 20 , 21 , 22 ]. This dynamic does not favour an authentic relationship and effective communication, resulting in damaged bonds with the patient. It can also cause a feeling of indignation and powerlessness in health professionals, triggering defence mechanisms in response to interpersonal and subjective issues that generate distress [ 2 ]. The perception that a patient is “difficult” and the relationship is challenging often comes from countertransference, a phenomenon that is inherent to healthcare environments, particularly in oncology clinics, which present a high emotional burden [ 17 ]. In the dimension of stigma, HNC is a disease marked by injuries, deformities, unpleasant odours, and the use of medical devices such as tracheal and nasogastric tubes. When these aspects are aggravated by compromised self-care, they contribute to a representation of the “grotesque,” making healthcare professionals alarmed. The clinical and psychosocial characteristics of HNC patients, combined with the disease manifestations, act in intense dynamics that disturb and challenge professionals. This is not limited to appearance and includes the harmful effects of the disease on the human condition, resulting in distress [ 2 , 18 ]. When providing care to patients with HNC, healthcare professionals have a direct visual understanding of the “shape” of the disease. It occurs through a spontaneous understanding that transcends conventional symbols, allowing a direct and intense perception. This reality affects professionals emotionally, generating a variety of reactions and distress. These reactions can influence the healthcare professional-patient relationship due to the transference and countertransference that occur in these environments [ 2 ]. Although it can be assumed that prior experience and knowledge about patients with HNC can attenuate the emotional effects, this disease is so intense that professionals assume a "neutral position" trying to suppress their own emotions. It occurs because the situation is both familiar and strange causing discomfort. Such suppression involves psychic defence mechanisms that require mental energy. Considering a patient with HNC as a “difficult” patient can be a defence strategy because naming is a way of framing [ 1 , 2 ]. Conclusions The findings of this study confirm the importance of addressing the meanings attributed to the perceptions of healthcare professionals who treat patients with HNC, since the way they symbolize their experience with the patient influences interpersonal relationships and care practices. The issue of sociological stigmatization is also present within micro-settings with its psychic symbolization. The perception of the “grotesque” is associated with distress among professionals, but also demonstrates a higher awareness and reflection. This awareness can develop healthier emotional coping strategies, which can contribute to a more balanced work setting and promote care harmonization. This research offers theoretical material for reading by professionals, to name and interpret emerging tensions in the clinician-patient relationship, which tend to disturb care and educational actions, so evolving towards gains with a more harmonious interaction, and consequent better adherence to treatments and abandonment of tobacco and alcoholic beverages. Group meetings with physicians and nurses to speak openly on the psychological handling of patients with HNC, led by a psychotherapist, can be an efficient space for thinking about the management in the assistance and a moment for group catharsis. Future research may include qualitative studies with nutritionists, speech therapists, occupational therapists, and social workers, to understand the specifics of how these professionals symbolize the relationship with NHC patients. Declarations Institutional Review Board Statement: The study was conducted in accordance with the Declaration of Helsinki and approved by the Research Ethics Committee of the Universidade Estadual de Campinas (protocol number 3.246.642 on April 05, 2019). Funding: This research received no external funding. Author Contribution All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Adriana Consuêlo Oliveira Bispo, Ricardo Souza Evangelista Sant'Ana, Rodrigo Almeida Bastos, Sarah Adriely da Silva, Milena Rossi Suedt, Jéssica Renata Ponce de Leon Rodrigues, Claudiane Graças dos Santos, Luciane Miranda Guerra, Carmen Silvia Passos Lima, Egberto Ribeiro Turato. The first draft of the manuscript was written by Ricardo Souza Evangelista Sant’Ana, and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. 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"My life's not my own": A qualitative study into the expectations of head and neck cancer carers. Support Care Cancer. 2022;30(5):4073–4080. https://10.1007/s00520-021-06761-1 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4115017","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":281995749,"identity":"d2cc86e4-ade9-423a-b45e-34626e118947","order_by":0,"name":"Adriana Consuelo Oliveira Bispo","email":"","orcid":"","institution":"State University of Campinas","correspondingAuthor":false,"prefix":"","firstName":"Adriana","middleName":"Consuelo Oliveira","lastName":"Bispo","suffix":""},{"id":281995750,"identity":"9356c1f7-cdd5-4814-a25b-1b199f57454f","order_by":1,"name":"Ricardo Souza Evangelista Sant'Ana","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA/ElEQVRIiWNgGAWjYDACZhDBhizC3gAiDxCrJQGIeQ4Q0MKAoUUiAb8W83bmh58rymwY5NvbH34u/GGXxz/zjfHnAoY7+bi0yBxmM5Y8cy6NweDMGWPpGQnJxRK3c8ykZzA8s2zAoUWCmYdBsrHtMIOBRA6DNE8Cc2IDUAtQ8LABLluAWph/grTIz3/++DdPQn3i/JtnjD8T0MIGtoXhBoMZ0JbDiRtu8BhI49fCZmbZcC6Nx+BMjpk1T9rxxI1n0sqkZxg8w62F//Djmw1lNnLy7ccf3+axqU6cd/zw5s8FFXdwaoEBHhQeMwNBDeiAmVQNo2AUjIJRMKwBAECyT/y2QhGiAAAAAElFTkSuQmCC","orcid":"","institution":"Universidade de São Paulo","correspondingAuthor":true,"prefix":"","firstName":"Ricardo","middleName":"Souza Evangelista","lastName":"Sant'Ana","suffix":""},{"id":281995751,"identity":"800a044d-ddb6-43c2-b352-cdb6d2d7a5a2","order_by":2,"name":"Rodrigo Almeida Bastos","email":"","orcid":"","institution":"State University of Campinas","correspondingAuthor":false,"prefix":"","firstName":"Rodrigo","middleName":"Almeida","lastName":"Bastos","suffix":""},{"id":281995752,"identity":"9d476fed-cd5a-4ee1-b497-e7f6f26a95a6","order_by":3,"name":"Sarah Adriely da Silva","email":"","orcid":"","institution":"State University of Campinas","correspondingAuthor":false,"prefix":"","firstName":"Sarah","middleName":"Adriely da","lastName":"Silva","suffix":""},{"id":281995753,"identity":"c95d6e28-11cc-430f-9db3-3a82f8fdf238","order_by":4,"name":"Milena Rossi Suedt","email":"","orcid":"","institution":"State University of Campinas","correspondingAuthor":false,"prefix":"","firstName":"Milena","middleName":"Rossi","lastName":"Suedt","suffix":""},{"id":281995754,"identity":"b49e355f-1d80-44b4-959b-9ff988152522","order_by":5,"name":"Jéssica Renata Ponce de Leon Rodrigues","email":"","orcid":"","institution":"State University of Campinas","correspondingAuthor":false,"prefix":"","firstName":"Jéssica","middleName":"Renata Ponce de Leon","lastName":"Rodrigues","suffix":""},{"id":281995755,"identity":"709f7034-95f7-4222-9e65-02cfed3addab","order_by":6,"name":"Claudiane dos Santos","email":"","orcid":"","institution":"State University of Campinas","correspondingAuthor":false,"prefix":"","firstName":"Claudiane","middleName":"dos","lastName":"Santos","suffix":""},{"id":281995756,"identity":"417b803e-b3ba-41b1-b48f-34fac6925f84","order_by":7,"name":"Luciane Miranda Guerra","email":"","orcid":"","institution":"State University of Campinas","correspondingAuthor":false,"prefix":"","firstName":"Luciane","middleName":"Miranda","lastName":"Guerra","suffix":""},{"id":281995757,"identity":"46897f23-b252-485b-a27b-46053e6e4a34","order_by":8,"name":"Carmen Silvia Passos Lima","email":"","orcid":"","institution":"State University of Campinas","correspondingAuthor":false,"prefix":"","firstName":"Carmen","middleName":"Silvia Passos","lastName":"Lima","suffix":""},{"id":281995758,"identity":"b98413f7-028f-498d-ba76-ac221d966874","order_by":9,"name":"Egberto Ribeiro Turato","email":"","orcid":"","institution":"State University of Campinas","correspondingAuthor":false,"prefix":"","firstName":"Egberto","middleName":"Ribeiro","lastName":"Turato","suffix":""}],"badges":[],"createdAt":"2024-03-17 01:14:19","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4115017/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4115017/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":55265680,"identity":"b59df444-a5f5-413a-80f3-2a97d70bd990","added_by":"auto","created_at":"2024-04-25 02:14:21","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":507768,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4115017/v1/70860294-c681-434f-9985-852851959e41.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Emotional Meanings of Clinical Practice with Head and Neck Cancer Patients: a qualitative study with Brazilian professionals","fulltext":[{"header":"Introduction","content":"\u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThe relationship between clinical team and patients is dynamically established in objective and subjective contexts, where social, individual, and interpersonal aspects interface with scientific, political, and cultural factors [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. These complexities are seen in the clinical and therapeutic environment, where psychological processes play a crucial role and are not always noticeable, but shape the clinical relationship and, consequently, the decision-making process.\u003c/p\u003e \u003cp\u003eTwo key elements in this context are the phenomena of transference and countertransference [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Transference refers to the emotions and attitudes of the patient concerning the healthcare professional, often reproducing patterns from previous relationships. On the other hand, countertransference refers to the emotions and reactions that healthcare professionals may experience in response to patients, often unaware, especially when challenges arise when managing this relationship. It may happen due to the characteristics of the disease, and the individual particularities of the patient or the family [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Therefore, transference originates in the patient, while countertransference is recognized and managed by the healthcare professional. However, these emotions are not always managed by healthcare professionals, exposing them to distress when they experience situations that go beyond the disease, challenging them in the context of the healthcare professional-patient relationship [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTherefore, the relationship between health professionals and patients involves emotions and feelings that, depending on the disease and the patient profile, can have a negative emotional impact on both. This way, health professionals experience an emotional burden with several patients, each with their unique way of handling the disease [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. In the case of professionals who treat patients with Head and Neck Cancer (HNC), these are recurring experiences.\u003c/p\u003e \u003cp\u003eHNC is a disease that has grown in Brazil, both in prevalence and mortality. It predominantly affects male individuals over 50 years of age with a history of high tobacco and alcohol consumption [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. This context follows international statistics, which list HNC as the sixth most common cancer worldwide, with 878,348 new cases and 444,347 deaths estimated in 2020 [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Most patients with HNC present locally advanced disease at diagnosis, and the standard therapy for these cases involves surgical resection and/or chemoradiation, which are commonly accompanied by physical and functional abnormalities. The treatment is complex and involves several specialists in a therapeutic proposal to minimize the impacts of interventions and improve the quality of life [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Therefore, these professionals must have interpersonal skills for the clinical management of these patients due to certain emotional and psychosocial demands observed since the beginning of treatment.\u003c/p\u003e \u003cp\u003eThe analysis of these complex emotional processes of healthcare professionals in the relationship with HNC patients can provide important insights into the underlying perceptions and attitudes of these patients [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. It allows healthcare professionals to improve their understanding of the patient\u0026rsquo;s individual needs and emotional reactions to diagnosis and treatment. This in-depth understanding can support the formulation of personalized therapeutic strategies, contributing to more appropriate and effective clinical decisions [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eStudies show that investing in support for the healthcare team can enrich the quality of therapeutic relationships, promoting a more empathetic and collaborative environment between healthcare professionals and patients [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Consequently, it may reduce the psychological stress associated with HNC treatment, contributing to improved patient engagement, which may have a positive impact on clinical outcomes. By recognizing and appropriately managing the personal emotions involved in the relationship with the patient, healthcare professionals and institutions can promote a more compassionate and sensitive approach to care, resulting in a more humanized experience for the patient during the treatment process [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn this context, to suppress distress resulting from the patient\u0026rsquo;s situation of fragility and vulnerability, health professionals end up facing some emotional disorganization when treating patients with HNC [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. By not understanding this phenomenon, these healthcare teams feel emotional exhaustion, mainly influencing clinical decisions and the process of building therapeutic relationships for humanized care [\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTherefore, this study was based on the hypothesis that a conscious understanding of the emotions of healthcare professionals in the clinical relationship with patients can be perceived as better management of emotional exhaustion, contributing to a healthier work setting and humanization of care. So, this study aimed to interpret the perceptions reported and meanings attributed by health professionals to the clinical management of patients with HNC in a specialised clinical service at a general hospital of a Brazilian public university.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSetting\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThis is a humanistic study using the Clinical-Qualitative Method (CQM) by Turato [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], which interprets psychodynamically the reports of study subjects about their experiences in clinical settings.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eData collection\u003c/h2\u003e \u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eData were collected using semi-directed interviews with open-ended questions in-depth, in the clinical oncology service of a public university hospital. This service has a multidisciplinary team for oncology patients. The interviews were conducted by the first author of this article, a female nurse, trained through the rolling-play technique. The speeches were audio-recorded and transcribed in full by a scholarship student. Additional observations, perceptions, and reactions of the participants and the researcher during the interviews were written in Field Notes, such as paraverbal and nonverbal languages, which were used when required to complement relevant information.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eAnalysis\u003c/h2\u003e \u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eData processing was conducted according to the Seven Steps of Clinical-Qualitative Content Analysis by Faria-Sch\u0026uuml;tzer and collaborators [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]: (1) Editing of the material for analysis \u0026ndash; transcription of whole interviews made by the researcher; (2) Free-floating reading \u0026ndash; search for cores of sense; (3) Construction of units of analysis \u0026ndash; identification of meanings, selection of speech excerpts, reflections on each fragment; (4) construction of meaning codes \u0026ndash; a grouping of similar units of analysis to structure the first meaning codes; (5) construction of categories \u0026ndash; organization of materials for analysis of all interviewees to group the meaning codes; (6) discussion \u0026ndash; a dialogue with literature; and (7) validity \u0026ndash; critical reflection on the processes conducted in each stage \u0026ndash; it is performed by all authors using the Standards for Reporting Qualitative Research (SRQR) [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. The theoretical framework used as support was the Balintian British Medical Psychology, which explores psychodynamic concepts of the professional-patient emotional relationship [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The final validation occurred in meetings of the Lab. of Clinical-Qualitative Research (LCQR) with peers who also conduct investigations with the CQM.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eData saturation\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eSample selection was intentional and used the information saturation criterion by Fontanella and collaborators [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] to close the group of persons from the staff, who are responsible for the routine with cancer patients. The inclusion criteria were: 1) resident physician in the third year of residency at the University Hospital; 2) nurse in the clinical oncology outpatient service for more than 6 months; 3) provide care to HNC patients in all wards of the clinical oncology outpatient service of the university hospital.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eEthical aspects\u003c/h2\u003e \u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e The study was approved by the Research Ethics Committee of the State University of Campinas and Brazil\u0026rsquo;s National Health Council under n\u0026ordm; 09048919.7.0000.5404. Healthcare professionals who agreed to participate in this study signed an informed consent form, within an empathetic relationship in a private room.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eTen professionals were interviewed, four physicians and six nurses, with a minimum professional experience of 5 years and a maximum professional experience of 32 years. Also, they had a minimum professional experience with HNC patients of 1 year and a maximum professional experience with HNC patients of 14 years (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), from August 2019 to January 2020.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBiodemographic characteristics of participants, Campinas SP, 2019-20.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCode\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOccupation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eExperience in months\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eExperience with HNC patients in months\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e 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\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNurse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e03\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNurse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePhysician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e03\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePhysician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e03\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePhysician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e03\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePhysician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e03\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eData categorization\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eFrom the analysis of the interviews, three categories were constructed for this paper: (01) An instituted stigmatization; (02) Wide-open reality; (03) Naturalization without trivialization. Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e summarizes these respective categories and themes analysed.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSummary of interview data categorization.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCategories of analysis\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSubcategories\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDescription\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1) Instituted stigmatization\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; Self-destructive lifestyle habits\u003c/p\u003e \u003cp\u003e\u0026bull; Damaged family relationship\u003c/p\u003e \u003cp\u003e\u0026bull; Shameful disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRepresents meanings of the univocal psychosocial characteristics of HNC patients.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2) Wide-open reality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIt refers to perceptions of how intriguing and disturbing it is to face a patient with HNC.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3) Naturalization without trivialization\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIt refers to the need to \u0026ldquo;dehumanize\u0026rdquo; themselves by suppressing their natural feelings and reactions when they have a humanized attitude with HNC patients.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eAn Instituted Stigmatization\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThis category is based on the perspective of healthcare professionals regarding the behavioural factors that contribute to the patient\u0026rsquo;s disease. It covers observations and perceptions about the disease stage and the social interactions involved. Also, healthcare professionals identify and emphasize the situations they will have to handle, revealing the subjective elements and the challenges involved in the relationship with a 'difficult patient\u0026rsquo;.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eSelf-destructive lifestyle habits\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThis subcategory is based on the perspective of healthcare professionals regarding behavioural factors.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;It is the classic profile of men, cigarettes and alcohol involved and sometimes drugs. [\u0026hellip;] Another thing we realize is that the patient is marginalized.\u0026rdquo;\u003c/em\u003e (P1)\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;He is a very stigmatized patient. I think he is stigmatized because of his lifestyle when compared to other tumours [\u0026hellip;]. A head and neck tumour sometimes doesn\u0026rsquo;t have that empathy and can even involve some contempt, let\u0026rsquo;s say.\u0026rdquo;\u003c/em\u003e (P8)\u003c/p\u003e \u003cp\u003eThe patient\u0026rsquo;s epidemiological profile is analyzed, together with the social implications of this profile and how such implications affect the dynamics of the relationship between the patient and healthcare professionals. Healthcare professionals act as observers, with the perception that patients may be subject to stigmatization and marginalization. However, this position seems to be an attempt to avoid labelling the patient, which generates emotional tension due to the conflict between this perception and the desire to adopt a less stigmatizing approach.\u003c/p\u003e \u003cp\u003eThis narrative is influenced by ethical considerations, with healthcare professionals seeking a neutral position when faced with moral judgments about the patient. However, it is important to recognize that these professionals are products of society and, therefore, are susceptible to influences from existing conceptions that shape their perception of patients. Given that underlying behaviours are often linked with addictions, they tend to see the patient in a one-dimensional way based on these habits. Healthcare professionals feel distressed when trying to avoid this marginalization. The simple perception that a patient is being marginalized can shape the attitudes of healthcare professionals towards the patient.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eDamaged family relationship\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eHealthcare professionals feel the presence of fragile affective-family dynamics when interacting with patients and the lack of support from the patient\u0026rsquo;s immediate family members. This perception conflicts with the traditional concept of family as an essential support during the disease process, especially for patients with cancer.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;[\u0026hellip;] Usually disconnected from the family, they have a neighbor, an ex-wife, a son who, let\u0026rsquo;s say, supports the patient. They go there and help this patient. Then they disappear! Most of them, not all.\u0026rdquo;\u003c/em\u003e (P8)\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Most of the time they are not accompanied by wives; they are cousins, uncles, friends, brothers-in-law, brothers.\u0026rdquo;\u003c/em\u003e (P7)\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;We see the caregiver is not even from the family, it\u0026rsquo;s a neighbor, a church friend, a friend from the bar.\u0026rdquo;\u003c/em\u003e (P1)\u003c/p\u003e \u003cp\u003eThe development of social dynamics associated with deep-rooted stigma is observed in clinical environments, that is, in microscopic contexts of practice. In these circumstances, there is an evident perception that the patient has irrevocably compromised family relationships. Healthcare professionals readily articulate a narrative of whether factual or symbolic nature that exposes the supposed transgression of moral values by patients with HNC, thus justifying the deterioration of family connections and fragile affectional bonds.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Head and neck cancer patients present a certain pattern. They are often patients who smoked a lot, drank a lot, and maybe because of that, they don\u0026rsquo;t have a strong family bond, then sometimes they come alone even with difficulties.\u0026rdquo;\u003c/em\u003e (P7)\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;The family tends to deny this patient due to the type of care, the dressing. Suddenly he was a guy who drank, he had a history of beating his wife, not giving money, spending the night drinking and using drugs. And there are families who say: \u0026lsquo;You see? Now he\u0026rsquo;s paying me back!\u0026rsquo; And then the only thing you can do is listen to what they say and try to mediate it. And how can we heal this wound from the past? It\u0026rsquo;s not easy, it\u0026rsquo;s very difficult.\u0026rdquo;\u003c/em\u003e (P2)\u003c/p\u003e \u003cp\u003eWhile recognizing the weakened family relationships in patients with HNC, healthcare professionals also realize they cannot fully count on family support. This scenario does not enable to creation of the vital triad of healthcare professionals, patients, and families, in which family support is recognized as crucial for both the patient and healthcare professionals during the treatment process. This undesirable situation becomes more relevant when considering the patient\u0026rsquo;s family issues are added to the disease demands that need to be managed. This dynamic also affects the relationship between the healthcare professionals and the patient, as these professionals will find themselves overwhelmed, handling complex subjective issues that involve their own family values.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eShameful disease\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eStigmatization of patients with HNC assumes a particular dimension in the clinical context. The term \u0026ldquo;stigmatized\u0026rdquo; is used by healthcare professionals to support the narrative of the patient\u0026rsquo;s perception of the disease, including its aesthetic issues. This term is also used to express the embarrassment shared by healthcare professionals, as they are perplexed and faced with deep existential questions, given the deterioration of the human condition they witness.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;He is strongly stigmatized. The patient feels embarrassed when he is around other people, because of the odour. Strong odour and a visual issue.\u0026rdquo;\u003c/em\u003e (P5)\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;The first impression is when you press to see the next patient in a queue, you often expect a patient with a physical deformity, sometimes with a strong odour, with devices such as a tracheal tube, a probe, wiping off drool with a towel [\u0026hellip;]. And we\u0026rsquo;ve already seen patients who came in with larvae, with myiasis.\u0026rdquo;\u003c/em\u003e (P7)\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I think that everyone who\u0026rsquo;s going to treat a head and neck cancer patient is nervous about how they look. I think it makes a big impression, right?\u0026rdquo;\u003c/em\u003e (P3)\u003c/p\u003e \u003cp\u003eThis phenomenon is clearly illustrated in the statements of interviewees P7 and P3. Although they understand the characteristics of the disease and the patient\u0026rsquo;s profile, and can handle these aspects in their routine, they still experience a feeling of surprise and apprehension regarding what they are about to see. This feeling reflects an intrinsic distress of seeing the \u0026ldquo;grotesque.\u0026rdquo; The impressive presence of characteristics such as intense odour, visible injuries, and deformations of the patient is perceived by the senses without requiring cognitive efforts.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eWide-open reality\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eProviding care to patients with HNC places healthcare professionals in contact with the reality of cancer since this disease is visually impactful. The speeches of interviewees P7 and P1 indicate they prefer to treat patients with other milder types of cancer, particularly concerning the underlying aspects. In contrast, the patient\u0026rsquo;s coping with HNC is described as intricate and distressing.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;These are patients who, I think, are the prototype of cancer, when you say it, cancer! In the case of breast cancer, there are bald women with mastectomies, and head and neck cancer patients are deformed guys, very ugly things, with face tumours.\u0026rdquo;\u003c/em\u003e (P7)\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Sometimes it\u0026rsquo;s easier to treat patients with stomach cancer because most of the time they have a gastrostomy, or not, and they\u0026rsquo;re intact on the outside. But not the head and neck cancer patient, he often arrives with an apparent injury, with a probe, he arrives with a tracheal tube, he arrives with some external injury.\u0026rdquo;\u003c/em\u003e (P1)\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eNaturalization without trivialization\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThe speeches suggest that healthcare professionals use strategies and natural attitudes to address what they regularly find, but such exposure still has mobilized them. These professionals can resort to the distancing technique, denying what they see as a mode to protect themselves against certain emotional tension.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I kind of transcended that, I receive this patient and see beyond the injury, I worry a lot about the patient\u0026rsquo;s prognosis, but I\u0026rsquo;m not very impressed. I don\u0026rsquo;t take that with me. It\u0026rsquo;s his thing. It\u0026rsquo;s his! [...]. When you see beyond the injury, then comes the person, right? Then I treat him as a person who doesn\u0026rsquo;t have an injury and that will work out. [...] I talk as if the person doesn\u0026rsquo;t have that injury.\u0026rdquo;\u003c/em\u003e (P5)\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;And I try to prepare myself to show the patient that it doesn\u0026rsquo;t matter to me whether he has a tracheal tube, whether he uses a probe, whether he smells bad or good. I try to prepare myself to treat him in the most receptive way, right? I try to prepare myself and be calm.\u0026rdquo;\u003c/em\u003e (P7)\u003c/p\u003e \u003cp\u003eIt is important to highlight that \u0026ldquo;I try\u0026rdquo; is present in the speeches of all interviewees, particularly when they say how they handle aspects of the disease that cause aversion, perplexity, and psychological discomfort. They also discuss how they try not to express these emotions. It requires considerable effort and mental energy to maintain constant control over their reactions. In this context, health professionals adopt a \u0026ldquo;dehumanization\u0026rdquo; approach, repressing their feelings and instinctive reactions to maintain a humanized stance both in terms of mental processes of perception and behaviours adopted when interacting with HNC patients.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThis study promoted a reflective analysis of the dynamic between healthcare professionals and patients in the field of clinical oncology. It is largely known that healthcare professionals who treat cancer patients face challenges due to the complexity of the disease [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. These challenges may vary with the type of cancer, the influence of the patient\u0026rsquo;s social conception, and perception of the disease in the clinical context [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. An important aspect highlighted in this study is the stigma associated with patients with HNC. This phenomenon is observed in the speeches of interviewees when discussing the particularities of these patients, constituting a central issue. Stigma was a social construct, shaped by beliefs and perceptions that are influenced by the culture and historical context of society. It refers to a negative or derogatory attribute that differentiates and diminishes the subject, which constitutes a disadvantage to this subject [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe perception of stigma by health professionals regarding HNC patients in clinical settings has an impact on the professional-patient relationship. Concretization of the symbolic meanings related to the patient\u0026rsquo;s status contributes to the distress of healthcare professionals, who strive to dissociate their patient perceptions from existing social conceptions. However, this relationship ends up generating a system of meanings arising from the social interaction itself [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBy building narratives based on the behaviours and lifestyle of HNC patients, healthcare professionals reinforce the stigma, even if involuntarily, creating thought models that justify or even understand family attitudes and behaviours that devalue the patient. These narratives, which can be critical or moralistic, can be influenced by individual beliefs and unconscious fantasies, leading to a punitive and judgmental attitude towards the patient. Such reactions would occur unconsciously to help healthcare professionals handle internal conflicts and personal values [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe attitude of family members often coincides with the marginalization of HNC patients, as perceived and mentioned by physicians and nurses. This context generates challenges since care practice is affected by ethical-moral issues, resulting in a conflict of emotional demands. The identification mechanism can occur more strongly with the patient\u0026rsquo;s family than with the patient himself, despite his condition of being affected by the disease. This process of non-perceived identification causes the person to project elements of their psychic structure onto another person, seeing this person as someone who can receive affection [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis dynamic does not favour an authentic relationship and effective communication, resulting in damaged bonds with the patient. It can also cause a feeling of indignation and powerlessness in health professionals, triggering defence mechanisms in response to interpersonal and subjective issues that generate distress [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The perception that a patient is \u0026ldquo;difficult\u0026rdquo; and the relationship is challenging often comes from countertransference, a phenomenon that is inherent to healthcare environments, particularly in oncology clinics, which present a high emotional burden [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn the dimension of stigma, HNC is a disease marked by injuries, deformities, unpleasant odours, and the use of medical devices such as tracheal and nasogastric tubes. When these aspects are aggravated by compromised self-care, they contribute to a representation of the \u0026ldquo;grotesque,\u0026rdquo; making healthcare professionals alarmed. The clinical and psychosocial characteristics of HNC patients, combined with the disease manifestations, act in intense dynamics that disturb and challenge professionals. This is not limited to appearance and includes the harmful effects of the disease on the human condition, resulting in distress [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWhen providing care to patients with HNC, healthcare professionals have a direct visual understanding of the \u0026ldquo;shape\u0026rdquo; of the disease. It occurs through a spontaneous understanding that transcends conventional symbols, allowing a direct and intense perception. This reality affects professionals emotionally, generating a variety of reactions and distress. These reactions can influence the healthcare professional-patient relationship due to the transference and countertransference that occur in these environments [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAlthough it can be assumed that prior experience and knowledge about patients with HNC can attenuate the emotional effects, this disease is so intense that professionals assume a \"neutral position\" trying to suppress their own emotions. It occurs because the situation is both familiar and strange causing discomfort. Such suppression involves psychic defence mechanisms that require mental energy. Considering a patient with HNC as a \u0026ldquo;difficult\u0026rdquo; patient can be a defence strategy because naming is a way of framing [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe findings of this study confirm the importance of addressing the meanings attributed to the perceptions of healthcare professionals who treat patients with HNC, since the way they symbolize their experience with the patient influences interpersonal relationships and care practices. The issue of sociological stigmatization is also present within micro-settings with its psychic symbolization. The perception of the \u0026ldquo;grotesque\u0026rdquo; is associated with distress among professionals, but also demonstrates a higher awareness and reflection. This awareness can develop healthier emotional coping strategies, which can contribute to a more balanced work setting and promote care harmonization. This research offers theoretical material for reading by professionals, to name and interpret emerging tensions in the clinician-patient relationship, which tend to disturb care and educational actions, so evolving towards gains with a more harmonious interaction, and consequent better adherence to treatments and abandonment of tobacco and alcoholic beverages. Group meetings with physicians and nurses to speak openly on the psychological handling of patients with HNC, led by a psychotherapist, can be an efficient space for thinking about the management in the assistance and a moment for group catharsis. Future research may include qualitative studies with nutritionists, speech therapists, occupational therapists, and social workers, to understand the specifics of how these professionals symbolize the relationship with NHC patients.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eInstitutional Review Board Statement:\u0026nbsp;\u003c/strong\u003eThe study was conducted in accordance with the Declaration of Helsinki and approved by the Research Ethics Committee of the Universidade Estadual de Campinas (protocol number 3.246.642 on April 05, 2019).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e This research received no external funding.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAll authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Adriana Consu\u0026ecirc;lo Oliveira Bispo, Ricardo Souza Evangelista Sant'Ana, Rodrigo Almeida Bastos, Sarah Adriely da Silva, Milena Rossi Suedt, J\u0026eacute;ssica Renata Ponce de Leon Rodrigues, Claudiane Gra\u0026ccedil;as dos Santos, Luciane Miranda Guerra, Carmen Silvia Passos Lima, Egberto Ribeiro Turato. The first draft of the manuscript was written by Ricardo Souza Evangelista Sant\u0026rsquo;Ana, and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eLorenc, A.; Greaves, C.; Duda, J.; Brett, J.; Matheson, L; Fulton-Lieuw, T.; Secher, D.; Rhodes, P.; Ozakinci, G.; Nankivell, P.; et al. Exploring the views of patients' and their family about patient-initiated follow-up in head and neck cancer: A mixed methods study. 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Support Care Cancer. 2022;30(5):4073\u0026ndash;4080. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://10.1007/s00520-021-06761-1\u003c/span\u003e\u003cspan address=\"https://10.1007/s00520-021-06761-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"healthcare personnel, head and neck cancer, qualitative research, lived experiences, clinical practice","lastPublishedDoi":"10.21203/rs.3.rs-4115017/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4115017/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eTo interpret emotional meanings attributed by healthcare professionals to the clinical management of patients with Head and Neck Cancer, in a university-specialised outpatient service at a public general hospital.\u003c/p\u003e\u003ch2\u003eMethod\u003c/h2\u003e \u003cp\u003eA qualitative study was carried out using semi-directed interviews with open-ended questions in-depth. The sample was closed by the saturation strategy. Data treatment was conducted by Clinical-Qualitative Content Analysis technique under theoretical framework of psychodynamic concepts from Medical Psychology, and validation by peers from a research group.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eTen clinical professionals were interviewed: four physicians and six nurses. From the analysis of the interviews, three categories are constructed for this article: (01) \u0026ndash; An Instituted Stigmatization; (02) Wide-Open Reality; (03) Naturalization without Trivialization. The aggressivity of these tumours, the association with harmful lifestyle habits, and the great concern of family members call for clinical-psychological management, in which subjective mechanisms such as denial or other more primitive psychological defences have no sufficient resolution.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThe stigma is a symbolic entity that takes distress for the clinicians, but also seems to highlight a higher level of awareness and reflection. This awareness can be a starting point for the development of healthier strategies for emotional coping, contributing to a more balanced work and personal harmonic relationship of care.\u003c/p\u003e","manuscriptTitle":"Emotional Meanings of Clinical Practice with Head and Neck Cancer Patients: a qualitative study with Brazilian professionals","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-03-22 18:38:30","doi":"10.21203/rs.3.rs-4115017/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f91bf561-ba38-453a-aca5-fb3ad9904b07","owner":[],"postedDate":"March 22nd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-04-23T19:01:03+00:00","versionOfRecord":[],"versionCreatedAt":"2024-03-22 18:38:30","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4115017","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4115017","identity":"rs-4115017","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}