RESEARCH ARTICLES

Repercussions of skin conditions in people's lives: socio-poetizing self-image and self-esteem

Iraci dos Santos^I; Patrícia Britto Ribeiro de Jesus^II; Euzeli da Silva Brandão^II; Elias Barbosa Oliveira^IV; Alexandre Vicente da Silva^V

^I Nurse. Full professor at the State University of Rio de Janeiro. Active role in the Graduate Program in Nursing (Master and Doctorate) and in the Undergraduate Nursing Course at he School of Nursing at the State University of Rio de Janeiro. Brazil, Email: iraci.s@terra.com.br
IINurse. Master's in nursing through the Graduate Program in Nursing at the State University of Rio de Janeiro, Professor of the Nursing and Obstetrics Course, Federal University of Rio de Janeiro. Macaé Campus, Rio de Janeiro, Brazil. Email: patty_brj@hotmail.com
^III Nurse. Ph.D. in Nursing through the Graduate Program in Nursing (Master and Doctorate) from the State University of Rio de Janeiro. Director of the Brazilian Association of Nursing in Dermatology - Rio de Janeiro Region. Assistant Professor, Department of Fundamentals of Nursing Administration and Aurora Afonso Costa Nursing School at the Fluminense Federal University. Niteroi, Rio de Janeiro, Brazil. Email: euzelibrandão@gmail.com.br
^IV Nurse. Post Doctorate in Alcohol and Drugs. PhD in Nursing, Associate Professor at the Graduate (Masters) and Undergraduate Program, School of Nursing at the State University of Rio de Janeiro. Brazil. Email: eliasbo@oi.com.br
^V Nurse. Master's in Nursing, Assistant Professor Medical - Surgical Nursing Department at the School of Nursing, State University of Rio de Janeiro. Brazil. Email: alexvicentesilva@uol.com.br

ABSTRACT

The study aimed to identify how skin conditions influence people's self-image and self-esteem, by applying the socio-poetic method via the analytical device of a Researcher Group of 18 clients with skin disorders conducted from May to August 2013 at a hospital in Rio de Janeiro, Brazil. Sixteen themes were delimited, giving rise to the thematic subcategories: beauty is in the eye of the beholder; demystifying society's grueling standards of beauty and acknowledging its values and realizing the beauty of life. These made up the analytical category: the beauty in the loved human person – a philosophical study. It was concluded that understanding these customers' limitations helps decision making. Establishing sensitive listening helps to encourage feelings to be expressed. Social skills, patience and a loving attitude contribute to promotion, prevention and preservation with regard to self-esteem and self-image; health professional-client empathy favors the understanding of nursing guidelines for self-care.

Keywords: Nursing; dermatological disorders; self-image; self-esteem.

INTRODUCTION

In a society that values ​​the beautiful, with pre-established aesthetic standards, the skin may be an attractive 'business card' to the critical and demanding eyes of people. When wholesome and healthy it promotes the interpersonal relationship, facilitating their development in psychosocial aspects. When affected by diseases, compromising its integrity, this can bring consequences for the individual.

Caring for people is essential in a society, which pressures regarding socio-cultural models, concerns about beliefs, values ​​and aesthetic constraints, which may distort their self-image and self-esteem.

The association between cutaneous disorders and psycho-emotional imbalances is a field of research in national and international publications, due to the complexity and challenges in its approach in daily clinical practice.

Although the relationship between the psychological changes and the dermatological diseases is a subject known, it has not yet been defined with clarity if psychological changes cause skin changes and/or if the chronic skin diseases carry, necessarily those characteristics, and significant psychopathological changes¹. Thus, some authors propose a technology for skin care of the client a perspective that privileges their entirety, because this requires an individualized care, enhancing their sensitivity and dialogue².

Therefore, it presents the research problem: what are the effects of cutaneous involvement in the lives of people?

This study's objective was to identify the influences of cutaneous involvement in the self-image and self-esteem of people.

LITERATURE REVIEW

Nursing seeks new ways of caring, distancing itself from the hegemonic biomedical model that fosters the healing of diseases. This search reveals a horizon full of opportunities due to the holistic perspective with the client.

It says that these changes contribute significantly to the possibility of research of the intrinsic aspects to the human being and to this profession, such as the concern, sensitivity and therapeutic relationship³.

In order to signify nursing care it is essential for a distancing from the biomedical paradigm, since adopting the comprehensive care of being, professionals meet the vital needs of the individual, contemplating their multiple body dimensions. Thus, the nurse together with the client develops the care recognizing their values ​​and knowledge to guide their practice without just follow prescriptive acts of other health professionals⁴.

On the consequences, resulting from skin conditions is emphasized that the image is a picture that the person has the object of their experience, with their concept linked to the idea of ​​social prestige. Its construction is related with feelings, ideas and attitudes. In this construction building cultural, religious, social, racial and other identities that are influenced by events experienced by the individuals⁵.

Self-esteem is made from love of the person for them self and self-confidence; it requires the combined efforts of intelligence and will. While self-esteem presents demands such as cultivating the path of detachment and embrace, the symbolic welcome messages from the unconscious. It is defined as the way a person sees them self and how they return to their interior, discovering the perceptions of themselves⁶.

METHODOLOGICAL THEORETIC REFERENTIAL

It was chosen to use the social poetics approach, a social practice, education, nursing, and research, setting up a method of collective construction of knowledge among the study subjects, mediated by the researcher/facilitator of this construction⁷.

The socio-poetical method apply five theoretical foundations, highlighting the pedagogy of the oppressed by Paulo Freire, and institutional analysis by René Lourau that allow Researcher Group (RG), an analytical device of this approach, interpret, criticize and self-criticize, allowing the research subjects to be creators. For the expression of emotions and feelings it is emphasized that mytho-poetic sensitive listening by Rene Barbier, encouraged in these people, by the researcher / facilitator considering its psycho-affective, existential historical, structural and professional implications ⁸.

In the application this method are used simultaneously, the theoretical foundations socio-poetics and the following philosophical principles: enhancing the role of the research subjects as jointly responsible by the knowledge produced; considering the importance of the dominated cultures and resistance of categories and concepts they produce; recognizing the importance of the body as a source of knowledge; valuing the role of artistic creativity, in learning, knowing and search; highlighting the importance of the spiritual, human and political sense of the forms and content in the knowledge construction process⁹.

The RG was composed of 18 clients of the dermatology ward of a university hospital in Rio de Janeiro, Brazil, including all who met the following criteria: Own transportation and indispensable to the development of research techniques verbal expression, and agreed to participate by signing the Statement of Informed Consent. Patients were excluded if they had extensive injuries, preventing them from taking part in the relaxation and sensitivity dynamics.

The participant clients were identified by C (client) and their number in the order of participation- C1, C2...

In relation to clinical characteristics of the RG, predominate seven psoriasis medical diagnosis. The 11 other diagnoses refer to systemic lupus erythematosus, Wagner granulomatosis, erythema nodosum, erysipelas, pyoderma gangrenosum, pemphigus vulgaris and venous ulcers.

The method was carried out from May to August 2013, after approval by the Ethics Committee in Research- Opinion No 258826-11 -04-2013, given the Resolution no. 466/2012 concerning research with human beings. An incentive for the clients to participate in the research was the offering of short-term course about self-care with skin and strengthening of self-image and self-esteem.

It is emphasized that this work is a cutout from a dissertation, from which was defined: an objective, a research technique; and data produced through this delimited by 16 themes, three subsequent subcategories, which originated the analytical category described below in the results session. Therefore, the decision to focus in this study only on the impact of the skin condition in self-image and self-esteem, relating to the narrative technique legend of beauty, can characterize a limitation of the study.

Data production and analysis

The data production was preceded by dynamic relaxation and sensitivity, for the stimulation of imagination, in all meetings with the RG. We used the artistic narrative technique - legend of beauty, adapted from an Indian tale of Malba Tahan, published in 1997, describing the task of a subject in finding the beauty and bring it to his lord. This led him to travel through several continents where beauty is described according to physical types of the location and standards of different cultures. The legend ends with the return of the subject without fulfilling their mission, because beauty always appears with beautiful faces, but different, in different parts of the world¹⁰. In this adaptation, the messenger's meeting with beauty in the African continent was added, valuing the attributes of black ethnicity, present in Brazil.

This legend discusses the tales and parables, which directly express the emotional. In this research, it has made it possible for clients with dermatologic diseases to speak about different aspects, discussing preconceptions and concepts of beauty, and finally reach the consensus of this relativity.

The narrative of the legend and its consequent discussion among the research subjects were recorded in MP4, with their consent. The six stages were conducted from the socio-poetical method: thematic research; data production and analysis from the RG with the researcher; presentation to the RG data organized by the researcher; counter analysis of the RG; validation of the results presented by the RG and researcher; and evaluation of the RG regarding the group work⁸.

The data produced were organized in two illustrations with the context of the speeches of the RG, demonstrating the dialog after the reading of the tale. From reading and analysis of dialogues on the legend of beauty, individual and group themes were outlined. According to the frequency of the latter, subcategories, which originated the analytical category emerged.

The results were described taking the data analysis considered the philosophical socio-poetical study. This is a trial / interpretation of the data produced from the major themes of the literature from Western culture. The discussion of the results considers the knowledge, culture and values of the RG, and the theoretical references, a posteriori identified by the researcher according to their knowledge and ideals⁹.

RESULTS AND DISCUSSION

The 16 most common themes from the individual thought of the 18 RG members can be seen in Figure 1.

FIGURE 1: Predominant themes in accordance with individual thought. Rio de Janeiro, 2013.

It is important to highlight that the themes 1 to 4 and 8 to 12, were described in Figure 1, more than once. From the meanings of predominant themes expressed in the discourse of the GP, were constructed three thematic subcategories: Beauty is in the eye of the beholder; demystifying the grueling standards of society as for the beauty and recognizing their values and realizing the beauty of life.

The delimitation of the three subcategories yielded the analytical category Existing beauty in the beloved human being: philosophical study. The three subcategories analyzed and their themes identified are listed in Table 1.

TABLE 1: Analytical Subcategories corresponding to the identified themes. Rio de Janeiro, 2013.

This begins their description from the subcategory - Beauty lies in the eye of the beholder. Recalling the description of Tahan on the Legend of Beauty, it is one of their questions and reflections¹⁰: But, after all, what is beauty? How can I find it, if I do not know it? However, the eternal and incomparable beauty only to find anyone to search wisely.

In this research, the researcher group reaffirms the thought of the writer expressing some regarded popular sayings and complaints on life:

[...] because 'he who loves the ugly, for them they look beautiful'. The beauty in the eyes of each one is in a unique way. Sometimes I think a person is beautiful and the other does not think so. (C2)

I found that, according to the saying 'beauty is in the eye of the beholder' has several ways to see the beauty ... (C9)

Sometimes the person does not think they are beautiful, they think that they are ugly. Sometimes they think the whole world around [...] beautiful, but they see them self as ugly. (C1)

They have their own lives! Because they look at a flowery field and think it is ugly, they look to the sea and think it is ugly. Then, they will not find anything interesting. (C12)

Now when a person is well in their mind, soul, they look and dazzle at the landscape and it gets easier. (C8)

In addition, this business of boredom, leads to depression and negativity only brings disease to the life of the person. (C1)

Defining beauty as an experience, cognitive, mental, or spiritual process related to the perception of pleasant elements singularly one who experiences it, the lines from the RG corroborate that the perception of self-image depends on the mode of being, of seeing and understanding the world around them ⁶.

Then, the term beauty can turn on, primarily, the aesthetic characteristics that constitute a harmonious image of the body according to the cultures, traditions and trends of ethnic standards, whereas, including cognitive dimensions, spiritual, social and physiological, almost always conveyed by journalistic and television media. Therefore, the beauty problems are closely linked to body image, as seen in the statements from the RG.

Considering the beauty of the person only from an aesthetic point of view, reveals the culture dictating rules to the body to which the person is likely, even with losses of their own body (skin, hair, nails and other organs) and / or rewards often financial, to conform to the standards of behavior that show them as natural and not harmful.

Body image is related to identity⁶. It is not a product of ownership of the bodies of others, though we may incorporate parts of body images of others to our personal style.

However, there are people who are always down, negative, finding nothing on them self-beautiful only in others and not in them self. (C1)

[...] with this class now, we reinforce skin care. And a little lesson that we must reinforce in our care ... I'm going back to Paraíba to do my paintings, and when I'm exposed in the sun, I know you have to wear sunscreen, or a big hat ... [laughing] (C6 )

Finding the beauty of your own life. Get rid of the boredom, finding beauty in oneself. (C2)

These statements the RG, observes the disconnection of the research subjects from the external body image, and the appreciation of their essence and talents fostering self-awareness and self-acceptance^5,6.

The dermatological disease is an objective event and endowed with a subjective meaning. The RG members, seeking subjective forms of overcoming, found other perspectives and meanings of beauty. In addition, by exercising self-care that they were oriented during the research they have undertaken in the social world.

The skin is an organ of the body that deserves attention and expresses beauty. Although the skin condition is often benign, skin diseases influence the client's life, often being the cause of doors that close in one's life, as well as the reason that leads to closures in many life situations.

The dialogue from the RG on the different existing racial and cultural aspects reveals pre-concepts and concepts of beauty that value the essence of the being human.

I always try to be well because I acquired a disease that devastated my life ... If I were to count all the bad traumas that I've gone through ... I should be buried in the ground by now. (C11)

However, I try to be always upbeat, I like to party, go out, and have fun, dance ... and much more up than many people who do not have half of what I have. (C2)

[...] then they tell me that I was stressed and I said that do not stress over anything, it was the lack of medicine. Everything well, sometimes may have appeared on behalf of traumas and everything, but when I am in crisis I take the medicine, but I don't know. (C1)

The client with a dermatological disease when associated with a disease feels stigmatized⁵. According to the statements of the RG:

Each one has their own beauty there is not a defined standard. If it were applied to the whole world in life, the world would be very different. Because today beauty is on the outside and it is what rules. (C10)

The person can be beautiful on the outside, and on the inside, garbage. (C7)

It is observed that the RG search of demythologizing the grueling standards of beauty, because it comprehends that it can overcome given this. As it seeks to overcome adverse situations, the social conventions regarding beauty can affect unconsciously dictating guidelines and generating distorted interpretations of self-image, thus producing low self-esteem⁶.

It is for the body that converges the look of the people. With it, build references of admiration/approval or rejection/censure, if they agree or disagree with the established normality standards¹¹.

Ratifying the rejection that reflects the concordance with established normality standards, describes that, in western societies that value the physical beauty, the visibility of dermatological disease impacts negatively on social functioning and emotional, particularly women^{12, 13}.

Abstain, therefore, that is in addition to their forces, the people did not slip into the error and prevent failures. Those who are unaware, ignore their own value and what they must do. Thus, by observing the statements of the RG in the discussion of the legend of beauty, one realizes that it recognizes their values, seeking to observe their environment realistically in a subjective dimension.

This dimension, where beauty pleases the beholder simply because people tend to feel good while admiring certain forms, figures, landscapes or people. Since the human standards for definition of beauty are cultural, geographical and temporal.

The following statements of RG express clearly, that beauty is in the nature, in things pure and in God. Realizing that the beauty is beyond its common meaning described in dictionaries:

To sum up everything, beauty is God! Then if you want to look for beauty, you demand it, you are looking in the sky and if you are sad, you look at the sky! ... (C-12)

We see the beauty in nature ... in a forest. (C11)

Thus, they recognizes their values and realize the beauty of life. Recognize their values is also related to self-care, how to reveal some of the subjects' statements referring to care with the skin exposed to the sun's rays, access to leisure, with family that are mechanisms of strategies to achieve wellness.

Therefore it is clear in the context of these statements, which describe how the disease represented for them the opportunity to reflect on how they related to the social world and can, observe how the people around you, and shall revise their values, attitudes and behaviors in this world¹⁴.

The inside influences the outside, but the opposite is also true, since adopting a correct size, an expressive perspective, a firm voice and relaxed attitude collaborate in the aggregation of the personal worth and self-confidence⁶. Thinking in the affirmation that influence the self-esteem, it outweighs the following statement of the RG:

Because if the person stops to think about it, the beauty is in speech and action of each one ... (C9)

CONCLUSIONS

Applying the qualitative research approach called socio-poetics it was possible to identify the influences of cutaneous conditions in self-image and self-esteem of people, through the examination of their testimony; whose thematic subcategories unveiled formed the analytical category - The existing beauty in the beloved human being.

The data production analysis showed that clients with the said disease had a high understanding of the technical research-narrative in the legend of beauty. In the same way, it revealed that nursing instructions for self-care helped reformulate their practice of skin care, even in situations of pain. They emphasize in their speeches characteristics of transcendence of suffering by stress, tensions, and perceptions of their living conditions by other people because of skin lesions, like finding the beauty in their own life. Getting over the boredom, with suffering, finding the very beauty of life itself.

Therefore outweighs the importance of a nursing care to this population favoring the completeness of their bodily dimension.

It was concluded that understanding the limitations of these clients and consequent interventions to reduce them helps the realization of their choices and decisions. The establishment of sensitive / therapeutic listening encourages the expression of feelings; social skills demonstrating patience and loving attitude contribute to the promotion, prevention and preservation of self-esteem and self-image. Maintaining a professional / client relationship, focusing attention, trust, love and care, favors the understanding of nursing guidelines to self-care, especially for the needs of hydration, nutrition, hygiene, specific skin care, leisure and self-knowledge practices.

REFERENCES

1.Grimalti F, Peri JM, Torres X.Transtornos psicológicos en enfermos dermatológicos como efecto de una psicodermatosis reconocida como tal. In: Grimalti F, Cotterill JA. Dermatologya y psiquiatría: histórias clínicas comentadas. Madrid (Es): Aula Medica Ediciones; 2002. p. 37-56.

2.Santos I dos, Brandão ES, Clos AC. Enfermagem dermatológica: competências e tecnologia da escuta sensível para atuar nos cuidados com a pele. Rev enferm UERJ. 2009; 17: 124-9.

3.Crivaro ET, Almeida IS, Souza IEO. O cuidar humano: articulando a produção acadêmica de enfermagem ao cuidado e ao cuidador. Rev enferm UERJ [online]. 2007; [citado em 30 jun 2013] 15: 248-54. Disponível em: http://www.portalbvsenf.eerp.usp.br/scielo.php?script=sci_arttext&pid=S010435522007000200015&lng=pt&nrm=iso.

4.Santos I dos, Caldas CP, Gauthier J, Erdmann AL, Figueiredo NMA. Cuidar da integralidade do ser: um desafio no domínio da enfermagem. Rev enferm UERJ [online]. 2012; 20: 4-9.

5.Guedes CR. A imagem social de mulheres negras universitárias: a silhueta esculpida durante o processo de formação [dissertação de mestrado]. Rio de Janeiro:Universidade do Estado do Rio de Janeiro; 2012.

6.Monbourquette J. Da auto-estima à individuação: psicologia e espiritualidade. Tradução de Benôni Lemos. São Paulo: Paulinas; 2008.

7.Gauthier J. O oco do vento: metodologia da pesquisa sociopoética e estudos transculturais. Curitiba (PR): CRV; 2012.

8.Santos I dos, Gauthier J, Figueiredo NMA, Petit SH. Prática de pesquisa em ciências humanas e sociais: abordagem sociopoética. São Paulo: Atheneu; 2005.

9.Gauthier J, Hirata M. A enfermeira como educadora. In: Santos I dos, Gauthier J, Figueiredo NMA, Sobral VRS, Marinho AM. Enfermagem fundamental-realidade, questões e soluções. São Paulo: Atheneu. 2001. p.123-41

10.Tahan M. Minha vida querida: os segredos da alma feminina nas lendas do oriente. Rio de Janeiro: Record; 1997.

11.Lima NRLB. Lúpus o que dizem as mulheres. Maceió (AL): Edições Catavento; 2011.

12.Steventon K, Cowdell F. Psychological impact of facial acne in adult women . Journal of the Dermatology Nurses' Association. 2013; 5: 148-52.

13.Jesus PBR, Brandão ES, Teixeira ER. Influências da autoimagem na vida dos clientes com afecções cutâneas hospitalizados. Rev Pesquisa Cuidado é Fundamental [online]. 2012; 4: 2394-400.

14.Jesus PBR. Perspectiva estética/sociopoética ao cuidar de clientes com alterações de autoimagem devido a afecções dermatológicas [dissertação de mestrado]. Rio de Janeiro: Universidade do Estado do Rio de Janeiro; 2013.