ORIGINAL RESEARCH

Being a woman with a heart disease and developing pressure ulcer as a hospital inpatient: sense of fear

Aurilene Lima da Silva^I; Lúcia de Fátima da Silva ^II; Ivis Emília de Oliveira Souza^III; Maria Vilani Cavalcante Guedes^IV; Michell Ângelo Marques Araújo^V; Maria Sinara Farias^VI

^I Nurse. PhD. in Clinical Care in Nursing and Health at Hospital Dr. Calos Alberto Studart Gomes. Fortaleza, Ceará, Brasil. E-mail: aurilenelimas@hotmail.com
^II Nurse. Phd. Professor at Universidade do Estado do Ceará. Fortaleza, Ceará, Brasil. E-mail: luthy2008@hotmail.com
^III Enfermeira. Professor at Escola Anna Nery, da Universidade Federal do Rio de Janeiro, Brasil. E-mail: ivis@superig.com.br
^IV Nurse. PhD. Professor at Universidade do Estado do Ceará, Ceará, Brasil. E-mail: vilani.guedes@globo.com
^V Nurse. Professor at Universidade Federal do Ceará. Fortaleza, Ceará, Brasil. E-mail: micenf@yahoo.com.br
^VI Nurse. MSc.candidate at Universidade do Estado do Ceará. Fortaleza, Ceará, Brasil. E-mail: sinarafariasbc@gmail.com

DOI: http://dx.doi.org/10.12957/reuerj.2017.14509

ABSTRACT

Objective: to reveal the meanings that the woman hospitalized for cardiopathy attributes to the experience of developing pressure ulcers. Method: a phenomenological study, for which declarations were collected in 2012 by interviews of eight women inpatients at a public hospital in Fortaleza, Ceará, Brazil. Approved by the research ethics committee (No. 858/11). The analysis rested on an understanding based on the philosophical thought of Martin Heidegger. Results: five units of meaning emerged: discomfort from pain, dressing and/or maintenance, and partial immobility in bed; fear of wound complication; helplessness regarding the hospital stay and desire to return home; (lack of) knowledge of the situation being experienced; and gratitude for the care received. Prominent among the meanings apprehended were fear, shown as a mode of being in dread, horror and terror. Conclusion: from the study, the nurses' reflection emerges in emphasizing the existential manifestations of the beings they care for.

Keywords: Nursing; cardiovascular diseases;women's health; pressure ulcer.

INTRODUCTION

Among nursing care contexts, those experienced by nurses in charge of patients with cardiac disorders stand out. In the case of those morbid conditions, one must enhance gender-specific issues when it comes to the presentation, evolution, and way the disease is displayed. Thus, gender has become a major issue in health care contexts¹.

On that scenery, both Nursing and the nurse, in particular, must pay special attention to females It is their interest to grasp human manifestations beyond biological issues involving the illness. In this fashion, complementary knowledge is made possible as qualitative phenomenological research is carried out. It can help the understanding of human beings' unique existential manifestations as well as human response in health-disease contexts.^2,3

Therefore, taking into account the contexts of cardiovascular conditions, this study comes into being out of the experience as a stomach therapist nurse caring for cardiac females in a cardiology hospital. It is concerned with the caring modes when females develop a pressure ulcer in hospitalization. Particularly, when assisted with showering or with having new dressings set in place, they express embarrassment and disgust about the ulcer, in addition to distress and stress. This way, nursing care can be meant for assistance with showering, dressings, alternative technologies for treatment of the ulcer, as well as with caring for the females' emotional issues⁴. All that considered has prompted the interest in a careful regard of all conditions they experience and speak about. Clinical practice helps the nurse with caring for the female with cardiac disorders in hospital facing injury or a pressure ulcer she might ignore. A pressure ulcer comprehends a skin and/or deep tissue ulcer, usually on a bone protuberance, as a result of either pressure or a combination of that with twisting forces⁵.

It is known as undesired occurrence and turns out to be a problem to health services, to the nursing team in particular.⁶. It usually raises hospital costs and lengthens hospitalization. It causes patients pain, discomfort, distress, low self-esteem, worries, and anxiety.^7,8. Treatment requires time and specific care, as well as coping within several contexts of the human dimension⁹.

Therefore, considering Nursing as a health care practice, in which the nurse has to stand by the patient, assisting him or her about genuine living, comprehension is sought of the pressure ulcer phenomenon affecting females with cardiac disorders in hospital. Nurses are thus meant to think over that phenomenon in search for clinical nursing care anchored on the search for revelation of those beings as unique and inserted in personal, family, and social contexts. ⁹.

This research, therefore, has been concerned with clarifying the following issue: how can the female with cardiac disorders, developing a pressure ulcer in hospitalization give meaning to that experience? Caring for those women must be regarded from the Being-with perspective, in a caring and helping relation so that caring is conducted on the basis of the existence of the one receiving care. That can be found in Martin Heidegger's phenomenology¹⁰, which has brought out existential aspects endowing the human being. Therefore, this research has aimed at revealing meanings the female with cardiac disorders in hospital endows her experience with.

THEORETICAL FRAMEWORK

Upon studying the phenomenology of Being, Heidegger, brought out his modes of Being-with in history and time of being-in-the-world. Among the modes of being, the philosopher describes the concern with whatever is the most proper to being, that which characterizes it as an existent in the world. By means of caring, the human being experiences possibilities of being, ranging within a healthy oscillation between authentic and inauthentic modes of being¹¹.

Authentically, man experiences intentionality of conscience, in search of living his possibilities of being with himself, with others, and with things in the world, by means of a concerned attitude. However, with worldly living, he falls back into the inauthenticity of living like everybody else.¹¹.

Among the worldly modes of being, the being is likely to fall back into the appropriation of the mode of being of fear, presuming being afraid, fearing the fearsome, which comes along with the person proper. Fear, therefore, feels like a threat, causing loss or damage, which may or may not be known, may be regarded as uncanning, harmful. Thus, even within short range, damage may be overcome or may be absent and even so, may be experienced as fear. The fearsome stands for a threat, even if it keeps distant ¹¹.

In Heidegger, presence as being in the world is fearsome. Fear may vary and within the range of those variations different possibilities of being of fearing: dread, characterized as an existing threat, something that is known and familiar. That is what suddenly threats and may show up all of a sudden, as it might not come to occur, but still may arrive at any moment. Horror is figured in the unknown, what threats is configured as something totally new, not familiar, which is still not known, and terror occurs when what threats is configured as dread (the sudden) as well as horror (unknown)¹².

Heidegger's thought is broad, complex and makes room for challenges to those who choose to pursue research within his theoretical framework. The philosopher stimulates the researcher to endeavor interpreting and disclosing what remains obscure and veiled in the language of the Being that experiences a condition of existing. Here, it is meant existing as a female with cardiac disorders and experiencing a pressure ulcer ¹².

From that stand, by comprehending existential manifestations, nurses are believed to be better able to assist with the experiencing of the given situation as well as help understand the existential manifestations of those receiving care.

Aware of both their potential and responsibilities over the female with cardiac disorders experiencing a pressure ulcer in hospitalization, the nursing team can favor experiencing that phenomenon, by means of Heidegger's phenomenology. Opening up room for dialogue, in search of listening to the patients' dilemmas can help coping with daily fears, and, therefore, promote and share strategies for coping with fear¹³.

Given the increasing diversity in nursing roles, the methodology herein offers a path for improving our comprehension of implications to nurses who lead specific roles and allows for actions

in several assistance, teaching and research scenarios^14,15.

METHODOLOGY

The research was developed at a public hospital, belonging on the heath assistance net of the Single Health System (SUS), of the Health Secretariat of the State of Ceará (SESA). Eight women between 46 and 91 years old, among those who were available to participate, were taken into the study. They were in hospital after a diagnosis for cardiac disorders, having developed pressure ulcer, and were accommodated in nursing units.

Phenomenological interviews were developed on the basis of voice recording, and were mediated by the guiding question: how do you feel about living with an injury/sore (pressure ulcer) in hospitalization? For the respondents' identification, they were given the letter E, followed by the sequential number of their interview.

Results came out of five, among those eight women, who more strongly expressed the sense of fear in their responses. (E1, E2, E3, E4 e E5). Clinical possibilities were taken into account as well as each patient's willingness to be interviewed at that moment and that place for an average of twenty to forty minutes. Each interview had a full transcript so that not just their words, but other forms of signifying communication and language could be registered, such as gestures, silence, facial expression., smiles, and so on. Participants' speeches were organized so that meanings ascribed to experiencing by those females with cardiac disorders could emerge.

Under Heidegger's comprehensive methodological moments, the first interpretive move was carried out. Also called median and vague comprehension, by means of which the immediate instance of experiencing was disclosed, it allowed for grasping the meanings in the respondents' speeches.

At that moment, what emerges and comes into light is called optical primacy or optical significances, out of which signifying units emerge. It was then that it was sought what the will be manifested on its occasionality, that is, its today, the historic will be, the daily nature found in its experiencing. Out of the respondents' speeches then, the following signifying units came about: discomfort by pain, caused by either a new or the existing dressing and partial immobility on bed rest; fear of possible complications with the sore; helplessness in face of hospitalization and homesickness; (not) knowing about the situation experienced; and gratitude for the care received..

Along the second analytic moment, one searches the disclosure of meaning under appearances, (ontological revelations), reaching the meaning of disclosures. Out of the significances grasped, fear is to be enhanced, showing as a mode of being of dread, horror, and terror. Three categories came out, namely, fear of treatment, of complications, and of the future.

The study meets Resolution 466/2012 by the National Health Council¹⁶ under approval by protocol n^o 858/11, by the Research Ethics Commission (CEP) of the hospital where the investigation was conducted. Respondents were made aware of both the objective and the methodological strategy of the study. They were additionally asked to facilitate its acceptance, and finally drawing up and signing of the Free and Clarified Consent Form (TCLE) took place. Benefits of the investigation were also spelled out, on the basis that the study is not meant wrongly, and that investigators would be standing by participants to ensure their well-being. They were also assured both about being able to discontinue participation if they wished and about their anonymity and secrecy on information provided.

RESULTS AND DISCUSSION

The search for comprehension assured emergence of meaning, that is, ontological disclosure manifested about the fear veiled in the meanings of being-a-female-with-cardiac-disorders-with-a-pressure-ulcer-in-hospitalization.

Fear of treatment

On the worldly hospital routine, those women fearful of clinical manifestations of treatment for the pressure ulcer they were subject to, manifested fear in the forms of dread and horror, either on account of pain deriving from having the ulcer dressed and/or keeping the dressing in place, or on account of impaired mobility on bed rest, in the following terms:

If I come to live one hundred, I will never forget {referring to the debridement of the ulcer} [...]. I was thus traumatized [...] when I saw you I instantly dreaded it, just to think about the pain to go about this ulcer [...] Me that cannot take it, I just can't take it. [.. .] (E3 )

[...] when I get home, what if it bursts {the ulcer} more and more? Because it's deep? And I fear that [...] I might get home and the ulcer might turn into something worse [...] (E1)

[...] I sort of feel, kind of [...] I can't sit straight [...] that's deep, with bulky dressings down there [...] and the female nurses treated that, they dressed it every day, every day [shows irritation, shaking her head]. (E2)

[...] I feel very impatient. I can't lie down this way {showed the lying position on her back}. I can just lie down sort of on my side. My neck hurts at times; that's the position! Ouch, that is really aggravating [...]. These ulcers on my body [...] at times you sort of think: I want to sit up. [...] (E5)

This way, women show discomfort upon being-in-the-world, particularly in face of the perception of pain or for fear of it. In principle, circumstances which might look colloquial, such as being subject to having the ulcer dressed, come to be fearsome, revealing the Heideggerian dread as they might again experience the pain from the dressing procedure they know about. Having the ulcer dressed makes them fearful, for having experienced pain, they fear chances of having pain again.

This way, for knowing pain, in particular that caused by a dressing procedure or that caused by a surgical debridement of the ulcer, those women show dread in face of new threats and terror for they might have even stronger pain. Manifestation of pain causes them to have a degree of discomfort that interferes with their sleep and rest, bothering them even on account of impaired mobility.

Fear of complications

Disclosures by those women were also concerned with fear of possible complications with the ulcer:

The doctor said that when I'm back home, if [the ulcer] bursts even more? Because it's deep? I'm afraid.. [...].(E1)

[...] I'm afraid it might turn into something else. Cancer, you see? That's what I have in mind [...].(E4)

[...] such a problem. [the ulcer] what can I do about it? Suppose it grows worse[...].(E3)

[...] because that's just the ulcer, but she [the daughter] thinks it might become a different kind of disease[...]. (E2)

They imply fear there might be complications about the ulcer, expressing horror the ulcer might become cancer. In their speeches, treatment and evolution of the ulcer are disclosed in modes of terror, when considering implications in the lives of those women, by fearing they might not take care of the ulcer until it scars. That terror neither decreases nor restricts fear, despite visible chances it might disappear and take distance; on the contrary, it is part of it.¹¹. Fear of complications with the ulcer is existential; even if it does not turn into cancer, which characterizes a threat to them.

Pressure ulcers are also a hindrance to hospital discharge, bringing about anxiety to the patient, family and health professionals. They look forward to the discharge, but are ambiguous about leaving hospital still with the ulcer, afraid they might not take care of it at home as well as it might infect and worsen.

Occurrence of a pressure ulcer affects the context of the patients' life and implies complex issues as a source of concern for them and their families. It must be enhanced that the damages coming out of that phenomenon hit several segments in the personal and family lives of those who suffer.

Fear of the future

The phenomenon of fear can be addressed under three perspectives: that which one is afraid of; what it is to be afraid of; and who for one is afraid of. That which one is afraid of, the fearsome, is always an entity that comes along to meet inside the world and that which is just given ¹². According to Heidegger, there is no acknowledgement of a future evil (malum futurum) so that one is afraid of. It is by fearing that it can be clear what it is to be afraid of. Only the Entity, which, being, its very being is compromised, can fear. The being afraid brings on to those women a set of dangers, at the same time; being and being-in danger changes their expectations, as for instance, the fear of going back home with an ulcer to take care of.¹¹.

Fear for is another Heideggerian concept, by means of which one can fear for somebody else, as E2 reveals when referring to the fear shown by her daughter, which makes her also fear with her, in addition to her own fear. Most times, we fear for somebody else exactly when that somebody else is not afraid and copes with whatever threatens him or her. That's not the case of different degrees in feelings, but of existential modes ¹².

Women still disclosed the fear of the future or even of difficulties related to the lack of physical vigor. Despite their stable clinical cardiac condition, allowing for their discharge and return home, the presence of the ulcers bind them to hospitalization. Thus their fear of physical deterioration as well as the loss of their ability to resume their daily routines:

I'm sorry when I leave here I can't go about the things I used to do {weeps} [...] not even go about my own laundry [...] I feel like going back home, to get well and go home. [...] I'm here alone, without a companion or so, I miss my husband, I miss sex [...] I'm afraid he might find somebody else [...]. (E1 )

Those women feel like going back home, but along with a horror move, for they fear they cannot go about their daily chores, such as do the laundry, take the children to school, leave home to work, they fear sexual performance, their living with their families, shaping their speeches around their failure, stating they fear they might fail taking care of their homes. Existing as a possibility of being-in-the world, fear is fearsomeness, and as such, it opens up the world so that the fearsome can come close to them. Fear in face of the ulcer opens up in those women's existence a set of feelings of danger, for presence while being-in-the-world is a being of occupations and, most times, presence is what it becomes occupied with.

Likewise, manifestation of fear of failing to resume their daily lives is Heidegger's presupposition characterized by the decadence of being in the world at a moment endowed with horror about what is unknown to him/her, manifesting itself as inauthentic existent.¹¹.

Despite that, they acknowledge genuine helpfulness by the nursing professionals, showing consolation and hope, towards the come-into-being, that is, towards a search for new possibilities of existing, although, to that, they depend on the de-cadence of faith in God.

CONCLUSION

The disclosure of the phenomenon investigated allowed for the emergence of the reflection on the need for the health professionals, nurses in particular, to value the existential dimension of those under their care.

Disclosures of this investigation can contribute to the nurses' being-with as well as to that of those women experiencing that health condition. Heidegger's existential, in that case the range of fear as dread, horror, and terror, are mandatory so that nurses can understand the manifestations of those modes of being in their clientele, favoring authentic care.

Searching actions that can help nurses develop better practices, to support the patient and her family during hospitalization, in such a way as to develop a way of caregiving which encompasses several dimensions of the human being, will certainly help a positive change in the worldly daily actions in nursing.

The search for the application of intersubjectivity under a phenomenological perspective can lead nurses to being-there-with the patients. Disclosing the meaning and the manifestation of the pressure ulcer phenomenon, from the perspective of the woman experiencing it, favors caregiving together with those who receive it.

One must register the difficulties faced and inherent to the development of a phenomenological qualitative investigation, as highlighted in the phase with the qualitative interviews. Despite the impossibility to universalize results for a phenomenological-qualitative research, one can consider generalization of the knowledge built up in face of the use of that comprehension to guide the professional being-with of the nursing team in caring for women whose health conditions are similar to that of those participants.

As the phenomenological investigation can help comprehension of the phenomena without ever grasping them all in full, production of other studies are suggested so that new faces of Being-a-woman with cardiac disorders with a risk to develop pressure ulcers in hospitalization can help prevention.

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