Untitled Document

RESEARCH ARTICLES

 

Nursing and self-care: perception of oneself as an existential body in the world

 

Adão Ademir da SilvaI; Marlene Gomes TerraII; Maria da Graça Corso MottaIII; Marinês Tambara LeiteIV; Stela Maris de Mello PadoinV
IM.Sc. in nursing. RN at the Psychiatric Unit of the University Hospital of Santa Maria. Santa Maria, Rio Grande do Sul, Brazil. E-mail: adaoademirdasilva@yahoo.com.br.
IIPh.D. in nursing. Adjunct professor at the Nursing Department of the Federal University of Santa Maria. Santa Maria, Rio Grande do Sul, Brazil.  E-mail: martesm@hotmail.com.br.
IIIPh.D. in nursing. Adjunct professor at the Nursing Department of the Federal University of Rio Grande do Sul. Porto Alegre, Rio Grande do Sul, Brazil. E-mail: mottinha@enf.ufrgs.br.
IVPh.D. in nursing. Adjunct professor at the Nursing Department of the Federal University of Santa Maria. Santa Maria, Rio Grande do Sul, Brazil. E-mail: tambaraleite@yahoo.com.br.
VPh.D. in nursing. Professor at the Nursing Department of the Federal University of Santa Maria. Santa Maria, Rio Grande do Sul, Brazil. E-mail: stelamaris_padoin@hotmail.com.


ABSTRACT: This qualitative study was grounded on the theoretical-philosophical framework of Maurice Merleau-Ponty and on the methodological framework of Paul Ricoeur, which aimed to understand the self-care of mental health nursing professionals. The study was developed with 10 mental health nurses, in a population of 15 professionals, by means of an open interview. The study setting was the psychiatric unit of a university hospital in central Rio Grande do Sul state, Brazil. The interviews were performed between September and December of 2010. The interpretation and understanding of the speeches originated the theme ‘perception of oneself as an existential body in the world’ and the subthemes ‘existentiality as a dormant phenomenal body’ and ‘existentiality as a being of ambiguity’. In conclusion, self-care happens as the professional values him/herself, places him/herself in the world as an existential body, and relates to others dialogically.

Keywords: Nursing; nursing staff; nursing care; mental health.


 

INTRODUCTION


The concept of self-care in this study is based on a complex web of meanings, which designates self-care, as well as the knowledge and dedication towards oneself. Therefore, self-care is understood as a reflection of one’s own existence in consonance with the relationships of power, established either voluntarily or involuntarily, throughout life1. In this path of knowledge regarding oneself, the other plays a fundamental role, since s/he is the mean reference and subject of our concerns and desires. It is based on the interactions with the other that the subject finds and builds himself in the world1.

In the discussion of self-care, it is evident that despite being an essential instrument in nursing, the definition of care is still not clear. In this sense, it is important to emphasize a care view that values the historicity of the individual and her/his relationship with others and the environment in which s/he lives, so that both the one who delivers care and the individual being cared for are subjects of the care construction2.

In this search for understanding self-care, this care is revealed as a pause to look into one’s own life and to observe what is being experienced “[...] not aimed at judging it, nor blaming ourselves, but to question ourselves regarding the intentions proposed and not achieved, regarding the way our existence is being managed, as something to be preserved”3:935.

Based on the framework of self-care, it is understood that nursing requires a self-reflection so as to deliver effective care to another being. It is a profession that, especially towards the care of people with mental suffering, requires a demand of attention, compassion and affection. Professionals in face of this situation might feel irritated, sad, disappointed, and experience feelings of guilt and anxiety, due to being generally observed as incompatible with the professional profile4.

Mental health professionals face difficulties in their own care at a psychiatric hospitalization unit, which is observed and experienced in this world of care and, at times, negligence with self-care5. In this setting, patients are usually hospitalized with risks for themselves and other people. The setting of care, in general terms, is fatiguing, with long work hours, demands from the hospital institutions, as well as their self-demands6. However, the emotions of the professional are not taken into consideration and, subtly, they are denied at the hospital, which may result in the reflection of the professional’s attention towards her/his self-care on the quality of the care to the patient6.

In this sense, the question that guided this study was: what is it like for the mental health nursing professional to take care of him/herself? And based on this concern, the purpose of this study was to understand the self-care of mental health nursing professionals.

THEORETICAL FRAMEWORK

Understanding Merleau-Ponty

The philosopher Maurice Merleau-Ponty emphasizes the concern with the human being as a subject body, since concrete life is always incarnated and no thought disregards the sensitive experience. In addition, s/he recognizes the body as an essence of the subject, through which the individual world is built, formed and inserted in the given world, in a situation of circumstantial space and time, which contributes to constitute the subjectivity and the expressiveness of the subject7. The body, in Merleau-Ponty, is not a group of organs, but an experienced body or sensitive body, located in the encounter with the world. The experienced body transcends the physiological body, making the relationships and limits between subject and objects movable and ambiguous7.

The body is the vehicle of the being in the world, and inquiring about the body means inquiring about the existence. There are intentional threads between the body and the world, and describing the bodily experience requires, at the same time, to describe the experience that the body keeps with its world8.

This emphasizes, thus, the expression of subjectivity, which is necessarily manifested through the body, as a representation of the subjects in the world, involving a subjective view of the body as a primordial being. The human being must have the experience of the world before getting to know it, before the objective experience of the world7. It is based on the experienced body that experiences and meanings of the world are accumulated, creating and broadening habits, thus, approaching the individual to the comprehension of the world, which is not hers/his, but a common world to all experiences8.

Hence, phenomenology is highlighted as a pathway to study the processes of care. This nursing care reveals singular and authentic meanings, which show the subjectivity of the subjects, opening ways to the signification of experiences from both the one who delivers care and that who is cared for9.

Understanding Ricoeur

Paul Ricoeur, a French philosopher who was involved with the world of several areas, contributed effectively with the theory of discourse. S/he adopted the argument of Merleau-Ponty, of which the body is in a bodily situation, incarnated in the world by means of its expressiveness. This body is language, produces signals and meanings that may be apprehended by the hermeneutic work, through the linguistic interpretation of the spoken and written productions of the subjects, and through the perception of the researcher. By means of the perception, the human being is able to apprehend and interpret the world and the surroundings, opening countless possibilities to enter the world experienced by the other10.

The hermeneutic work relates with phenomenology and must not be limited to capturing the meaning of texts and signs, as it is necessary to go further and to make an effective effort to understand the man and the world11.

In this perspective, it is necessary to search the essence of the phenomenon in question in the process of hermeneutic interpretation, which presupposes an exhausting search for the revelation of implicit meanings in the discourse12. The interpretation of the discourse in the study represents a movement to decipher hidden meanings, searching for the manifested symbols, which are chains of meanings that can only be understood through the comprehension of the direct and indirect meanings present in the worlds, metaphors of the discourse11,12.

Understanding the metaphor in a sentence, as a constituent form of the language, implicates to redirect the language from the classificatory aspect to that of the signification. Provided with the sentence, the language leaves its form, and the reference indicates its transcendence11. The metaphor, as does the entire proposition, points to the construction of the signification, that is, content and vehicle are neutral, and its association is what constitutes the metaphor, revealing a broader meaning, from metaphor to predication. In other words, through this view, the metaphoric construction is not based on the figure of the single word, which brings the new meaning, but on the predicative construction11.

METHODOLOGY

This study was originated from a dissertation of master’s degree in nursing13, in which the author used the qualitative phenomenological approach grounded on Maurice Merleau-Ponty and on the hermeneutic-phenomenology of Paul Ricoeur. The study was developed in a psychiatric hospitalization unit, at a teaching hospital in central Rio Grande do Sul state. The authors used the phenomenological interview, which was recorded, with ten mental health nursing professionals (three men and seven women), namely three nurses, three nursing assistants and four nursing technicians, in a population of 15 professionals, aged between 31 and 60 years, in the period between September and December of 2010. The number of professionals interviewed was established according to the saturation of discourses, which configured the purpose of the study14. All the professionals of the service were considered for the interview, except those who were on medical leave during the interview period.

In the phenomenological interview, the researcher tries not to induce the answers or restrict the speech of the subject, using only one open guiding question15. After the interviews, personal notes were taken and the researcher’s impressions were recorded in audio and then transcribed. In this sense, the interview was based on the following question: how do you take care of yourself, being a mental health nursing professional?
The discourses of the nursing professionals were understood and interpreted using the hermeneutic method11,12, which consists on the interpretation of the spoken and written discourse, the search for the metaphor of the written work and the appropriation11. In the appropriation, the researcher must use a theoretical-philosophical framework11, which in this study was the phenomenology of the perception, emphasizing the man as subject body, with habits, and whose existentiality is materialized in the encounter with the other16.

Based on the perception of each professional, the theme perceptionof oneself as an existential body in the world emerged, along with two sub-themes: existentiality as a dormant phenomenal body and existentiality as a being of ambiguity.

The study complied with all the principles of the resolution 196/96, of the National Health Council, which addresses ethics in researches involving human beings17. The nursing professionals were informed about their right to participate or not in the study, the possibility to quit their participation at any time, as well as the need to sign and Free and Informed Consent Form, so that the interviews could be initiated. The research proposal was approved by the ethics committee for research involving human beings of the institution, under the protocol 0.274.0.243.000-10, on October 19, 2010. For ethical reasons, the professionals were identified after the letter N(N1, N2, N3...), as in the initial of the word nursing, followed by a number, which does not necessarily represent the sequence of development of the interviews.

RESULTS AND DISCUSSION

Perception of oneself as an existential body in the world

The metaphor revealed that mental health professionals are human beings incarnated in the world, who are historical, temporal, spatial, intentional, wishing and seek for their place in the construction of themselves. In the world of mental health care, there is the possibility of encounter of subjectivities, in which the professionals may recognize and find themselves engaged through their body in a world with which s/he establishes empathy, due to an older connection than her/his personal history, of a being in the world, such as in relation to her/his task and vocation7.

Therefore, the body, subject of the perception, is the means through which the conscious relates and is expressed both with and in the world, the visible figure of the intentions16

Existentiality as a dormant phenomenal body

The phenomenal body is not the objective body of biology and medicine, neither the subjective or purely cognitive body7. The phenomenal body is the body of the human being, as s/he experiences it, as it rises towards the world from within. It is the particular, individual body, which must be expressed in the singular form of the first person. It is the body through which the feelings and thoughts of the man make contact with objects, so as the world exists for her/him, being the subject of the experience7.
The mental health professionals of this study appear as phenomenal bodies of expression, which have dormant aspirations and desires due to the agreements and disagreements experienced in the world of care of the other. The discourses revealed the intentionality of the professionals, as well as the several factors that interact and interfere in the action of self-care. This does not appear in the explicit form of action for its development, but in what was unsaid in the discourses, as difficulties for its construction11,12. Self-care is found as something extremely important, something to be achieved and assimilated as a habit of the action of a phenomenal body in construction7.

[...] I think I don’t take care of myself, you know. I get so involved with things [voice variation], I do a lot of things at the same time, and in the end I don’t observe my limits. That’s why I don’t take care of myself, I don’t see my needs, the need to stop, to think more about myself,to look after my things. Like getting my hair cut, or dyed, taking care of my physical appearance, my self-esteem, I was neglecting all these things. (N4)

This speech reveals that the professionals neglect their own care over the care of others, as if an action invalidated the other. By watching for the other being, object of their care, they see themselves as a phenomenal body. The human being recognizes her/himself as a subject in the encounter of another8. When a human being looks at the mirror, s/he sees her/his image reflected, based on her/his perception. But it is at the moment s/he looks at the other, in an open and reflexive manner, in a true encounter, that s/he may have the perception of the other towards us. This implicates, thus, our dependence on the constant encounter with the other, so that we may constantly be in a process of discovery of our other self, which is historical, temporal and intentional7,16.

The following discourses reveal bodies that are used to appear well, even though everything may be falling apart in their lives. In this exposure of the difficult situations experienced, the importance of the relationships and interactions between the professionals stand out, including the opportunity to have more time for listening and talking13.

[...]I think that as incredible as it may seem, the most complicated thing in working in the psychiatric area is the team of colleagues. It is not a unanimous thought. There are divergences [...] it is difficult to live in a large group.Not everyone thinks the same.And,sometimes, we argue [...] then we have to talk and see what must be changed, we argue a little, discuss [laughter] and try to talk it out. (N8)

In this discourse, it is observed that the professional appears willing to open her/his world, but find difficulties in the structure of operation of the service and in the configuration of the relationships with the other16. The encounters between the subjects are not merely professional and objective. In the world of mental health care, the encounters reveal subjective relationships loaded with meanings, especially emotions. As in any human relationship, these are not exclusively peaceful and spontaneous relationships, but full of divergences and conflicts with the other, which, in the encounter, reveal contents lost in the subjective world of every subject16.

In this perspective, it is positive to discuss the characteristics of the speaking discourse (what is unsaid) and the spoken discourse (what is said), present in every linguistic construction of the human being. In the daily world of experiences, the fact that the professionals speak among themselves and to themselves, using the spoken language, stands out7,8,16.

It is understood that the professional uses only the spoken language in her/his work shift, mechanically and automatically. This difficulty of interpersonal and truly human exchanges, in the world of mental health care, is perceived by the professionals as one of the great issues for the full development of self-care13.

Existentiality as a being of ambiguity

Self-care and the care of the other emerge as a relationship that is intensely experienced, supporting an existential experience that is ambiguous and, above all, sensitive18. Sometimes as a relationship that generates joy, and other times as a generator of suffering. Hence, the professionals appear as frail human beings, who feel the encounter with people as a movement of discovery of themselves and the others16. This encounter shows a stage of intersubjective exchanges in which the self may find things of their own, which are forgotten, in the other16. This intentionality is manifested as a request, which is often hidden, for listening or dialogue by the other (colleague, patient or relative of the professional)13.

Based on the comprehension of the professionals, it is perceived that the world of significations of every one makes it a body, which may or may not take care of itself and is intimately related to the encounter with the other, in an interpersonal exchange.
The ambiguity of the relationship of self-care and care for the other, in psychiatry, is manifested in the disclosure of experiences with mental illnesses, as a reason for suffering, stress, tension, lack of confidence and fear, at the same time they generate satisfaction, learning and growth11,12.

I like working in psychiatry a lot, I identify with it, I think I do it well and have a good relationship with the patients, I have a good bonding with them. I feel good working with them.(N8)

I have experienced situations of serious trouble, aggressiveness, violence, which we face with a lot of anxiety, we face our own condition of powerlessness.(N9)

The anxiety generated by the experience of living with the psychic suffering and pain of the patients is revealed as a factor of personal suffering for the professionals, but which is relieved by the emotional bonds built with the other (patient), in the encounter in which they allow themselves to be subject of their own existential metaphor11-12. It is understood, thus, that the care is based on interpersonal exchanges, and that it happens when the existence of the other is found important for us19.

CONCLUSION

This study has revealed that human relationships are the key to understanding self-care. Professionals do not take care of themselves on their own, they depend on the other in the daily living, valuing the body as the unit of relationships between subjects and as vehicle of expression of feelings. They appeared as a habitual body, but also allowed themselves to expose their private world, to which they did not have access.

It was also possible to observe the transforming nature of the encounter between people, in the sense that the professionals see themselves ambiguously connected to the other, in the existentiality of the encounter, whether it is due to the pleasant or distressing nature of the relationships, which is part of being with the other in the world. As perceived, in the scope of mental health care, people built superficial relationships, which are controlled by spoken discourses, evidencing dormant phenomenal bodies. However, these same people intend to seek the pathway of intersubjective exchanges and speaking discourses, which are more inclined to the construction of rich and harmonious relationships from the human point of view. Hence, that which was said and unsaid in the discourses manifested the understanding of the professionals regarding their own action of self-care. A difficult action, in which self-care ends up cast aside and, in its place, there is the defense against the conflicts and anxieties resulting from the situations experienced in the world of the mental health care.

This study shows mental health professionals as existential human subjects, with desires and interests that are repressed in terms of manifestation of original emotional contents, which could make the relationships spaces for exchanges, happy and pleasant experiences, in which self-care would be, at last, a reality instead of a mere intention.

Regarding the limitations of this study, there is the question of the emerging paradigm and the dominant paradigm, which appear in the study as antagonistic factors and may produce contradictions and suffering in the development of mental health nursing, as well as be the ground for future studies. In addition, the reduced professional group studied does not allow the findings to be generalized.

REFERENCES

1. Castro FCG, Viana TC, Bara O. O "cuidado de si" em Platão e em Balzac: algumas páginas da história da subjetividade. Rev Mal-Estar Subj. 2010; 4:1271-1300.

2. Boff L. Saber cuidar: ética do humano-compaixão pela terra. 2ª ed. Petrópolis (RJ): Vozes; 1999.

3. Lunardi VL, Filho WDL, Silveira RS, Soares NV, Lipinski JP. O cuidado de si como condição para o cuidado dos outros na prática de saúde. Rev Latino-Am Enfermagem. 2004; 6:933-9.

4. Preto VA, Pedrão LJ. O estresse entre enfermeiros que atuam em Unidade de Terapia Intensiva. Rev esc enferm USP. 2009; 4:841-8.

5. Baggio MA, Erdmann AL. Multiple relationships of nursing care: the emergence of care “of the us”. Rev Latino-Am Enfermagem. 2010; 5:895-902.

6. Robazzi MLCC, Mauro MYO, Secco IAO, DalriI RCMB, Freitas FCT, Terra FS, et al.  Alterações na saúde decorrentes do excesso de trabalho entre trabalhadores  da área  de saúde. Rev enferm UERJ. 2012; 4:526-32.

7. Merleau-Ponty M. Fenomenologia da percepção. 3ª ed. Tradução de Carlos Alberto Ribeiro de Moura. São Paulo: Martins Fontes; 2006.

8. Terra MG, Gonçalves LHT, Santos EKA, Erdmann AL. Fenomenologia de Maurice Merleau-Ponty como referencial teórico-filosófico numa pesquisa de ensino em enfermagem. Rev Gaúcha Enferm. 2009; 3:547-51.

9. Duarte MR, Rocha SS. As contribuições da filosofia heideggeriana nas pesquisas sobre o cuidado em enfermagem.  Cogitare Enferm. 2011; 2:361-4.

10. Delavechia RP, Terra MG, Noal HC, Padoin SMM, Lacchini AJB, Silva MEN. A percepção de si como ser-estomizado: um estudo fenomenológico. Rev enferm UERJ. 2010; 2:223-28.

11. Terra MG, Gonçalves LHT, Santos EKA, Erdmann AL. Fenomenologia-hermenêutica de Paul Ricoeur como referencial metodológico numa pesquisa de ensino em enfermagem. Acta Paul Enferm. 2009; 1:93-9.

12. Carvalho MF, Moreira MRC, Nunes CM. Estágios do pesar nos discursos de jovens em tratamento renal substitutivo. Rev enferm UERJ. 2012; 2:203-8.

13. Silva AA. O cuidado de si do/a profissional de enfermagem em saúde mental [dissertação de mestrado]. Santa Maria (RS): Universidade Federal de Santa Maria; 2011.

14. Fontanella BJB, Ricas J, Turato E. Amostragem por saturação em pesquisas qualitativas em saúde: contribuições teóricas. Cad Saúde Pública. 2008; 1:17-27.

15. Melo HC, Araújo SEG, Santos VEFA, Veríssimo AVR, Alves ERP, Souza MHN. O ser-enfermeiro em face do cuidado à criança no pós-operatório imediato de cirurgia cardíaca. Esc Anna Nery. 2012; 3:473-79.

16. Merleau-Ponty M. A prosa do mundo. Tradução de Paulo Neves. São Paulo: Cosac & Naify; 2002.

17. Ministério da Saúde (Br). Conselho Nacional de Saúde. Comitê Nacional de Ética em Pesquisa em Seres Humanos. Resolução nº196, de 10 de outubro de 1996: diretrizes e normas regulamentadoras de pesquisa envolvendo seres humanos. Brasília (DF): CNS; 1996.

18. Terra MG, Gonçalves MG, Santos EKA, Erdmann AL. Sensibility in the relations and interactions of teaching and learning to be and do nursing. Rev Latino-Am Enfermagem. 2010; 2:203-9.

19. Santos VEP, Radünz V. O cuidar de si na visão de acadêmicas de enfermagem. Rev enferm UERJ. 2011; 1:46-51.