Multiple Relationships of Nursing Care: the Emergence of Care "of the us"

Abstracts

Se trata de un estudio de abordaje cualitativo con el objetivo de comprender las relaciones de cuidado de sí, del otro y "de nosotros" en las diferentes dimensiones del cuidado, a través de un proceso educativo/reflexivo/interpretativo con profesionales de enfermería de un Hospital Escuela, bajo la perspectiva de la complejidad. Los datos fueron recolectados mediante talleres y sometidos al análisis de contenido. Surgieron las categorías: reflexionado sobre el significado del cuidado de sí, del otro, y "de nosotros" para el "yo - ser humano" y para el "yo - profesional de enfermería"; y, reflexionando y (re)construyendo los significados de las relaciones del cuidado de sí, del otro y "de nosotros". El cuidado "de nosotros" es un tema nuevo, en construcción, incentiva la preocupación con el colectivo y se relaciona con la comprensión de los fenómenos múltiples e inagotables del constante movimiento entre los seres y de estos con su ambiente, modificando, alterando y haciendo alterar las redes de relaciones existentes.

Enfermería; Grupo de Enfermería; Atención de Enfermería

Este é estudo de abordagem qualitativa, com o objetivo de compreender as relações de cuidado de si, do outro e "do nós", nas diferentes dimensões do cuidado, através de um processo educativo/reflexivo/interpretativo com profissionais de enfermagem de um hospital escola, sob a perspectiva da complexidade. Os dados foram coletados mediante oficinas e submetidos à análise de conteúdo. Emergiram as categorias: refletindo o significado do cuidado de si, do outro e "do nós" para o "eu - ser humano" e para o "eu - profissional de enfermagem" e, refletindo e (re)construindo os significados das relações do cuidado de si, do outro e "do nós". O cuidado "do nós" é tema emergente, em construção, impele a preocupação com o coletivo e remete à compreensão dos fenômenos múltiplos e inesgotáveis do constante movimento entre os seres e, desses, com seu ambiente, modificando, alterando e fazendo alterar as redes de relações existentes.

Enfermagem; Equipe de Enfermagem; Cuidados de Enfermagem

ORIGINAL ARTICLE

Multiple Relationships of Nursing Care: the Emergence of Care "of the us"¹

Maria Aparecida Baggio^I; Alacoque Lorenzini Erdmann^II

^IRN, Doctoral Student, Programa de Pós-Graduação em Enfermagem, Universidade Federal de Santa Catarina, Brazil. Scholarship holder CNPq. E-mail: [e-mail]

^IIRN, Ph.D. in Nursing Philosophy, Full Professor, Universidade Federal de Santa Catarina, Brazil. E-mail: [e-mail]

^{Corresponding Author}

ABSTRACT

The aim of this qualitative study was to comprehend the relationships of the care of the self, of care of the other, and of care "of the us" in the different dimensions of care, through an educational/reflexive/interpretative process with nursing professionals in a University Hospital, using the complexity perspective. The data were collected through workshops and submitted to content analysis. The following categories emerged: reflecting upon the meaning of care of the self, care of the other, and "of the us" for the "I – human being", and for the "I – nursing professional"; and reflecting and (re)constructing the meanings of the relationships of care for the self, care for the other, and care "for the us". The care "for the us" is an emerging theme, in construction, and impels a concern for the collective, as well as remits to the comprehension of the multiple and unending phenomenon of constant movement among the beings and between them and their environment, modifying, altering, and causing to be altered the networks of existent relationships.

Descriptors: Nursing; Nursing, Team; Nursing Care.

Introduction

The existence of the collective, of the society, of human beings occurs through the interdependence and inter-relationships, through the culture, language, education^(1-3). Thus, by coexisting and cohabitating the world the beings depend on, the interactions established in their environment, the establishment of relationships with other beings for their socialization becomes central, with the condition that this impels mutual comprehension in unique ways of intimacy and care^(4-5).

The relationships that permeate the work environment are part of the creative process, and also part of the process of care of beings⁽⁶⁾, which develop the psychological, personal and individual autonomy from multiple dependencies such as family, school, university, etc⁽²⁾. The quotidian practice of care also depends on the relationships established in the work environment, a space that is a potential trigger of stress situations, physical and mental fatigue⁽⁷⁾ with the environmental, cultural and social conditions having influence in the process of care of the beings. Thus, we can say that beings depend on each other for their autonomy, their survival and their personal and professional care in a constructive and creative relational process in the context in which they live.

On this basis, human beings/nursing professionals needs to be instigated to look in a broad, accurate and reflective way at the reality that surrounds them in order to understand the human dimension of care in its complexity. A critical and reflective attitude should be promoted considering the interrelation and interaction of care in their relationship environment, being care of the self, care of the other and care "of the us" in the circularity that is constituted, as a concept in construction challenged by focus and domain of knowledge or comprehension of the "us", mutually associating/integrating the relationships of the self with the other; favoring exchanges among the beings involved; bringing together the comprehension of the relationships, interactions and associations established between human beings, of the beings with their environment, with their reality and with themselves, as well as private and reciprocal influences; allowing the construction of new ways of thinking and acting which, consequently, impel into new and better healthcare practices.

Thus, the encounter with nursing professionals can be seen from individual/personal and collective/professionals experiences that come from existing and living in a complex world, the unique and ordinary, as a possibility to question: How the relationships of care of the self, of the other and "of the us" occur in the different dimensions of care in a hospital unit?

Given the above, this study aimed to comprehend the relationships of care of the self, of the other and "of the us" in the different dimensions of care, through an educational/reflective/interpretive process with nursing professionals of a clinical-surgical unit of a Teaching Hospital from the perspective of complexity.

Method

This qualitative study was developed through meetings, called workshops. Study participants were nurses, nursing technicians and nursing assistants of a medical-surgical unit of a University Hospital in southern Brazil, totaling ten professionals, who authorized voluntary participation after the clarification of the aims and proposed methodology, by signing the Free Prior Informed Consent form.

The study protocol was approved by the Human Research Ethics Committee of the Federal University of Santa Catarina, under number 266/07, with the ethical aspects respected in all stages of the research, conforming to Resolution 196/96⁽⁸⁾.

Five weekly workshops were carried out in October 2007, with the duration of approximately an hour and the participation of seven professionals per workshop, on average. The dynamics of the workshops were constructed^* and developed by the authors, with the theoretical framework of complexity^(1-3), with each workshop having three distinct moments. The first moment, called "Preparing us for the workshop", aimed at raising awareness and introducing the thematics, with text reading and production of posters. In the second moment, called "Going to point X", a space for deepening discussions about the relationship of care of the self, of the other and "of the us" was promoted. The last moment, called "Closure", attempted to combine the manifestations of the care relationship meanings, based on the circularity of complex thinking, from the interpretations and constructions of the workshop participants.

The discussion script, which contained the guiding questions of the workshops, was based on the Principle of Uncertainty^**, Edgar Morin, which guided, according to the adaptation of pronouns (I, you, us), all the workshops. The following questions guided the discussion: Are the I (self), the you (other) and the us (un)defined pronouns? How do I perceive/see and how do I care for myself – human and/or professional being, for the other, and "for the us"? In which dimensions of care? How does it occur and which meanings represent this care? Which relationships are established between the care of self, of the other and "of the us"? Can I integrate knowledge for conducting my life, for my care, for the care of the other and for the care "of the us"? To which extent do I take care of myself, of the other and "of the us", to which extent do I make a personal and autonomous discourse, to which extent, under the guise of believing myself to be a personal and autonomous being, do I do no more than repeat acquired ideas? Am I an anonymous infra-personal machine who cares? Do I discourse on caring/care and give the illusion of taking care of myself, of the other and "of the us"?

Data were recorded by digital recording of voices of participants and field notes. To protect the identity of the participants, these were identified with the letter "P" followed by the ordinal number corresponding to their participation in the dialogue (eg, P.1, P.2, P.3 ...).

For the analysis of the study the method used was the systematic content analysis of the participants’ speech after transcription, reading and rereading of the data, which constituted the units of meanings⁽⁹⁾.

Several readings of the data were carried out in order to search for the meanings of the subjects’ statements and keywords or phrases of meaning were cut from the text, that contemplated significant importance for the formation of record units or units of meaning. These were later classified and aggregated and then the categories that would command the specifications of the themes (thematic units) were defined. Following this the interpretation of the material was performed based on complex thought and literature review.

Results and Discussion

The results that emerged from the educational/reflective/interpretive process, which, through content analysis, comprised four categories and thirteen subcategories, will be presented as follows.

The category that reflects the meaning of care of the self as "I – human being" and "I – nursing professional" reveals the care of myself – of the human/professional being, in multiple and interlinked dimensions, designed in their specificities, which determine the type of relationship established in the movements of complex living, described in six subcategories:

Conflict and dichotomy in the discourse of the care of I - human being and I - professional

The participants, in the dialogical movement, show the possibility of separating the "I – human being" from the "I – professional" as well as the difficulty to separate them in the care, as shown by the statements: I think that we separate, as we work in a very stressful environment, sometimes we unwittingly separate. For example, sometimes there is a patient who is very seriously ill; you do not want to get involved too much. I think it’s more professional than being human (P.4). Actually, the two are integrated, but we have to know how much of each to use. In this moment I cannot be only professional or only human, more professional and more human, I don’t see them as separate, they are integrated (P.7).

In the statements the uniduality of the human and professional beings who mutually engage with the cared beings is identified, without clearly distinguishing when they are caring as professionals or as human beings, which configures the impossibility of division, i.e. of being divisible individuals in the relationship with the other. In the circularity of to care/the care, the involvement of the "I - human being" and of the "I - professional being" with the client is processed naturally, whose human and professional being in their unity/multiplicity are singular and plural individuals, therefore, cohesive⁽¹⁾.

Nursing professional as I - machine/robot

Nursing professionals equate to a machine or robot in the dimensions of work, of care for themselves and for the other. Regarding the dimension of nursing work, this is considered as a robotic task, compared to a machine, when related to technicistic activities performed in the quotidian work. The dissatisfaction of not getting the desired valorization, including financial, is pointed out, as the professional says: The nursing staff becomes a machine, that comes and works, and sometimes cannot look to the side, it just wants to look ahead and work, work, and often thinks that it is not valued. I’m not just talking financially (P.1).

In the dimension of care of the self the neglect with the own care is manifested when compared with a machine, as shown: If you see yourself as a machine, in fact, you will only care when it goes wrong. And it is like this that we end up doing this with ourselves. It is only going to remember about itself when something goes wrong with the machine, when it has some pain (P.8).

In the dimension of caring for the other - client, the professionals compare themselves with robots when they use a non-affective involvement or avoid close contact with the cared being, as a personnel defense or coping mechanism, deployed internally to support the conditions of the work environment, translating in their actions the disinterest for the other, the devaluation of the care and the mechanized action^(10-11). In contrast, the capacity for empathy and sensitization with the pain of the other is seen as imperative to human care, being impossible to care for the other as a machine, i.e. without feelings and emotions.

Dimensions of care of the self - human/professional being

The study reveals the care of the self - human/professional being in the spiritual, biological, physical, aesthetic, loving, social and cognitive dimensions of care. According to the complex thought^(1-4) they are multiple interlinked dimensions, conceived in their specificities, and determine the type of relationship established with oneself, with the other and with the ‘us’, in a broad and collective sense.

The health system/service and its implications for care of the self

The professionals qualify the health service/system as poor to meet the needs of health care and show intolerance to consider themselves in the condition of patient/sick person, having to use the health system/service either for diagnosis or treatment, not regarding this as a personal need, but as a continuity of the work in health: We have no tolerance for running around as a patient, having to run about the health system. We always find a way. And we do not see this as a personal need; we see it as work (P.10).

However, the professionals use the knowledge gained in their formation and work and the inter-relationships in/of their own work environment, termed as "finding a way" to combat any health problem⁽¹²⁾. This way aggregates knowledge and actions arising from particular experiences, expressed in an attitude of solidarity, of exchange and care⁽²⁾.

Formation and practice in health and nursing: determinants of self-care/self-medication

Self-care/self-medication practiced by nursing professionals, as in other studies^(13-14), is based on knowledge gained in their formation and professional practice in health: I cannot sleep, I turn to one side and it hurts my neck, turn to the other it hurts my shoulder, I lay on my back I snore. It takes a long time to sleep! I take medicine, it goes away, went away and will go away. When I go to the doctor it is because I cannot take anymore (P.3).

Self-medication is a risky and inappropriate conduct in the care of the self of the professionals who, in theory, should educate and guide lay people, discouraging this practice, which may mask an apparent disease, possibly leading to the problem resurfacing potentiated⁽¹⁴⁾.

Not caring for the self, being cared for and taking care of the other

In the hierarchy of care in the life of the nurse is the care for the other, whether at work or in the family: I think we even look at our problem, but end up not looking too much, not giving it due importance. We worry about the house, family, work ... And putting aside that problem. We fail to look at ourselves with more affection (P.7).

It is understood that the small amount of time, due to the many professional activities, is a prevalent reason for the lack of care of the self⁽¹⁵⁾. Faced with the emerging signs of not caring for the self, understood as a problem, this is given little importance, due to the quotidian demands of caring for other beings (family members) and other things (the house). When caring, they feel cared for, but they do not offer themselves the due care.

The category that reflects the meaning of caring for the other for the "I - human being" and "I - nursing professional" includes caring for the other – for the client and for the colleague (the latter challenged by conflicts that permeate human relationships) and, the (in)visibility of the care for the other and for the nursing professionals themselves, presented in four subcategories.

Care of the other - client

The care of the other – client is subjective and individual, being essential that it is voluntary, sensitive, supportive and empathic and that it processes the exchange between the beings involved, in the openness and integration of the self with the other^(1-4): The care, actually, is sometimes not professional. For example, if someone is upset, I will not use any nursing technique to care for that person, sometimes it is enough to listen, to offer a shoulder. It’s not professional, there is no technique for this (P.8).

Thus, according to the complexity, the uncertainties of the structures of knowledge and of technical expertise do not meet the needs of the other alone, and so attention must be given to the dynamic movement of care and the fragilities present in many different shapes, dimensions and knowledge of human acting must be recognized⁽¹⁶⁾.

Care of the other-colleague

The many hours passed together every day in the work environment, allows interaction and integration with colleagues, promoting the formation of emotional bonds, the care for the other – colleague. The fact they spend time together and share feelings, experiences and achievements strengthens the ties of friendship and solidarity, and also, the acceptance of/by the other – colleague promotes a change from professional relationship to interfamily relationship, overcoming the institutional space: As we spend a lot of time here, we become a family. It feels as if it were brothers. The colleague starts to become like a member of our family (P.1).

However, in areas of the hospital, the relationships with the other-colleague are permeated by conflicts related to the movement and fluctuations common in the complexity^(1-4), as in this statement: It’s complicated, it is complex, people are different and you have to know how to deal with that (P.2).

The nursing professional experiences the human care for spending time together in a healthier way, but they also experience and face the problems of quotidian life, which disturb the self and the collective. Nevertheless, they seek to overcome the animosities of/in the relationship environment that permeate spending time together in a complex world^(1-4).

The invisible and visible care of the other

The invisible care refers to silent, spontaneous, voluntary, non-explicit, non-evident or invisible care, which is not perceived by the other. The invisible care is felt when the nursing professionals perceive themselves as human and professional beings, invisible and ‘undervalued in the perception of the other’ being: The invisible care, that is for the other, but the other does not know what is being done for them, and because of that, sometimes, it is not expressed. But when someone fails to do it, doesn’t care for the other, this is noticed, we feel the lack (P.9). However, the invisible care becomes visible, as not caring, when it is not performed, including in the family dimension: The mothers also give the invisible care for the children ... the mothers complain about the invisible care, they complain that they do and that their children do not appreciate it, do not see it (P.9).

The quotidian routine of the female nursing professional, in this study, is also marked by housework and caring for children, although scholars suggest the occurrence of significant changes, from the mid-twentieth century, in the quest for equity between genders, both in the private life and in private^(17-19).

Invisibility of nursing professional according to their category

The invisibility of the nursing professional is inferred due to the inadequate understanding or to the lack thereof, by the client, with respect to the sphere of the profession, to its status and to the competence of doing and of knowing: When we say that we are nurses, they say: ah, but don’t you intend to study to be a doctor? Don’t you want to study more? (P.7) Oh, but you are a technician? But are you more than a nurse? (P.1).

The nursing profession historically portrays an image of dedication to the poor, being responsible for the care of the body of the other. The practice of this profession, mostly occupied by women, is perceived by society as subordinate, worthless and that does not require the knowledge and skills for its performance, and therefore, socially and economically unrecognized⁽²⁰⁾.

In the category called reflecting the meaning of care "of the us" to "I – human being" and "I – nursing professional", the participants gave meaning to the care "for the us" as collective care, covering the subjects of relationship/integration that represent a set/team/group/meeting of people, that aggregates others rather than I; they indicate nursing as an example of collectivity, and also the violence present in human relationships, presented in the three sub-categories below:

Discourse "of the us" designated as collective responsibility, power, authority and strength

The statement "of the us" means collective responsibility; represents the work of each other related to the others for the constitution of the whole, in the complex and dynamic interdependence/interrelationship of the beings^(1-4): Sense of responsibility. Like it or not, when you say ‘us’, you are including yourself ... (P.9). They point out that something decided collectively guarantees the strength and power of decision, denotes authority, as it represents the argument of many thinking people, the us, suggesting an awareness of the need to give attention to the political positions and to the explicitness of to know/to do by nurses, in their quotidian life⁽²¹⁾.

Care "of the us": meeting and exchange from the relationship with the other, with the collective

In this study, in the process of nursing organization/self-organization as a group, the meeting of the care of the self, of the other and "of us" emerges, in which relationships are fed from care: I think the group itself, when it gets together, or when it takes care of itself, has a little bit of this, of exchange (P.2). The moment of meeting, the concern, the solidarity and the caring for the other refer to the care "of the us".

Thus, by being an open system, the care and the relationships in nursing dissipate, exchange, receive, give, regenerate, disintegrate, degrade, transform and organize themselves from the integrations, interactions and interrelationships of the beings of care⁽¹⁾.

Violence in the relational/collective attitudes

The participants concern themselves with the presence of violence in people’s lives, and indignantly point out: There are animals that are better and that cannot be compared with the human being (P.1). The world we live in, a world of violence. What happened to us? This killing in the slums, the inequality [...] Some have so much and others have nothing. And people with little content themselves with so little and the ones who have, the more they have, the more they want, by walking on people (P.1).

According to complex thought, there is a need to enlarge, sharpen and develop a worldview that allows one to look to the other and to oneself, including the local view and the global view of the individual, of the environment, of the collective, of the society^(1-4,22). Attitude change is necessary, as individuals and humans, as is the exercise of respect and solidarity with the other and, why not say, with ourselves.

The category reflecting and (re)constructing the meanings of the relationships of care of the self, of the other and "of the us" highlights the concern of professionals with the us, in the sense of ecological/planetary/collective/environmental care. As critical and reflective subjects, the professionals refer to local acts and events that impact globally, specifically they highlight the concern with the control of epidemics, such as dengue, which affect the population in the country (at the time of the study); the preservation of the natural environment; the promotion of human health aiming for individual and collective care, citing the use of pesticides; the preservation of water and of the environment, pointing to the risk of natural resource scarcity, if not preserved; the care of the planet as a whole, which depends on each subject.

Such points motivated thinking and (re)thinking the individual practices in order to ensure their own health – the care of the self and of the entire population - the care of the us, considering that diseases once eradicated or until now controlled are returning or spreading with great virulence⁽²³⁾ and denote an important symptom of the civilizational crisis faced in contemporaneity, where ecological consciousness underlies the crisis of environmental degradation⁽²⁴⁾ and the individualism underlying the collective: It is that, in fact one thinks about oneself. We’re not thinking about us (P.1); Social responsibility as a duty of the self, of the other and of all of us (P6); We have to have respect for each other and for us (P4).

For the professionals this category implicates analysis of their quotidian practices, considering environmental, social and cultural aspects for the promotion of new and better practices for collective and planetary care^(1-4).

Final Considerations

It was possible to comprehend that the relationship of care for the self, for the other and "for the us" combines the multiple dimensions of the human being, designed in its own specificities, which determine the type of relationship established with oneself, with the other and with the us in the broad and collective sense. The caring relationship takes place in the relationship with other beings, particularly in the exchanges that are promoted when meeting the individual and collective expectations.

The study points out the impossibility of separating the "I – human being" from the "I – professional", both of which are inherent to a single being, indivisible, irreplaceable, in which the care relationships established with oneself and with the others, in their movements, present multiple and interlinked dimensions, resulting from complex living.

The relationship of care for the other, being a client or a colleague, corresponds to the complexity that permeates human living together, being subjective, plural, and also singular to the human experience; involving, in addition to the formation of bonds and mutual exchanges, the conflicts, strife and animosities inherent to collective relationships.

The care "of the us", an emerging theme under construction, is designated as collective responsibility, highlighting the ecological/planetary/collective/environmental care, referring to the comprehension of the multiple and inexhaustible phenomena of constant association among the beings and between them and their environment, which modifies, alters and causes to be altered the existent relationships, the continuity and expansion of the comprehension of the relationship of care "of the us" being imperative.

However, the theoretical framework presents limitations regarding the reflections of the issues related to being a person and being a nursing professional, when having to become a person and to become a professional in the context of human care, specifically; it does not contextualize the identified reality and it does not dialogically address the meanings of the person-nursing professional, the existential and cultural, personal and group questions of the being-nursing professional.

Received: Ago. 24^th 2009

Accepted: Jul. 28^th 2010

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1

Paper extracted from Master’s Thesis ‘Os significados das relações múltiplas do cuidado de si, do outro e "do nós" sob a perspectiva da complexidade’ presented to Universidade Federal de Santa Catarina, SC, Brazil.

*

The construction and development of the workshops were a requirement of the discipline "Assistance Projects in Nursing and Health", from the Nursing Post Graduation Program, of the Federal University of Santa Catarina - UFSC.

**

Morin E. A cabeça bem feita: repensar a reforma, reformar o pensamento. Rio de Janeiro: Bertrand Brazil; 2000.

Publication Dates

• Publication in this collection
  01 Dec 2010
• Date of issue
  Oct 2010

History

• Received
  24 Aug 2009
• Accepted
  28 July 2010