Care, self-care and caring for yourself: a paradigmatic understanding thought for nursing care

Abstracts

Este artigo tem como objetivo apresentar uma reflexão sobre os conceitos de cuidado, autocuidado e o cuidado de si, estabelecendo suas relações com os paradigmas da totalidade e da simultaneidade. Na primeira parte do texto, contextualiza-se o cuidado nos seus aspectos gerais; na segunda parte aborda-se o cuidado na perspectiva filosófica de Martin Heidegger; na terceira parte explora-se o autocuidado na concepção de Dorothea Orem; na quarta parte discute-se o cuidado de si preconizado por Michael Foucault; e finalmente, na quinta parte, busca-se estabelecer a relação entre os conceitos autocuidado e o cuidado de si, com os paradigmas da totalidade e da simultaneidade. O autocuidado e o cuidado de si estão atrelados ao objetivismo da totalidade, e ao subjetivismo da simultaneidade havendo, para a Enfermagem, a necessidade de se compreender esta herança paradigmática e suas implicações para o cuidado de enfermagem.

Enfermagem; Cuidados de enfermagem; Autocuidado; Teoria de enfermagem; Filosofia em enfermagem

THEORETICAL STUDY

Irene de Jesus Silva^I; Marília de Fátima Vieira de Oliveira^II; Sílvio Éder Dias da Silva^III; Sandra Helena Isse Polaro^IV; Vera Radünz^V; Evanguelia Kotzias Atherino dos Santos^VI; Mary Elizabeth de Santana^VII

^IRN. MSc. in Nursing. Assistant Professor at Faculty of Nursing, Federal University of Pará. Member of Research Group on Nursing Education, Policies and Technology in Amazonia - EPOTENA. Belém, PA, Brazil. [e-mail]

^IIRN. Assistant Professor at Faculty of Nursing, Federal University of Pará. Doctoral student in DINTER/UFPa/UFSC/CAPES. Member of Research Group Caring and Comforting and Research Group EPOTENA. Belém, PA, Brazil. [e-mail]

^IIIRN. Assistant Professor at Faculty of Nursing, Federal University of Pará. Doctoral student in DINTER/UFPa/UFSC/CAPES. Member of the Study Group on Nursing Knowledge History and EPOTENA. Belém, PA, Brazil. [e-mail]

^IVRN. Assistant Professor at Faculty of Nursing, Federal University of Pará. Doctoral student in DINTER/UFPa/UFSC/CAPES. Member of EPOTENA. Belém, PA, Brazil. [e-mail]

^VRN. Faculty in Graduate Nursing Program at Federal University of Santa Catarina. Member of the Research Group Caring and Comforting. Florianópolis, SC, Brazil. [e-mail]

^VIRN. Associate Professor at Nursing Department and Graduate Nursing Program, Federal University of Santa Catarina and DINTER/UFPa/UFSC/CAPES. Leader and Researcher in the Research Group on Women's and Infant Health Nursing - GRUPESMUR /PEN-UFSC. Florianópolis, SC, Brazil. [e-mail]

^VIIRN. MSc. and PhD. in Fundamental Nursing. Adjunct Professor at Faculty of Nursing, Federal University of Pará. Local Operating Coordinator of DINTER/UFPa/UFSC/CAPES. Belém, PA, Brazil. [e-mail]

Correspondence addressed to

ABSTRACT

This article presents a reflection about care, self-care and caring for oneself and establishes these issues' relations with the paradigms of totality and simultaneity. On the first part of the text, care and its general aspects are contextualized; the second part discusses about care in Martin Heidegger's philosophical perspective; the third part explores self-care on Dorothea Orem's conception; the fourth part considers Michel Foucault's care of oneself. And finally, the fifth part aims to establish the relationship between the concepts of self-care and care of oneself, and the totality and simultaneity paradigms. Self-care and care of oneself are connected to the objectivism of the totality, and to the subjectivism of the simultaneity. These subjects lead nursing to comprehend such paradigmatic inheritance and its implications on the nursing care.

Key Words: Nursing. Nursing care. Self care. Theory of nursing. Philosophy, nursing.

RESUMEN

Este artículo tiene como objetivo presentar una reflexión sobre los conceptos de cuidado, auto cuidado y el cuidado de sí, estableciendo sus relaciones con los paradigmas de la totalidad y de la simultaneidad. En la primera parte del texto se contextualiza el cuidado en sus aspectos generales; en la segunda parte se aborda el cuidado en la perspectiva filosófica de Martin Heidegger; en la tercera parte se explora el auto cuidado en la concepción de Dorothea Orem; en la cuarta parte se discute el cuidado de sí preconizado por Michael Foucault, y finalmente en la quinta parte, se busca establecer la relación entre los conceptos auto cuidado y el cuidado de sí, con los paradigmas de la totalidad y de la simultaneidad. El auto cuidado y el cuidado de sí están unidos al objetivismo de la totalidad, y al subjetivismo de la simultaneidad habiendo, para la Enfermería, la necesidad de comprender esta herencia paradigmática y sus implicaciones para el cuidado de enfermería.

Descriptores: Enfermería. Atención de enfermería. Autocuidado. Teoría de enfermería. Filosofia en enfermería.

INITIAL THOUGHTS

When pondering over the process of care, one will most certainly be tempted to speculate about what it actually is, about whom takes care and why we do so. Under this perspective, care encompasses several meanings which makes it complex and with no pre-conception. Care has been part of mankind since the beginning of time; it has followed the evolution of man, it cohabits with even the most variable societal forms and resides among the subjects of discussion from different collective contexts.

Speaking of the particularities of care makes us reflect deeply while necessarily being open for debate on the many different ideas present in our contemporary world. An ethical kind of care is suggested, so care can be spread throughout the planet, providing harmony for its inhabitants and promoting, above all, devotion, solicitude, diligence, zeal, attention and a tepid treatment; it should be a way in which one forgets about oneself and focuses on the other with devotion and solicitude. Care only exists when one who is of prime importance to me exists and, so, I can dedicate myself to that person⁽¹⁾. Therefore, caretaking care of someone is to esteem and to estimate for one whose complete well-being is our absolute goal.

For this reason, searching for different ways to help others and to discuss the particularities of the human care phenomenon composes a series of theoretical concepts about health care and nursing practice.

Taking care of people has been cited as an epistemological goal in nursing. It is a way of being with someone else, when it comes to certain particular matters in that person's life; such as health promotion and recovery, birth and even death. It is understood that care breaches the body/mind, normal/pathologic fragmentation. It is a much more humanized care, which favors a healthier and better life. The idea of care in the XXI century still remains as a basis to integrate people around their well-being as well as to provide social bonds with political, social and cultural commitment and engagement, thus preventing ruptures in our society and contributing to its improvement. In these terms, social commitment and engagement basically refer to the preservation of the human species socially and politically, along with the preservation of our global culture, our ecologic and cosmologic lives, participating in the sustainability and care for our future generations⁽²⁾.

When reflecting about care in nursing, considering the complex health-disease process and the numerous challenges that emerge from providing health care, it is justified that a deeper understanding about the terms care, self-care and care of the self is needed, as these terms have endured since ancient times and have become distant from the epistemological care process due to scientific and technological development, which has resulted in a fragmentation of the subject. Because of that, human beings become isolated, parted, broken and separated from the collective and social dimensions, reducing the entire care process into a disease-treating protocol.

In the light of such facts, the aim of this study was to reflect about the concepts of care, self-care and care of the self, establishing their relationships with the paradigms of totality and simultaneity.

Nursing and Care

The word care comes from the Latin word cogitatu which means thinking, imagining, meditating⁽³⁾. Care also refers to

dedication, whose behavior, appearance, moral and intellectual background are paramount (when referring to people); special attention, wary behavior, zeal and attention from someone who is dedicated to something⁽⁴⁾.

Care involves all the composing ontological structures of Dasein (being-there) such as being-in-the-world. In other words, it encompasses all existential possibilities which lie attached to things and to other beings. Care does not configure a situation which is limited to a single ontic sense, rather it extrapolates the theoretical or practical bases and considers its existence, the meaning of reality⁽⁵⁾.

Therefore, it is important to reflect and to question: what is care and this being-in-the-world? We can say that the meaning that it occupies is that of being released in a world. It is what Heidegger calls being in the game. It is to realize that in this game we take chances, we have limitations, we make mistakes and get some things right, but we also need to be taken cared of; we need to take care of ourselves and to take care of others. The author also discusses about an authentic care, considering the term sorge = cure; preocupation. This is what unifies reality and possibility, but a possibility in terms of human condition, that is, it does not grant only theorization over action, but a real possibility for the human condition. In other words, it does not confer only theorization over action, but also configures behaviors and attitudes of man. Theory and practice are ontological possibilities from a being whose existence should be determined as the cure⁽⁵⁾.

However, to reflect about care is also to consider Hyginus' Fabulae, The Myth of Care, in which the philosopher gives a pre-ontological testimonial about his care doctrine and limits himself to present the final sentence of the cited fable which goes like this: as he who created man was taken care of, he shall stay with him for life. Such phrase from the pre-ontological testimonial, as Heidegger himself designates,

receives a special meaning not only due to the fact of seeing the cure as something to which the human condition belongs to, but because cure emerges in a context in which man is seen as a being of body and spirit [...] this being originates from his own self in the cure [...] this being is not abandoned because of this origin, but, on the contrary, he is maintained and dominated by the cure while residing in the world⁽⁵⁾.

This is one of the meanings we must understand. One in which the cure executes the constitutive part, but time is the one to make all decisions, for man is nothing if time and the world are disregarded. The man- being only exists while being-in-time. Thus, care is responsible for reuniting the several moments of being-there we find in the world, composing what was called a structural whole. Care is the existential factor that confers totality to the being-there, which is highlighted by Heidegger in the analysis of Being and Time⁽⁶⁾.

Discussing care and totality does not infer that being-there is a sum of all connected parts, for it cannot be simplified into a bundle of existential pieces. Care is a dynamic relationship that unites oneself before the comprehension of a somewhat incompleteness and the imminent necessity of thriving in its fulfillment in each moment of one's existence. In this context, human beings' own identities are built from co-existence and inter-relations. In the foundation of this perception resides care itself, comprising solicitude, dedication and inquietude for the other.

From a Heideggerian perspective, care cannot be performed without considering the ontological determinations of the human condition; it is not possible to care authentically without assuming appropriately and freely without considering its limitations. Therefore, we understand that the essence is to understand the perspectives that involve human care.

NURSING AND SELF-CARE

Self-care was first mentioned in nursing in 1958, when RN Dorothea Elizabeth Orem started reflecting on the whys and wherefores of individuals necessitating nursing care and how they could be assisted. From her contemplation, three theories were originated: The self-care theory (describes and explains self-care); The self-care deficit theory (explains how nursing can assist people); and the Theory of the Nursing Systems (describes the necessary relationship so nursing itself may come to exist)⁽⁷⁾.

Self-care is an activity learned by the individual and oriented towards a certain goal. It is an action that takes place in a specific moment of our lives to which the individual orients himself or to which he orients his own development in the form of activities for his well-being. The ultimate goal in self-care, according to Ms Orem, is a group of actions that follow a model which could contribute to human development. The actions that constitute self-care are the universal requirements of development and those related to health compromises⁽⁸⁾.

The universal requirements of self-care are common to all human beings and encompass the conservation of air, water, food, the need for resting, solitude, and social interaction, risk assessment, and the promotion of human activities. The cited requirements represent the type of human actions which supply us with the necessary internal and external conditions to maintain the structure and activity to support the development and human aging processes. Self-care can promote the well-being of those when used and centered in such universal requirements⁽⁸⁾.

Another requirement of self-care pertains to health changes. In Ms Oren's opinion, a disease or injury not only affects the physiologically and psychologically-controlled mechanisms and structures, but also the entire functioning process of the human being. It is made clear that the individual's developed (or under-development) capacity of self-care is severely hampered, temporarily or permanently, when disease processes have been installed. This analysis suggests that during a health-change process the need for self-care emerges both from the pathological condition and from the procedures employed for its diagnosis. When under a health-change process, it is paramount that people are able to apply necessary and convenient knowledge for their own good in order to use self-care systems⁽⁸⁾.

Other aspects discussed by Oren are: therapeutic demand, self-care actions, self-care agent, dependent assistance agent, self-care shortage, nursing actions and the nursing system. Self-care therapeutic demand is notably a human entity whose objectiveness describes the individual from a structural and functional stand-point of development. This is based on the theory that self-care is a human regulatory force. The actions of self-care are the acquired abilities to identify the necessities and care which regulate vital processes, keep and promote organism integrity and human development and, furthermore, contribute to one's well-being. Attached to these aforementioned concepts are the self-care agent, who denotes the self-care-executing person, and the dependent assistance agent, comprising someone who takes care of children and dependent elders or adults⁽⁷⁾.

Self-care deficit concerns a relationship between self-care therapeutic demand and the actions of self-care in which attitudes developed for self-care constitute an action which is adequate for one to know and identify some or all of the components of existing or predicted self-care therapeutic demand. It must be noted that all limitation from people to commit themselves to practical efforts, within the limitations of nursing, are associated with the subjectivity pertaining to adult individuals, of actions related to or derived from health care, which capacitate them partially or totally to understand the existing or emerging requirements of their own regulatory care. That being said, it becomes necessary to commit oneself to the fulfillment of health care measures to control or question, somehow, the factors that regulate their proper functioning and development and that of those who care⁽⁸⁾.

The nursing system is something that is built through development of nursing activities and the relationship between the nurse and the patients. It is something that should be beneficial for those who work with it. Nursing systems are divided in: fully compensatory nursing system, partially compensatory and of educational support. A fully compensatory nursing system takes place when the nurse attends to all therapeutic needs of the patient or compensates the patient's incapacity to carry out all self-care activities which may require some degree of manipulation and ambulation. Partially compensatory systems are those in which both nursing and patients carry out supportive actions and other activities that require manipulation and ambulation. When the patient is capable of fulfilling such actions or is able to learn them so to carry out actions of internal and external therapeutic self-care, they are called of educational support⁽⁸⁾.

Based on what has been explained, the role of nursing as a health-encouraging promoter can be noted; and that can only be achieved with the implementation of supportive and educational practices which value the act of self-care.

The five essential axioms from the general theory of nursing as stated by Orem were formalized in the early 70's and are as follows: human beings need to be stimulated continuously to stay alive and act accordingly with natural human qualities; human action and the capacity to act deliberately are put to motion to help oneself and the others, to identify the necessities and create essential stimuli; adult human beings experience privations in the form of limitations so they act for their own good and of close ones through contributions that support life and regulate its functions; human action leads to discovering, developing and transmitting to all means the necessary contributions to oneself and the others⁽⁷⁾.

The premises employed in the theory of self-care are logical and accepted by the nursing community. The concepts are applicable in nursing in its implicit and explicit relations and are also useful to explain the concept of patient and the relationship between patient and the nursing system.

NURSING AND THE CARE OF THE SELF

When recalling the term care of the self, we searched in history, philosophy, nursing and, precisely, in the work of Foucault and Radünz for its origin and meaning. In Foucault's opinion, care is replaced by the care of the self, which derives from the Socratic-platonic knowledge understood by the cited author as the art of existence, in other words, a principle according to which it is convenient to get busy and from that produce social imperatives and elaborate a collective knowledge⁽⁶⁾.

Foucault describes the development of oneself hermeneutics in two specific situations: the first is found in Greek-roman philosophy from the two first centuries of the Roman Empire and the second comes from the Christian spirituality and monastic principles such as what we had in the IV and V centuries during the Lower Empire. In ancient times, the care of the self meant, for the Greek, a search in people's social and personal behavior and, thus, directed the living of each person, their conduct and moral behavior. After the arrival of Christianity, behavior started being conducted by rules and regulations whose main propose was a certain aestheticism in human existence⁽⁹⁾.

The cited author refers to specific techniques which man utilized to comprehend what and who they are. Such techniques are classified into four groups: production techniques, signal system techniques, power techniques and techniques for the self.

In Foucault's opinion, the techniques for the self are those which permit individuals to carry out alone or with the help of others a certain number of operations about their bodies and souls, about their thoughts, their way of living; it is what allows them to transform in order to achieve a certain state of happiness, purity, wisdom, perfection or immortality⁽⁹⁾.

Foucault still contextualizes the individual both from a theoretical point of view as well as from a group of practices from ancient times. The Greek visualized the practices as a principle – epimeleisthai sautou, which means, take care of yourself, care about yourself, worry about yourself, attend to yourself. This is the principle of care itself⁽⁹⁾.

The care for the self is only questioned or valued and realized as something essential for the human being from the moment that people become aware of their right to live and aware of the life style they lead. This can be observed in our daily life as people don't give proper attention to the constant exercise of care for the self when they seem apparently well and healthy⁽¹⁰⁾.

The care of the self is not an exclusive characteristic of nursing. Every health care professional must take care of him or herself, so he or she may also take care of someone else. However, nurses usually spend most of their time with the healthy and sick beings, they share the other's suffering and, thus, cannot abstain from their own care, from having a healthy relationship with him or herself, because this is the only and single way to relate well with others and to take care of them.

When we relate the care of the self with the care for the other, we say that the relationship of care assumes the perspective of taking care of the self as we take care of the other; a situation in which the nurse develops and allows the other to develop as well⁽¹⁰⁾.

The development of a care practice has essential principles which favor care itself, for it will promote knowledge about the matter, improvement and development of the care-taker as well as of the person who is taken care of. Among the principles that are thought to be related with the being, we must highlight self-knowledge and care of the self⁽¹¹⁾. These principles have a close connection with the interrelations of the being and with the relations of the being with all that is care-related and governed by the presumptions of health promotion, life quality, ethics and aesthetics.

When we associate care of the self-related practices with health promotion, it must be pointed out that at the very moment they are performed, we will adopt an ethical behavior towards life, and responsibly preoccupying ourselves with the act of living. This is considered health promotion¹².

Among viable techniques for the care of the self some should be recommended, such as: resting, eating adequately, exercising regularly, dancing, walking, hugging, kissing, singing, praying, working creatively and having healthy relationships. It must also be emphasized that even though nursing is a subject whose prime attention relies on care, nurses have considerable difficulty in taking care of themselves⁽¹¹⁾.

THE PARADIGMS OF TOTALITY AND SIMULTANEITY: REFLECTIONS FOR THE UNDERSTANDING OF THE SELF-CARE AND CARE OF THE SELF

Paradigms are ways of thinking, rules and values shared by a certain scientific community, or even recurring and practically standardized explanations from different theories while being conceptually and instrumentally employed or gained from practical observation⁽¹³⁾. This lead to the development of two paradigms which are present in nursing; the paradigm of totality and the paradigm of similitude; for the terms self-care and care of the self mean much more than their semantics designating them so. They are actually paradigmatic quarrels between totality and simultaneity.

The paradigm of totality has its roots in positivism, while simultaneity bears it origins to existentialism; more precisely to phenomenology. Thus, we comprehend the importance of correlating concepts of self-care and care of the self with the paradigms based on which they were created⁽¹⁴⁾.

In the paradigm of totality, health is seen as the proper functioning of the body, as a form of well-being, and a as a healthy condition; it is a measurable and observable entity and it cannot be conceived as something subjective or as an existential problem. Health, within this paradigm, is the state of which man is in constant pursuit, it is something man can grasp, it is a common goal, present in all of us; it is determined by social standards and medial models⁽¹⁵⁾.

In nursing, the paradigm of totality is aimed at helping people to deal with and adapt to pathologies and to the limitations that the latter may cause, along with modifying the environment to reduce stress-causing agents and to teach people how to take care of their health⁽¹⁵⁾. We then realize that nursing starts to see the person as a being that does not have control over his or her health standards and, for that reason, requires proper orientation to stay healthy. It must be noted that this supremacy of nursing over people's knowledge is due to strong influence of a Cartesian model which states that there is a need for a certain level of understanding that orients the human being to be healthy – it is called medical knowledge.

Self-care is focused on the paradigm of totality, in other words, the human being is seen as a summative entity that needs to adapt to his environment to reach his goals. We realize that self-care, due to its bond with the paradigm of totality, sees the individual as a fragmented being that needs to adapt to the environment where he lives and, so, needs to self-care. Even though the paradigm of totality is considered a reaction of nursing to positivism, when it comes to self-care, the latter already has an important factor to self-care – the relationship with others.

The comprehension that human beings are a summative compound of biological, psychological, social and spiritual aspects favored the appearance of a new assumption which began to see that the sum of all parts does not make it whole again – hence, the paradigm of simultaneity originated. The paradigm of simultaneity makes evident that the whole is bigger than the sum of all parts, just as each part represents a part of the whole. This assumption conceives the human being as an open agent, much bigger than the sum of all his parts would allow to, and also someone who transforms through interactions with the environment⁽¹⁵⁾. This new paradigm already sees that the individual is not an enclosed construct to the environment, but, on the contrary, a being that will thrive far beyond mere adaptations with the environment; for the individual interacts and transforms it.

Health is, therefore, understood under what a person grasps from life. It is a moment, a situation which holds meaning only to that person who has experienced it⁽¹⁵⁾. Health is what the individual lives; it is a process of becoming which is meaningful solely in the perspective of the person; it cannot be defined by someone else⁽¹⁶⁾.

Nursing is guided by quality of life under the point of view of the individual offering its presence and directing its goals towards the individual's dreams⁽¹⁶⁾. The individual is given proper value, he and not nursing is the authority. For that reason, health care plans are not based on health problems, but in complex plans created by the person. For nursing, it is fit to direct people towards comprehending their health standards and, thus, improving their quality of life.

Care itself is based on this paradigm and, for such reason, it is employed in studies which recommend understanding the environment where the person is inserted in order to define how the individual wishes to take care of himself. Nursing begins to assume a mediating position, for it is open for dialogue with the other, recognizing the other as the only one who knows the situation – because it is the only one living that situation.

FINAL THOUGHTS

The aim of this study was to understand human care under the paradigmatic perspective of totality and simultaneity. We have noticed that care is a characteristic of the human being which is made into the essence of nursing, leading to what is called nursing care. On the other hand, nursing care, when carried out by the other to assure his well-being, is described under two terms: self-care and care of the self, which do not only posses a difference in semantics, but also in paradigm.

Self-care is centered in the paradigm of totality. It assumes that human beings are the sum of his parts: the sum of what is biological, psychological, spiritual and social, and also makes evident that the person has to adapt to the environment. Care of the self, on the contrary, is bonded to the paradigm of simultaneity, which dictates that the person is not a sum, for the whole is bigger than the sum of all parts, just as the parts are a representation of such a whole. Another aspect to consider is that the individual does not rely only on the need to adapt to the environment, but also to interact with it and maybe transform it or be transformed by it.

We have realized that because self-care is based on the paradigm of totality, health has acquired an objective aspect which allowed it to be quantified. Nursing becomes responsible for guiding the person in adapting to the environment. The care of the self, on the other hand, follows assumptions of the paradigm of simultaneity which values what is subjective in the human being and states that nursing should care about the individuals, respecting their life experiences to improve their quality of life. Another point that ought to be highlighted is that self-care is linked to the objectivism of the health-disease process, while the care of the self is riddled by the subjectivism of the referred process. Respectively, one terminology leads us to the conditioning of the human being to a situation of care that determines how the individual will adapt under real-life conditions; the other terminology is centered in the dialog with the person, recognizing the individual as the only person who really knows the experienced situation. For that reason, it is necessary to implement a care plan based on the life experiences of the cared individuals to improve their quality of life.

Therefore it is reasonable to think that life events are unstable and, despite the existence of a system of concepts, assumptions and paradigms which govern the actions of human care, one cannot regard them schematically.

Within a heideggerian perspective, care is not something instrumental, and not even disciplinary, but actually reflexive and which contributes to our well-being, allowing individuals to express themselves. It still considers the importance of recognizing our finitude.

These perspectives of care discussed in the text are largely employed in nursing studies and, for that reason, we stress the importance of understanding the paradigms to which we are attached. This understanding will provide better comprehension of the referred terms, thus assisting in their proper usage. We must also emphasize the need to understand this paradigmatic heritage and that the important part is not the validity of this or that theory, but the sufficiency they have towards new dimensions of human actions.

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Care, self-care and caring for yourself: a paradigmatic understanding thought for nursing care

Cuidado, auto cuidado y cuidado de sí: una comprensión paradigmática para el cuidado de enfermería

Publication Dates

• Publication in this collection
  22 Sept 2009
• Date of issue
  Sept 2009

History

• Accepted
  08 Oct 2008
• Received
  08 Apr 2008