Social network of support for stomized seniors according to complexity

Abstracts

OBJETIVO: Descrever a rede social de apoio às pessoas idosas estomizadas representada por ecomapas das relações múltiplas de apoio, à luz do referencial da Complexidade. MÉTODOS: Estudo de caso realizado em um serviço de estomaterapia de um hospital universitário da região Sul do Brasil. Foram sujeitos quatro pessoas idosas estomizadas, três mulheres e um homem, entrevistados em ambiente domiciliar. RESULTADOS: Evidenciou-se a importância do suporte familiar, rede de amigos/vizinhos, serviço de estomaterapia com seus trabalhadores/estagiários de outros estomizados no cuidado às pessoas idosas estomizadas. Apesar da Unidade Básica de Saúde ser a porta de entrada ao atendimento do Sistema Único de Saúde, os sujeitos deste estudo buscaram no hospital a atenção as suas necessidades de saúde. CONCLUSÃO: A rede social de apoio mostra-se, por meio de relações e interações, inseridas no sistema social complexo. As relações de cuidado se fazem presentes nesta rede social de apoio às pessoas idosas estomizadas e família.

Estomas cirúrgicos; Idoso; Assistência a idosos; Ostomia; Apoio social

ORIGINAL ARTICLE

Social network of support for stomized seniors according to complexity^*

Red social de apoyo a las personas de la tercera edad estomizadas a la luz de la complejidad

Edaiane Joana Lima Barros^I; Silvana Sidney Costa Santos^II; Alacoque Lorenzini Erdmann^III

^IM.Sc, Member of the Study and Research Group in Gerontogeriatry, Nursing/Health and Education (GEP-GERON/CNPq) and of the Study Group of Complexity (GEC/FURG/CNPq) - Rio Grande (RS), Brazil

^IIPh.D, Professor at the Undegraduate and Graduate Nursing courses at Universidade Federal do Rio Grande – FURG – Rio Grande (RS), Brazil

^IIIPh.D, Full Professor at Universidade Federal de Santa Catarina – UFSC - Florianópolis (SC), Brazil

Corresponding Author

ABSTRACT

OBJECTIVE: To describe the social network of support for stomized elderly people, represented by eco-maps of the multiple supporting relationships according to the Complexity referential.

METHODS: Case study, carried out in a stomatherapy service at a university hospital in the Southern region of Brazil. Patients were four elderly stomized people, three women and one man, interviewed at their homes.

RESULTS: The importance of family support, friend/neighbor network, stomatherapy service with its workers/interns of other stomized people in the care for elderly stomized people became evident. Although the Basic Health Unit is the entry door for the Single Health System service, the subjects of this study sought care for their health needs in the hospital itself.

CONCLUSION: The social network of support reveals itself through relationships and interactions inserted in the complex social system. Care relationships are present in this social network of support to elderly stomized people and their families.

Keywords: Surgical stomas; Aged; Old age assistance; Ostomy/nursing; Social support

RESUMEN

OBJETIVO: Describir la red social de apoyo a las personas de la tercera edad estomizadas representada por ecomapas de las relaciones múltiples de apoyo, a la luz del referencial de la Complejidad.

MÉTODOS: Se trata de un estudio de caso realizado en un servicio de estomaterapia de un hospital universitario de la región Sur del Brasil. Como sujetos participaron cuatro personas de la tercera edad estomizadas, de las cuales tres mujeres y un hombre, entrevistados en su ambiente domiciliario.

RESULTADOS: Se evidenció la importancia del soporte familiar, red de amigos/vecinos, servicio de estomaterapia con sus trabajadores/practicantes de otros estomizados en el cuidado a las personas de la tercera edad estomizadas. A pesar de que la Unidad Básica de Salud sea la puerta de entrada a la atención del Sistema Único de Salud, los sujetos de este estudio buscaron en el hospital la atención a sus necesidades de salud.

CONCLUSIÓN: La red social de apoyo se muestra, por medio de relaciones e interacciones, insertada en el sistema social complejo. Las relaciones de cuidado se hacen presentes en esta red social de apoyo a las personas de la tercera edad estomizadas y la familia.

Descriptores: Estomas quirúrgicos; Anciano; Asistencia a los ancianos; Ostomia/enfermería; Apoyo social

INTRODUCTION

Stomy may represent a limitation to people's projects of life, mainly when they are old. After undergoing stomy, people are encouraged to maintain a strict control in their lifestyle, in addition to continuous vigilance for signs and symptoms and the reappearance of tumor cells and infections, by periodical health education and follow-ups.

A stoma is a surgical opening in the abdomen, from where excrement is expelled when the regular function of the intestine or bladder is interrupted. There are three basic types of stomies: ileostomy, which is the opening originating at the small intestine - ileum portion; colostomy, an opening originating at the large intestine or colon; both allow feces to pass through; urostomy, which is the opening that allows urine to pass through. The stomized person uses a collecting bag that adheres to the abdomen, in order to protect the skin and collect the excrement⁽¹⁾.

Seniors with stomy, either permanent or temporary, have many doubts about health conditions, and their inner fears make them resistant to orientations. They believe that they are not capable of breaking away from this situation of non-conformity, mostly due to age-related frailty. They also do not believe that it is possible to lead a healthier life in spite of the stomy.

Stomy surgery brings uncertainty to the seniors due to the changes that occur in their bodies and the new responsibilities emerging from stomy maintenance. The collecting bag becomes an essential element for that elderly person, becoming an extension of the body, enabling the materialization of a modified body experience and the perception of the stomized person's suffering. The bag and the stomy are parts of nursing care, and the nurses should use the experience of their usage as an educational strategy⁽¹⁾.

Currently, life addresses the possibility of pondering on the necessity of adopting new behaviors and attitudes, which are influenced by the way of thinking. So, thoughts determine the practices that are established and developed in societies. Frequently, urgency and rapid changes in the many areas of knowledge indicate that human learning takes place everywhere and at all times⁽²⁾.

For those reflections, stomy in seniors is perceived as a situation involved in complexity. Complexity is understood as a way to understand the world, integrating relations of co-existence between living and non-living beings, integrating concepts of order and disorder, single and multiple, stability and change, and, mainly, the notion of uncertainty⁽³⁾.

Complexity leads to complex thoughts, which it is the one that joins and searches the necessary and interdependent relationships of all aspects of human life, integrating the different ways of thinking. It is a thought that considers all the received influences, whether internal or external, and still faces uncertainty⁽⁴⁾.

Complexity involves some aspects, such as dialogic, recursive and hologramatic principles, which consist of an interconnected set, providing an integral view of the human being and of the whole that surrounds it.

The dialogic principle joins two principles or notions that should be reciprocally excluded, but are not dissociable in the same reality, allowing one to rationally assume the inseparability of contradictory notions in order to conceive the same complex phenomenon⁽⁵⁾.

The recursive or recurrent principle disrupts the principle of linear determination: the cause acts on the effect, and the effect on the cause, promoting processes in circuits, involving both perception and thought⁽⁵⁾.

The hologramatic principle highlights the apparent paradox of complex organizations, where not only the part is within the whole, but the whole is included in the part⁽⁵⁾.

Taking care of the elderly stomized person is not an easy task for healthcare workers or relatives, because it is necessary to prepare them to help stomized people to become used to to stomy for the rest of their lives⁽⁶⁾.

The human being, made up of complex and multidimentional units, is at the same time biological, psychic, social, affective and rational⁽⁵⁾. This complex human being represents the stomized seniors, their relatives and the nurse as well. Thus, each human being contains, in a hologramatic way, the whole they are part of and, at the same time, are parts of it.

Nurses need to recognize the impact of cancer and subsequent stomy surgeries in seniors, using healthcare strategies such as: orientations concerning the process of adaptation and use of the collecting bag; care with the stomy and adequate food, in addition to be referred to and encouraged to participate in support groups, which may help stomized people to become used to living with this new situation that begins to integrate the whole that makes up the elderly person's process of living.

Nurses are responsible for understanding the human being in its entirety, so that the whole may be involved plurally, even if the sum of its isolated parts is different, implying in complex connections of the individual being cared for⁽³⁾.

Encouraging the stomized senior towards well-being and providing incentives for the family and society towards the reformulation of perceptions related to old age such as prejudice and stigmas are actions that contribute to for change in the care for that elderly person, improving quality of life and contributing to increasing their self-esteem.

For such, the existence of an organized social network, including family, neighbors, a stomatherapy service and its workers, other stomized people and other healthcare services, the purpose of this study is to describe the social supporting network for stomized seniors, represented by eco-maps of multiple supporting relations according to the Complexity referential.

METHODS

This qualitative research uses the case study principle. It was first carried out at the stomatherapy service of a university hospital in the Southern region of Brazil, and later, at the stomized senior's household.

Three women and one man aged sixty years old or more registered in the stomatherapy service took part in the study. The participants had either permanent or temporary stomy surgery, resulting from accident/disease; they were oriented and able to interact, and agreed to have their data collected at home and by having their interviews recorded, by signing the term of consent. These inclusion criteria were addressed for this intentional sample. Seniors chose fictitious names: Daisy, Violet, Rose and Lily. Thus, their anonymity was protected.

The consent of the institution was also requested for ethical issues. The research project was approved, according to file #010/2007 of the Review Board at Associação de Caridade Santa Casa do Rio Grande, complying with the requirements of Resolution #196/96.

The following data were collected from the records of stomized seniors at the stomatherapy service: identification data, telephone and home address; a brief dialogue was established by telephone contact, but they had been informed in advance during one of the stomatherapy group meetings, informing them about the research and possibility of participation; convenient days and times for the routine of the elderly person/family were set up; the visit to the household was made with the purpose of recording the interview.

The core topics of the interview guide contained issues addressing the elaboration of the eco-map: supporting network, stomatherapy service attended regularly, the importance of other stomized people, community and society. The interview was performed by one of the study researchers who participated in some of the stomatherapy group meetings to promote the adaptation of the research subjects and/or their relatives.

The eco-map was prepared with data collected and the core topics of the interview, which were the representation of the overview of the family situation portraying important relations of education, or those oppressed by conflicts between the family and society. It shows the flow or lack of resources and privations. It also outlines the nature of the interface of resources to be sought and mobilized for the conflicts. Furthermore, it contributes to increase the nurses' perception about the family, as well as their interactions with wider systems⁽⁷⁾.

The eco-map is the presentation of relationships in a diagram, having visual impact as its main value. With the eco-map, it is possible to evaluate and overview the available support and assistance and their usage by the stomized person. The stomized person is shown in the center of the circle as part of a whole, and elements of connection are represented by outer circles. The lines indicate the type of connection. Continuous lines mean strong connections; dotted lines show weak connections; lines with bars denote stressful aspects; the absence of lines represents lack of connection⁽⁸⁾.

The graphic visualization of the research results takes place by looking at the eco-map, and the analysis is enriched and complemented because it shows the relations of support and assistance used. Thereby, such instrument, used in the evaluation of the social network, will facilitate the understanding of its operation, taking into consideration its social, emotional and health aspects, thus identifying its potentials and difficulties⁽⁹⁾.

RESULTS

Presented by eco-maps of seniors of the study.

Figure 1

DISCUSSION

The discussion is based on the analysis of the four eco-maps presented, bringing contributions from authors sharing the experiences of stomized seniors.

Daisy's eco-map shows that the connection flow between her and her relatives presents lines with bars, symbol of stressful situations justified by the distance between her and her family.

Three people are highlighted in this family group: a 45 year-old son who lives with her and works in the afternoon, leaving her alone. One daughter-in-law and a ten year-old grandson that accompany her daily, seeing to her needs and making a pleasant environment, thus establishing a continuous and strong flow. These two relatives live in a nearby neighborhood, facilitating the approach.

The eco-map represents an overview of the family situation, portraying its educational relationships, presence or absence of conflicts and their flow or lack of resources regarding the family/society interface⁽⁷⁾.

Daisy is visited by her friends and neighbors, mainly children and elderly people. It is a sign of affection and respect, highlighted in the eco-map through strong connections; due to her health difficulties, she does not go out to visit those people, which is expressed by weak connections, dotted lines.

In this dialogic perspective, the individuals do not live to survive; they survive to live; in other words, they live to live. Taking this into consideration, living means poetry, living on affectivity and rationality; in other words, fully assuming the human destiny⁽¹⁰⁾.

The service of stomatherapy provides education and every healthcare resource for the stomized person, regardless of age-group. It encourages the participants to take part in monthly events, which, in the eco-map is seen as a strong connection for Daisy, but, on the other hand, it is a weak connection due to her difficulty in going to the service.

Daisy's relationship with other stomized seniors, is represented by strong connections, because, in the beginning, when she attended the service regularly, contact with the other participants helped her to understand that she was not alone. She does not share those daily acquaintanceships any longer, a situation expressed by the absence of lines, due to her difficulty in walking and the costs involved in using a taxi. It is possible to realize, according to Daisy's statement, the reason that makes it difficult for her to participate in the service, therefore demanding her son's help:

"I seldom go. Last time I went was one year ago. My son is the one who goes there. I find it difficult to walk, I have bellyache, the stoma bothers me, I have to go by car and it gets expensive."

It is important that stomized seniors participate in a systematic group work, because they start to envision a new perspective about their health-disease process, generating new interpretations and promoting means of assuring their well-being through the identification of the same and/or other difficulties in other stomized human beings⁽¹⁰⁾.

A process of identification with others allows for the projection from subject to subject, highlighting intersubjectivity, as in a circle, from the interactions that individuals produce in society. As society emerges, it influences the human nature of these individuals⁽⁵⁾, denoting recursivity as a continuous movement.

And with healthcare services such as the Basic Health Unit (UBS, in Portuguese), the eco-map is represented by the absence of lines. Daisy prefers to attend the hospital due to the proximity with her house, comfort and safety of being assisted appropriately as well.

In Rose's eco-map, strong connections are observed between her and her family, neighbors and friends. This flow convention also takes place between one of her daughters and the stomatherapy service, because she is the one who goes to the service to collect karaya bags for her mother.

Her family, which consists of the husband who takes care of her, five children, one daughter who lives with her and another who gives her more support, eight grandchildren and six nephews articulate a strong relationship with Rose, represented by a continuous and uniform flow, since all of them worry about her health condition and support her, according to her needs.

During the interaction process between nurses/senior/family, family members can participate actively in the care for the elderly person, which is better visualized by the eco-map. This moment represents an important information strategy to be used by the nurse towards the family and to develop the care addressed to stomized senior⁽⁷⁾, so that relatives can learn how to act at home.

The relations of Rose with the stomatherapy service are represented by connections with bars, expressing stress, since she is not able to participate in the activities proposed by the service due to her limitations. On the other hand, the relationship is dialogic when expressed by strong connections, since it encourages her towards self-care.

Human beings are both single and multiple, involving a complex universe in its essence; They comprise a set of individual autonomies, their participations in the community and have the feeling of belonging to the human species⁽¹¹⁾.

The connection of Rose with other stomized seniors participating in the stomatherapy service is expressed by dotted lines showing weak connections, since she participated in the meeting once. However she had a good impression. Since she cannot go to the stomatherapy service, factors related to her condition of stomized senior emerge, making the exchange difficult. The same occurs between her and her friends/neighbors, since she prefers to stay at home and does not like to visit them due to her limitations, which is made by her statement:

"After those surgeries I can not think right. It is just bed and sleep. A visit comes, I talk for a while and soon I lie down. Thereby, I have to be at home".

Also, the lack of connections between Rose and other healthcare services (and vice-versa) is verified, since she prefers the hospital for the stomatherapy service and the ability to schedule appointments with the desired specialists.

On Violet's eco-map it is verified that her family consists of four children (two are her neighbors), seven grandchildren and two great-grandchildren living in Porto Alegre. A continuous flow of contact is observed, being an incentive for self-care considering her stomy. Consequently, it promotes quality of life, because the family is an important supporting network day by day.

The family constitutes a linked unit, being home to a protective shelter. Even when its members are scattered they remain inserted in a network of solidarity⁽¹¹⁾.

It was possible to realize that strong and continuous connections were established by Violet between her and the stomatherapy service as well as with other stomized seniors, since she often attends the meetings. As a result, a continuous link was established, contributing to her opinions for the improvement of the view of others stomized in relation to herself, in addition to actively participating in the internal changes of the service itself.

So, recursivity⁽³⁾ can be observed between the stomatherapy service and Violet. The recursive idea represents the rupture with the cause/effect, product/producer, structure/superstructure linearities, since everything that is produced goes back to what is produced in a cycle, which is self-constructive and self-organized and self-produced in itself.

The eco-map can be used in all healthcare environments to enhance the nurse's perception of the families and the subjects, as well as in their interactions with wider systems. Also, it shows the intra-family systems, referring to issues that surround the family or subject construction^(7).

Friends and neighbors are introduced by Violet as cordial, which allows for a closer approach and friendship in which she places herself as an articulator in view of their needs, and them as well. Recursively, Violet is at the disposal of her friends and neighbors, aiming at strengthening ties among them through her determination and courage.

The lack of connections is evidenced between Violet and other health services, since she does not seek them, simply looking for care at the hospital because of the stomatherapy service. Violet says that other healthcare services such as the UBS in her neighborhood and another nearby are considered less comprehensive, not assisting her appropriately. This as happened in a previous experience, which discouraged her to go to these places. This statement is made evident by her statement:

"The closest service is the healthcare center, but I never go there. It's been three years since last time I went to a doctor. [laughs]. I go to the university hospital to get the bags."

One type of service provided by the UBS, especially the Family Health unit, is to provide support and to strengthen the families under its responsibility, because the family is the unit of care in the Family Health Strategy. However, the instrumentalization of workers is necessary so that this approach can be adopted^(12).

On Lily's eco-map, it is possible to observe the stomatherapy service as one of the components of his social network, presenting strong connections, and he realizes the importance of the service by constantly attending it, as well as the importance other stomized people in their process of accepting the stomy.

His family consists of three children, with one of the living with him, and five grandchildren. The structure of support is represented by strong lines, due to the relatives' proximity and dedication. He considers the family an extension of his love for his wife, who is dead. It was easier for Lily, to accept the stomy surgery than his the death of his wife, which was by his side all her life. This is evident in his statement:

"I do not care about the stomy. I have no pleasure in going out. I am always thinking about her [wife], I miss her a lot. Unfortunately, she is no longer here with me, she was my right hand. No one has ever thought my wife would die first."

In the event of death, such a human experience contains "an understanding of death as a black hole, where the individual is annihilated; at the same time it contains a refusal of the individual's disappearance"⁽¹¹⁾.

A connection of respect and trust is seen with friends and neighbors, since all of them participate actively in his care. These people accompany him frequently, reconnecting him, amid the feelings of emptiness resulting from his wife's death.

Caring according to complexity happens by considering that "complexity is a challenge, not the answer"⁽³⁾; the idea of complexity contains imperfections, since it brings uncertainty and the recognition of the irreducibility; complexity gathers scientific and non-scientific aspects, without nullifying it, but allowing it to express itself; complexity contains solidarity, and mainly complicity⁽³⁾.

The visualization of links in Lily's eco-map, whether right or wrong for the subject, makes the instrument important for the nurses to observe the existence of mutual bonds and how they are expressed. This will be influenced by issues such as gender, race, culture, sexual orientation and social class⁽¹¹⁾.

The relations of Lily to other healthcare services, such as the UBS, are demonstrated by the absence of connections, denoting the lack of contact with these services. He has appointments with physicians at the hospital he already knows, which provides him more safety regarding the service and his treatment.

CONCLUSION

Upon establishing a dialogue through recorded interviews at the residences of the four seniors researched, Rose, Daisy, Violet and Lily, all of them registered in a stomatherapy service in the Southern region of Brazil, it can be observed that their perceptions about the stomy surgery is unique, representing an universe of feelings and including several categories.

With the eco-map of each senior, it was verified that the need for a therapeutic and complex look undergoes an entire support network, such as the family, which participates in the daily routine of coping; friends/neighbors, who follow the whole change respectfully; the stomatherapy service, which helps them understand the phenomenon; other stomized seniors, who serve as encouragement to face a new way of living. In view of the above, nurses need to look at stomized seniors in a new way, and thereby advocate new types of care where these people are seen and (re)considered for their potential.

Therefore, it is necessary to realize that nursing care need to be reformulated, aiming at the reconstruction of the comprehension about stomy as part of that new body image, encouraging seniors to pursue better quality of life and soothing the effects of that change, often characterized as physical disability.

A gap was verified in the relationship between stomized seniors and the basic healthcare network, mainly UBSs, with more integrality being necessary. The deficiency found may be understood in two ways, whether on the part of the basic network, for not seeing to the needs of stomized people appropriately, or for their own habit of seeking hospitals, even in simpler situations. Thereby, it is important for these basic services to be reorganized of, since they are the entrance door to the Single Health System service.

As for the eco-map, using it was seen as a technological resource regarding findings about the study subjects and their real dimensions, contributing for the indication of strategies that promote wide and dynamic care for the stomized seniors and their families, in addition to exposing the easy and the challenging situations faced by these people and their relatives in the process of stomy surgery.

It was observed that the social supporting network is shown to be inserted in the complex social system, with its relationships and interactions, and that relationships of care are present in this social social supporting network for stomized seniors and their families.

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*

Estudo desenvolvido em um serviço de estomaterapia de um hospital universitário da região Sul do Brasil, sendo parte da dissertação do Mestrado em Enfermagem da Universidade Federal do Rio Grande – FURG – Rio Grande (RS), Brasil.

Publication Dates

• Publication in this collection
  13 Jan 2009
• Date of issue
  2008

History

• Received
  18 Mar 2008
• Accepted
  10 July 2008