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Revista Latino-Americana de Enfermagem

On-line version ISSN 1518-8345

Rev. Latino-Am. Enfermagem vol.17 no.2 Ribeirão Preto Mar./Apr. 2009 



Understanding the dimensions of intensive care: transpersonal caring and complexity theories



Keyla Cristiane do NascimentoI; Alacoque Lorenzini ErdmannII

IUniversidade Federal de Santa Catarina, Brazil: Doctoral Student, Scholarship holder CAPES, e-mail:
IIUniversidade Federal de Santa Catarina, Brazil: Ph.D. in Nursing Philosophy, Full Professor, e-mail:




This is a descriptive, interpretive and qualitative study carried out at the ICU of a Brazilian teaching hospital. It aimed to understand the dimensions of human caring experienced by health care professionals, clients and their family members at an ICU, based on human caring complexity. The Transpersonal Caring and Complexity theories support theory and data analysis. The following dimensions of care emerged from the themes analyzed according to Ricoeur: self-care, care as an individual value, professional vs. informal care, care as supportive relationship, affective care, humanized care, care as act/attitude, care practice; educative care, dialogical relationship, care coupled to technology, loving care, interactive care, non-care, care ambience, the essence of life and profession, and meaning/purpose of care. We believe in care that encompasses several dimensions presented here, based on the relationship with the other, on the empathetic, sensitive, affectionate, creative, dynamic and understanding being in the totality of the human being.

Descriptors: intensive care; intensive care units; nursing care




Nursing, as a scientific discipline and profession at the service of humanity, is committed to contribute to the improvement of living conditions and health. This commitment can be facilitated by the development of awareness on caring presented in practice, teaching, theory and research.

Because care is a complex concept, it has been a concern not only of nursing scholars, but also of researchers from other knowledge areas like philosophy, theology, education, psychology and anthropology(1-2). Care has been highlighted in nursing, however, as the essence and main reason for its existence as a field of knowledge and profession.

This article is the result of the researchers' experience in the care process and research in a intensive care unit (ICU). ICUs are designed to provide specialized care to clients in critical conditions and at risk of death and have increasingly improved technologies available in the attempt to save clients' lives, which requires highly qualified health professionals(3). Equipments favor immediate care, provide security for the entire ICU team, but are not conducive to human relations, perhaps because one knows more about equipment and less about the human being who is being taken care of.

Improved technology permits the gradual modification of the dynamics operating in ICUs. Consequently, decisions need to be made in the face of death and the dying process and also on the longer permanence of critical patients in these units. These facts have led to the conclusion that harmonious relationships should exist among professionals working at ICUs, patients admitted in these units and their family members(4). Therefore, those who provide care to critical patients need to attempt to improve this care.

As the reality of nursing practice is concerning, the following question arises: What is the meaning of care experienced at the ICU for hospitalized clients, their family members and professionals? This study aimed to understand the dimensions of human caring experienced at an ICU by health professionals, clients and their family members through the transpersonal caring and complexity theories.



The complexity perspective is a way of understanding the world, including in the real world the relationships that support coexistence between beings in the universe, allowing for the acknowledgment of order and disorder, the unique and the diverse, stability and change(5). Complexity attempts to dialogue with the several dimensions that constitute phenomena and objects, that is, with reality. It comprises seven basic, complementary and interdependent principles: systemic or organizational, holographic, retroactivity, recursion, autonomy, dialogical and reintroduction(6).

The organizational system of nursing care is composed of social actors: caregivers and care recipients, including people who are close to those who receive care, creating ties of mutual help. They are people who act, react, interact, share, are interdependent, help each other, exchange experiences, differentiate and integrate, get close and get distant, connect, involve and negotiate with each other, living in a conflictual harmony. They occupy a physical, social and political-institutional space(7). Care is presented as an emergency in this system, which by intuition, reason and logic of its actors allows for interactive processes of inexhaustible and unpredictable multiple relationships.

The notion of care priority, stronger in the subsystem of intensive care, is linked to the risk of death, which oscillates between real-hidden, certainty-uncertainty, truth-deception, where possibilities, chances and opportunities are at stake in acknowledged or routinely elected priorities, where uncertainty seems to arise as people become aware of the risk(8).

The perspective of transpersonal caring within Jean Watson's theory is based on her beliefs and values of human life, and on health and healing, which are the result of her experiences and observations(9). Watson emphasizes the humanistic approach, that is, to attend the biopsychosocial, spiritual and sociocultural individual; and the goal of nursing, which is to help people to achieve the highest level of harmony within mind-body-soul(10).

For Watson, the main goal of Nursing contains ten carative factors that originate from a humanistic perspective combined with scientific knowledge(10). They are: 1) practicing love, kindness and consistency within a context of conscious caring; 2) being authentic, be present, be able to practice and maintain a system of deep beliefs, and a subjective world of one's life and of the patient's life; 3) cultivating one's own spiritual and transpersonal practices of the self; 4) developing and maintaining authentic, caring, helping and trusting relationships; 5) being present and providing support to expressions of positive and negative feelings; 6) creative use of the self, of all forms of knowledge, as part of the caring process to be artistically committed to the care and protection practices; 7) being genuinely committed to the experience of teaching-learning practice; 8) creating a protective environment at all levels, where one is aware of the whole, beauty, comfort, dignity and peace; 9) meeting human needs, consciously administering essential human caring, which strengthens mind-body-spirit; 10) be open and attentive to spirituality and the existential dimension of life itself.



This is a qualitative and interpretative study with a phenomenological perspective that aims to broaden and understand the phenomenon: dimensions of care existent in critical units, more specifically at the UCI of a teaching hospital in Florianopolis, Brazil. Its target population was the ICU team (two physicians, one physiotherapist, three nurses and four nursing technicians) who agreed to participate in the study, signed the informed consent term and accepted the use of a recorder. In addition, clients who were hospitalized at the ICU at the time of the study and respective family members (six clients and nine family members) were selected according to the following criteria: being hospitalized at the unit (or with a hospitalized relative at the unit), older than 18 years of age, being aware of time and space, able to verbally express themselves and agreement to participate in the study. Data were collected through in-depth interviews and observations carried out by the first researcher, guided by the second researcher. The study participants comprised 25 people with ages varying between 22 and 80 years, number considered sufficient by data saturation in the preliminary analysis.

Discourse analysis was based on Ricoeur's hermeneutic analysis, which consists of five moments: initial reading of the text, distancing, structural analysis, identification of the metaphor and appropriation(11).

The material was organized during the initial reading, and several testimonies were read to grasp the meanings that emerged from the discourse. In distancing ourselves, we sought to suspend beliefs and clarifications on the studied phenomena so as to be able to look at it as presented by the participant. Through structured analysis, the veiled meaning was discussed and understood, generating subthemes and themes of discourse produced from the reality experienced by the participant. Understanding of the metaphor was achieved as from the understanding of the text. The themes that described participants' dimensions of care were merged into categories, analyzed according to the theory of Jean Watson and complexity. Appropriation was the last moment of the hermeneutic interpretation and means to be apt to understand the metaphor of the text world. This method of analysis permitted to interpret and understand experience with care systems in ICUs, and connections between respondents and the world they live in.

The code of professional ethics and resolution 196/96 were followed during the development of this study, which was initiated only after agreement from the institution and approval by the Human Research Ethics Committee at the Federal University of Santa Catarina were obtained (Process N. 311/04)



The set of discourse transcriptions comprised the body of text. This gradual construction (discourse after discourse) made a partial and crescent codification to emerge. Recording of observations was incorporated in the construction of the body of text, followed by data analysis. The veiled meaning was discussed and understood, generating subthemes and themes of discourse produced in the existential moment, of the reality experienced by the participant. Thus, the structural analysis led to the unveiling of subthemes and themes obtained through convergences, totaling 17 categories or dimensions of care according to the following presentation.


"Complex knowledge demands that we locate ourselves in the situation, understand ourselves in the understanding and know ourselves in the state of knowing"(5) . Self-care passes through a dialogue with oneself and a dialogue with others. Awakening to self-knowledge and self-care is part of the process of learning how to take care.

I believe that we can only transmit tranquility, attention and human warmth to people under our care, if we have already resolved our own conflicts, taking care of ourselves (4P)*.

When one experiences self-care, there is opportunity to perform self-reflection, express emotions, absorb experiences that become knowledge and develop self-perception as subject whose subjectivity and sensitivity are put in action.

Care as individual value

Value is everything that in a given condition contributes to the development and improvement of essential components of the human condition in social coexistence(8). Human values present personal and individual identifications but also expression in social coexistence. Individual values are added to professional values like love, honesty, spirituality, liking, joy, pleasure in constant improvement, which are important in the establishment of the current view of care.

Human care is included in values that emphasize peace, fraternity, religiosity, individuality, respect and love [...] (22F).

In this perspective, care provides people the feeling of being in harmony with themselves and with the environment, which treats not only physical health but also shows affection, sympathy, attention and respect for everything that permeates the other's subjectivity. Faith and belief are evidenced in relationships of care. Practicing and maintaining a system of beliefs, faith and hope is presented as a care factor(10).

Professional x informal care

Many times, professional care is distinguished from informal care in the participants' discourse.

Professional care is more specialized (1C). Informal care is provided by family members with warmness, comfort, attention, dedication and affection (16F).

Professional care is the care delivered by professionals with scientific knowledge in the health area and who have technical abilities to help individuals, families and communities to improve or recover their health. Professionals have technical-formal education and acquire a professional perspective of health, disease and care(12).

Informal care comprises attitudes, techniques and processes based on cultural values, helping people to take care of themselves in situations of health and disease. Professional care and informal care happen in the beings, from them, to them, through them, and coexist in the nature and in the same structure of organization of the life of human beings, in their several biological, anthropological, psychological, sociological and other domains(8).

Care as a supportive relationship

Care as a way of being with the other was evidenced in the discourse, establishing a supportive and trustworthy relationship:

Caring means helping the other person to get better so that she can take care of herself (7P).

Being with the other in care as a supportive relationship requires closeness. Thus, for a relationship of care to exist, professionals need to develop abilities to get close, observe the client at all dimensions and perceive situations in a relationship of respect and trustiness. In this relationship, they express and share their knowledge, sensitivity and technical ability and help the other to grow. The other shares his(er) self, rituals and personal characteristics that mobilize the care system.

Affective care

Affective care is present in health professionals' attitudes with several kinds of feelings in their relationships of care experienced at the ICU. In learning about positive and negative feelings in daily routine, one gathers information about the patient. De-codifying the meanings of these expressions and feelings present in their actions is a complex process necessary to ease approximation and relationship with patients. Being present and experiencing an authentic affective and empathic relationship is not only a coming-and-going to permit forward and backward perceptions and feelings, but also means causing "ruptures", "landing in other areas", expecting insights, not only knowledge of situations, but looking at what can be different, from which ambiguous, intuitive and creative forms of thinking/acting can emerge(8).

Humanized care

Health/nursing professionals are constituting a humanistic care, focusing on human care and affective touch.

Care should be like, from human being to human being, so it is humanized, right? I was cared for as a human being; there was trustiness, security, respect, you know (18C).

In the humanization of care, the caregiver is a human being who respects and values the being under care in his(er) existentiality, understands this being as someone who has his(er) own experiences that accompany his(er) existence(13).

Affective touch is essential when it is transformed in attitude by the hand that establishes the relationship(2). Touching represents the care per se, the professional's sensitivity and solidarity. Touching is revealed as a humanistic attitude, strengthening the bond and establishing an encounter between the caregiver and the care recipient.

Care as act, attitude

Care is seen as an action, idea of movement, carrying out an activity, acting jointly with an agent, realizing something for or jointly with another being, acting in favor of the other's health.

Care is the professional's set of attitudes to attend the severe patient and family members so as to maintain the patient's living condition (14C).

Care is an action of familiarization, understanding, technical abilities and feelings of each caregiver who experiences the care process. This is a cyclical process, of relations and organization of care by attitudes like: be with, take care of, help to do, orient and educate.

Care as care practice

This dimension includes carrying out technical procedures and also refers to commitment and responsibility among those involved in the relationship of care.

They are activities of care and support to a family member or a client with a view to recovering health (25P).

Care as assistance practice includes carrying out technical and supportive procedures for the client in his(er) integrality as a complex being, oriented by Watson's ten carative factors. It is supported by the systematization of care or nursing process under the nurse's responsibility.

Educative care

Educative care refers to information, teaching and formal and informal training programs(2). It is the springboard for seeking knowledge for the evolution of society; one cannot detach care from education(9). Educative care is the exercise of critical thinking, spirit of citizenship and continuous search for new horizons.

Care means to have knowledge, means to know the developed health actions (18C).

Educative practice strengthens the nursing team so as to provide a more authentic care. Re-educating oneself means to stand out of a minority; it means caregivers feel the need and help others to change(6).

Care with a dialogical relationship

In care systems, a human relationship is constructed through the encounter of the client and the caregiver and is expressed through a dialogical relationship. This relationship is evidenced when the caregiver turns to the client with reciprocity and affection and is able to conceive and be conceived as a human being.

[...] I keep talking whenever I'm performing a procedure, not only a mechanical talk, I think the patient feels safer when there's verbal communication (11P).

Discourse reveals that the caregiver's intention to be authentic, present and able to experience the subjective world of care with the other concretized the dialogical relationship. When the caregiver awakes to the care full of sensitivity, (s)he fully experiences the moment and values not only technical-scientific aspects, but also essentially the human being, and promotes the care encounter. This dialogical encounter is the result of understanding the other's expression in a loving and respectful manner, perceiving the other's feelings and emotions and respecting his(er) way of being and being in the world.

Care coupled to technology

It is evidenced as something properly valued. Technology is a way to ease the care delivered to the client, oftentimes vital to preserve life. However, it is necessary to avoid greater concern with equipment than with clients because caring is not limited to technology.

[...] the development of technology is necessary, but we should follow principles for its use, it's impossible to expect attending severe patients without technological support, it facilitates our activity and, in many cases, keeps patients' life (4P).

Technology as part of human caring was created by and in favor of human beings, without the intention to overcome the dimension of their essence.

Loving care

Care is understood as an act of love, exchange between caregiver and care recipient, in which both share love to achieve successful results.

You can tell there're many people here who work for love, because there is attention, their smile (2F).

Love as dimension of care works as a facilitator, energetic and tender element that nurtures and exalts the care. Through the development of one's own feelings, one can really interact in a sensitive manner with another person(10). In relationships of care, one can transcend the physical and material world and get into contact with the individual's subjective world. Loving care implies sharing, sensitivity, trustiness, communication, understanding, empathy, commitment, view of the other as unique, perception of the other's existence, acceptance, respect, receptivity, competence, touch, smile, involvement, moments of encounter, presence and others.

Interactive care

Health care is a process of interaction and association between beings, and is an organizing part of the health system and organizing part of care systems, and co-organizes jointly with the remaining social systems(8). They are links, information and connections in an interactive and relational care, indicated in the following discourse.

Care is an interaction process between professionals, patients and family members, where they experience an unstable situation, aiming to re-establish people's health (11P).

Interactive care is established based on internal forces, that is, by the subjective transaction between the inner and outer worlds of the caregiver and the client, in unique ways and moments and with different people, and that is why they are genuine.


In the dialogue with some health professionals, the way they would not want to be cared for appears implicitly. Non-care is to use artifacts so as not to get too close to clients, performing care in a hurry and keeping distance from people. In such circumstances, clients and family members feel inhibited to express or request support. Certain terms may seem neglectful or forms of non-care: I'm in a hurry, I do not have much time, be brief, among others, limiting the space and closeness, distancing patients from professionals.

Non-care is to perform activities in a hurry and distracted (23F).

Broadening the understanding of care so as to improve the relationship with patients should be an important concern for health professionals.

Care, the essence of life and profession

Care is showed as a value essential to people's life. Care is the essence, the moral ideal of nursing, whose aim is to protect, aggrandize and preserve human dignity(10).

Professional care is the essence of nursing and includes actions developed in common agreement between two people, the one who takes care of and the one who's under care (7P).

Human caring, understood as the moral ideal of nursing, represents a set of transpersonal efforts focused on patients to help them acquire knowledge and self-control, promoting and preserving their existence. And care as the essence of the profession is the professional's commitment to take care of so as to give sense to life. This essence of care is to be and to make a difference in the relationship of care.

Care ambience

Clients and family members consider the environment hostile, feel insecure and afraid because of the difference between the hospital environment and that of clients/families. Clients consider the ICU hardly cozy and impersonal and perceive the standardization imposed by the institution, which does not consider their individualities. It is a well-equipped physical structure, with modern technological resources, but which can sometimes pass to the client a feeling of coldness and indifference in the way care is delivered.

There is little to recall from there. I know we get very thirsty, the lips get dry, we don't talk, stay quiet, have no contact with anyone, it's scaring (20C).

They alluded that the caregiver is also influenced by the environment, which affects the care process. Caregivers need a cozy and comfortable environment because it is in this place they interact to develop their attributions.

Promoting a supportive environment, of biophysical, psychophysical, psychosocial and/or interpersonal protection is one of the requirements of care. The interdependence between people's internal and external environments influences health and disease conditions(10). There is an ongoing interaction process between the environment and the human being that can either favor and create or hinder the relationship of care between human beings.

Meaning/purpose of care

The clients' clinical improvement and recovery emerges as essential purpose of the care process, that is, care is a way of reestablishing clients' health, a way of helping the other to grow and self-fulfill, to die a peaceful death, contributing to the quality of human beings' process of being and living.

The big result is the patient's improvement or at least seeing he is well, that you can do something to improve his health (16 F).

Care is focused on the needs and desires of human beings involved in the care relationship. Health/disease is permeated by movements of living at the limit of sensations, comfort and discomfort, hoping for new moments in the possibility of being in a situation and get prepared to be in another. Health is in the organizational care system where being healthy means living ups and downs, in a come-and-go of joy and sorrow, in a conflictual harmony mediated by the threshold of intersection between death and life(8).



The content that emerged from the reflections, based on complexity and transpersonal caring theories, on the discourse regarding the relationship of care experienced in organizational care systems reveal the dimensions of care.

The qualitative research with a phenomenological perspective and Ricoeur's interpretative analysis was a dynamic process that permitted a broader understanding of the phenomenon: dimensions of care existent in an ICU. The moments experienced and shared with the study participants were moments of complicity, reciprocity, interest and solidarity. They provided the perspective of new paths and different attitudes in terms of care and people, that is, human caring with sensitivity, empathy and satisfaction.

We expect to provide fellow nurses the pleasure of exercising transpersonal caring and complexity in the daily routine of nursing care, in its multiple facets and aspects of structures and interactions. We also expect they reflect on the care provided at ICUs. We believe in human caring composed of several dimensions presented here, based on the relationship with the other, on empathic, sensitive, affective, creative, dynamic and understanding being in his(er) totality as human being. Behind all those wires, tubes, slides, lights and alarms, there are human beings taking care of and human beings being cared for, hoping to live a little longer and better.



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Recebido em: 18.7.2007
Aprovado em: 1º.4.2009



* The letters P, F and C stand for Health Professionals, Family members and Clients, respectively, and numbers refer to codes given to each participant in the study.

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