The nursing care towards individuals with diabetic foot: a phenomenological focus

Abstracts

Esta pesquisa tem como ponto de partida experiências compartilhadas com portadores de diabetes mellitus. A fenomenologia existencial de Martin Heidegger possibilitou a apreensão dos momentos vividos por esses seres. Entrevistou-se, em seus domicílios, oito pessoas que residem em Bandeirantes, cidade situada no norte do Paraná, e que tiveram alguma complicação podológica decorrente da doença, no período de fevereiro a agosto de 2007. O estudo teve como objetivo compreender suas vivências ao experienciarem uma complicação podológica em seu existir-no-mundo. Para desvelar a linguagem dos sujeitos, empregou-se a seguinte questão norteadora: Como é, para você, viver com uma complicação podológica desenvolvida por consequência do seu diabetes mellitus? Da linguagem dos sujeitos emergiu o tema: O ser-aí e o cuidado inautêntico. Os resultados obtidos revelam a importância de oferecer um cuidado holístico ao Ser que vivencia esta facticidade, pois muitas vezes a subjetividade do cuidado fica absorvida pela massificação das regras e normas institucionais.

Diabetes mellitus tipo 2; Pé diabético; Cuidados de enfermagem; Acontecimentos que mudam a vida

ORIGINAL ARTICLE

The nursing care towards individuals with diabetic foot: a phenomenological focus^*

El cuidado de enfermería para con el ser portador de pie diabético: un enfoque fenomenológico

Ricardo Castanho Moreira^I; Catarina Aparecida Sales^II

^INurse. Master in Nursing by Universidade Estadual de Maringá. Professor at Universidade Estadual do Norte do Paraná, Faculdades Luiz Meneghel Campus. Bandeirantes, Paraná, Brazil. [e-mail]

^IINurse. PhD. in Nursing. Professor of the Master's in Nursing Programa at Universidade Estadual de Maringá, Paraná, Brazil. Member of Núcleo de Estudos, Pesquisa, Assistência, Apoio à Família (Center for Family Studies, Research, Care and Support). Maringá, Paraná, Brazil. [e-mail]

Correspondence addressed to

ABSTRACT

The starting point of this study stands on the experiences shared with individuals presenting diabetes mellitus. The existential phenomenology of Martin Heidegger allowed the apprehension of the moments lived by these individuals. Interviews were performed, at their home, with eight people living in Bandeirantes, a city situated in the North of Paraná, and who had had a podological complication due to the disease, in the period from February to August of 2007. The study aimed to comprehend their experiences when dealing with a podological complication in their being in the world. In order to study the language of the subjects, the following guiding question was employed: What is it like, for you, to live with a podological complication developed due to your diabetes mellitus? From the language of the subjects, the following theme emerged: The being (Dasein) and the unauthentic care. The obtained results showed the importance to offer a holistic care to the being who experiences this situation, since the care subjectivity is often absorbed by the massification of the institutional norms and rules.

Key words: Diabetes mellitus, type 2. Diabetic foot. Nursing care. Life change events.

RESUMEN

Para esta investigación tuve como punto de partida experiencias compartidas con portadores de diabetes mellitus. La fenomenología existencial de Martin Heidegger posibilitó la aprensión de los momentos vividos por esos seres. Fueron entrevistados en sus domicilios ocho personas que residían en Bandeirantes, ciudad del norte de Paraná, Brasil, que tuviesen alguna complicación podológica derivada de tal patología, en el período de febrero a agosto de 2007. El estudio tuvo como objetivo comprender sus vivencias al experimentar una complicación podológica en su existir-en-el-mundo. Para revelar el lenguaje de los sujetos, utilicé la siguiente pregunta orientadora: ¿Cómo es para usted vivir con una complicación podológica desarrollada como consecuencia de su diabetes mellitus? Del lenguaje de los sujetos surgió el tema El ser-ahí y el cuidado inauténtico. Los resul-tados obtenidos revelan la importancia del cuidado holístico al Ser que vivencia esta facticidad, pues muchas veces la subjetividad del cuidado resulta absorbida por la masificación de las reglas y normas institucionales.

Descriptores: Diabetes mellitus tipo 2. Pie diabético. Atención de enfermería. Acontecimientos que cambian la vida.

INTRODUCTION

My interest in studying the everyday lives of patients who experienced foot complications caused by diabetes mellitus, also referred to as diabetic foot, emerged from meetings that I had with those patients since my nursing undergraduate years, when I did all the interviews to register them in the Plan for the Reorganization of Primary Health Care to Hypertension and Diabetes Mellitus (HIPERDIA: acronyms for Plano de Reorganização à Atenção Básica à Hipertensão Arterial e ao Diabetes Mellitus)⁽¹⁾. In this context, I realized that the patient with diabetes mellitus often dealt with the disease by masking their feelings and wishes. Still under the influence of a education process that addressed diabetes patients in their technical-biological dimension, emphasizing on the subject-object dichotomy, my idea of care was that I should instruct them about the main aspects related maintaining a good glucose level, such as through a balanced diet, physical exercises, insulin therapy and adherence to the drug therapy. I felt uneasy when I noticed that the knowledge I obtained throughout that period would make me perform programmed consultations with those people, conceiving only their physical body, i.e., seeing nothing but the wound on their limb, without trying to understand them in their existentiality.

My professional experience as a clinical nurse and faculty revealed that patients valued the drug treatment and sought through that treatment exclusively the therapeutic resource that would meet their needs, but they often failed to comply, and those patients failed to avoid complications resulting from those problems. During nursing care, I always instructed them to assume self-care, in order to control and prevent complications resulting from diabetes mellitus.

With this attitude, and together with a group of nursing students from a state university from Northern Paraná, I implemented an extension project in nursing care for the prevention and treatment of wounds. The referred extension work allowed me to become closer to people, as I was responsible for their home care, emphasizing on the prevention and treatment of wounds occurring on their extremities.

Through domiciliary visits to the patients and by being closer to the context in which they lived, I realized that the instructions that were given at consultation offices were sometimes insufficient to fully meet their needs. I noticed that many of them were forced to assuming the responsibility for their own care, more as a way of showing the professionals that they were taking care of themselves as they had been instructed, but without understanding and assuming the importance of living well with the disease.

I believe that when providing care to patients with diabetes mellitus, the main focus is on the disease, asking them questions that permit to learn about their kidneys and if they are functioning well, if their eyes have preserved precision, if their blood vessels do not present reduced lumen rates, and if their feet are free from wounds that could predispose them to amputation. However, one does not consider they are dealing with a person that relates to the world and is part of that world in specific social, cultural, educational and economic contexts. Furthermore, another factor that is often disregarded is the time that that being lived in the world with their healthy feet.

When I read the remarkable description that Heidegger made about the Van Gogh's masterpiece A pair of shoes, this issue caught my attention:

In the stiffly solid heaviness of the shoes there is the accumulated tenacity of her slow trudge through the far-spreading and ever-uniform furrows of the field, swept by a raw wind. On the leather there lies the dampness and saturation of the soil. Under the soles there slides the loneliness of the field-path as the evening declines. In the shoes there vibrates the silent call of the earth, its quiet gift of the ripening corn and its enigmatic self-refusal in the fallow desolation of the wintry field.This equipment is pervaded by uncom-plaining anxiety about the certainty of bread, the wordless joy of having once more withstood want, the trembling before the advent of birth and shivering at the surrounding menace of death⁽²⁾.

Through that interpretation I began to see human beings beyond the wound on their foot, the risk of an amputation, the necrosis formed with time. At that moment, I was able to see the Being experiencing the facticity of being-thrown-in-the-world with a diabetic foot. I also understood that under the soles slides the loneliness of the field-path as that is lost in the dawn of amputation.

This reflection was central for me so I would seek a new attitude towards nursing care: one that would allow me to understand how the patient with diabetes lives with the disease. I believe that this understanding is capable of generating a care that fully meets their needs, permitting them to assume their own path-ways, grow, mature and meet with themselves, respecting their ideas and leading them towards an everyday life in which they assume making the decisions about the possibilities of living with diabetes mellitus and, especially, with their foot complication.

Hence, I set the starting point of this study on the experiences I have shared with diabetes patients. For me, that experience revealed a certain contradiction between the individual's existential dimension and the care provided by the health team, which gave rise to a new phenomenon that to be unveiled, i.e., the Being with a diabetic foot. I believe that the results will allow professionals to help those individuals o recover their own moral value as beings-in-the-world, always aiming to assist and prepare them to deal with their existential conditions, build their authentic living and, most of all, obtain, through their discourses, the light to direct their actions in the sense of changing the reality they live in.

OBJECTIVE

The objective of this study is to understand the experiences of people with diabetes with a foot complication in their existing-in-the-world.

METHOD

When I started the Master's course, entwined in my conceptions about care, I was unable to see it as an essentially existential category. Nevertheless, through reading about the phenomenological method, especially Heideggerian Existential Phenomenology⁽³⁾; little by little I learned that its presuppositions contributed with my full development, thus discovering new landscapes in which the Being with a diabetic foot could be understood in their existence.

That certainty emerged in my pathway, because the phenomenological methodology, with through its urge to understand the other in their facticity, comes close to the actual tendency of nursing, which sees human beings as a whole⁽⁴⁾.

Through the readings I also learned that the greatest attribute of qualitative phenomenological research stands in the language, because it is through discourse that what makes sense to the subject becomes reality, and that meaning is manifested through the description. By formulating the question about the phenomenon that is meant to be unveiled, the researcher should be aware that total unveiling is not possible, due to the philosophical fundamentals of the method-dialectic relationship unveiling/occultation⁽⁴⁾. Other authors reinforce this thought when they state that

The phenomenological investigator, thus, seeks to see things directly, open to its possibilities of appearing. By focusing on the phenomenon meant to be studied, the way this phenomenon is seen by those seeking to understand it is in perspectives. It is revealed through its possibilities of appearing, because as it is not an objective reality, concretely given and ready, it may only show itself in its being. These manifestations, or perceptions, or, yet, sensorial intuitions that eventually comprise the study data, by means of descriptions or statements by those who have had such experiences⁽⁵⁾.

With this thought, I understood that to formulate a question it is necessary to verbalize it as a clear question, one that not only allows for a simple answer or definitions, but also permits subjects to give spontaneous statements about the situations they have experienced and persist in their everyday life. The description of their experiences should involve thoughts, feelings, and actions about the reality they experienced. In this sense, the following way of questioning them emerged: What is it like, for you, to live with a foot complication due to diabetes mellitus?

The region of questioning or the ontologic region was the situation in which the phenomenon that I sought to unveil occurred, i.e., the experience of each person suffering the implications of existing-in-the-world with a foot complication caused by diabetes mellitus.

The criteria that I determined for people to participate in this study was that they should have diabetes mellitus, live in the city of Bandeirantes, in Northern Paraná, have some kind of foot complication, i.e., diabetic foot, with or without previous amputation, be at least 18 years old and agree to participate in the study. Considering these criteria, interviews were performed with eight patients who participated in a wounds project that I coordinated. I would like to emphasize that the World Health Organization⁽⁶⁾ defines the term diabetic foot as an

infection, ulceration and/or destruction of deep tissues, associated to neurological abnormalities and several degrees of peripheral vascular disease on the lower limbs.

Because this study involves human beings, I followed the ethical aspects ruled by Resolution 196/96 of the National Health Council- Ministry of Health. The application to participate in the study was followed by two copies of the Free and Informed Consent Form. In the application, I notified the possible participants about the purpose of the study, the type of participation that was wanted and the expected amount duration of the interview. I also assured the participants the dissociation between the study and the health care service, besides the fact that they could withdrawal from the study any time they wished to, and I guaranteed the confidence regarding any information they provided and anonymity whenever the results were published. I emphasize that the project was approved by the Review Board at Universidade Estadual de Maringá - PR under Document Number 379/2006⁽⁷⁾. I clarify that, in order to preserve the subjects' identity and use a generic form of treatment (subject 1, subject 2, subject 3 ...), I used planet names to refer to them.

To fully capture the subjects' expression in their languages, I chose to analyze each discourse individually. Therefore, a priori, I made a few careful reading of each statement, extracting the sections or meaning units (MU) which, to me, appeared pertinent to the formulated question. A posteriori, I began interpreting the meaning units of each statement, seeking to understand what was hidden in the subjects' language, because one meaning unit generally consists of feelings that are revealed by the respondents and that contemplate my question. I also emphasize that while interpreting each meaning unit, I removed excerpts that, to me, revealed the basilar essence of each subject's message⁽⁸⁾. After interpreting each statement, I highlighted the feelings that were the most evident in each discourse, from which emerged three existential themes that express their existing-in-the-world with a foot complication: The being-there and the unauthentic care; The being-there and the concern with what is to come; The being-there and the authentic care. These themes were interpreted under the light of some ideas of Martin Heidegger's existential analytics.

I chose to work, in this article, he existential theme The Being-there and the unauthentic care, in which I evinced the following feelings: living an unauthentic being-with-the-other of health professionals and the inhospitable experience at the hospital.

RESULTS AND DISCUSSION

The being-there and the unauthentic care

Man, facing his perspectives, is the creator of his own history, the one who plans and executes his projects in the world. He is concerned with his own beauty, health, and dynamism, but when he sees himself in the world with something that may destroy his will to live, his vanity, hope, self-confidence and control, he becomes a being that is defeated by that situation⁽³⁾.

Regarding that thought, Venus says;

[...] I had to amputate my toes. That made me so nervous, it made me want to cry. I even told the women at the Santa Casa hospital: you know what's worse, you left me here alone, you think I have the so-called cancer, to be left here to rot, you left me alone in this room.

She saw all her meanings dismantle, and, because suffering is never expressed through one determined existing object, the respondent feels uneasy, helpless and with no sense of direction, watching her familiarity with everyday life fall apart, and that made her more vulnerable to the suffering she experienced.

That fragility is revealed through situations that are often experienced at hospitals and comes to show that hospitalized patients are subject to painful experiences that limit their liberty, invade their privacy, hinder them from performing everyday activities - such as talking and walking - and lead them to losing consciousness about themselves, leaving them to the fate of the care from the health professional⁽⁹⁾. In this sense, I understand that the environment may influence care, but, in my opinion, nursing has the duty of using its power-to-be to guarantee an appropriate environment, or, in other words, an environment of care, involving the physical, administrative, social and technological settings⁽¹⁰⁾.

[...] To me, that room was a disease, there was nobody to talk to, for God's sake. It was like a dead place. I stayed in there for nine days, and for me it was like a year, a year! That is no place for a person to be [...].

In this statement, Venus expresses here resentment towards her experience at the hospital ward, after the amputation, not only because of the conditions of the room itself, but also for the temporality, the loneliness, the absence of someone close to share her fears. From a philosophical perspective, there are two forms of noticing time: there is objective time (chronological time) and subjective time (the intensity that was felt during that time)⁽¹¹⁾. From this perspective, I observed that the respondent described her existential temporality in the hospital not through chronological time, as tracked on a watch, but by the intensity of her suffering during that period.

For me, it also becomes evident that Venus experienced the fear of mutilations to her body, the everyday life in a different environment, the limitation imposed to meeting with her relatives- all of which were now determined by chronological time -, the lack of information, and, especially, the distance kept from health professionals.

By being-in-the-world, man exists in a situation of uncertainty, i.e., he is free, but that is also circumstantial. It is only in the scope of that circumstantiality that he holds the basic human conditions of his existence, i.e., the having-been-thrown-in-the-world regardless of his will and without having the right to choose.

Being human is to live in a permanent situation of making choices, taking risks in those choices, assuming compromises and suffering the consequences of the decisions that were made⁽¹²⁾.

[...] Here (at home) it is different, I have no problem controlling. Here I can control well. You see, I have already insulin and now I only have to take it again tomorrow morning. And it is low, when I see it´s too low, I change the type of shot [...] here I control much better than at the hospital. They never took good care of my diabetes there. At the hospital my diabetes would reach 400, here it is never more than 300[...].

Analyzing this language I understood that Uranus clearly expressed his preference for taking care of his diabetes at home, once again emphasizing the unauthentic care experienced at the hospital.

Regarding the unauthentic care by health professionals, Uranus also reports;

[...] I got really bad... bad... I said: I'm going to die! Then a white guy came next to my bed and asked: - what's wrong? - Son, I feel awful, I think I won't see the light of day, I'd like you to call my wife in, so I could talk to her at least a little bit. - Look, I'll call your wife, but tell her to stay just a little bit, because it's not allowed for people to stay in here. He left and never came back. [...] From midnight on they simply abandoned me, they ignored me. God is who cured me, because I thought I was going to die. God told me: no, you're not going to die. So I got up [...].

In this meaning unit I see that, when he suddenly felt ill, Uranus asked for the presence of an employee, trying to get help; but because he did not receive care from the health team as it would be expected, he asked for his wife to come stay by his side, even if it meant for just a few minutes. That would have been enough for him to find emotional and spiritual comfort, but he came to see, with sorrow, that the employee did not keep his word when he promised he would call his wife in, once again characterizing a being-with-the-other in an unauthentic way. I also realize that in his report, the respondent shows his suffering for feeling like an insignificant Being, a nothing in the world, as if the Being with diabetes that experienced a foot complication cannot receive care as a being among other beings.

However, the being-with-the-other in disease may become a significant participation when it enunciates expressions of solicitude, which translated into consideration and patience towards the other. From this perspective, I highlight that

The care with therapeutic means aims at recovering the essence of nursing, and is not exclusive to the technique, rather, surpassing it, establishing an effective person-person interaction. It is this care that perceives the human being as a whole, taking into consideration their culture, religiosity, fears, taboos, and coping experiences that bring us closer to an ideal care that I search for the being with diabetes⁽¹⁰⁾.

The statement presented by Uranus also made me think about hospital care, which is based on routines and tasks that health institutions are forced to comply with, almost mechanically, because of tradition and habit⁽¹³⁾. In my opinion, we must avoid mechanization to overcome the true objective of our profession, which is humanized care.

Meditating about these words, I understood that, in the everyday life of people with diabetic foot very often and in many ways, health professionals have deficient attitudes in terms of solicitude, at times exalting institutional rules, as learned in the statement above, while, at others, considering technological resources the only valid means of caring for the patients' needs, as shown in the statement presented by Jupiter:

. [...] I asked if they shouldn't do some cleaning, but he said they wouldn't because there was no material available. I left the place and went to the emergency health care center because I was in extreme pain, I was going mad and could do something stupid at any moment[...].

By existing-in-the-world, human beings may unveil themselves in the different forms of solicitude, even if these deficient expressions of care are unveiled through a feeling of indifference from others, revealing a constant wish to escape from the responsibility of being-with-the-other in an authentic way⁽³⁾. I illustrate that with Jupiter's statement:

[...] At the emergency health care center they instructed me to schedule an appointment with the vascular doctor. I went to the city hall during lunch break and waited there for some time. I was close to crying from so much pain. I was able to schedule an appointment, but I remember that the employee responsible for the scheduling told me that the city bus that takes the patients to the appointment was full.

Therefore, the professional only considered the norms of the institution, neglecting the existential situation experienced by the Being.

Generally, the being-with may occur in a deficient way. It is the case when, in everyday life, the being starts treating others as objects or as a unit in the multiplicity, or exclusively in terms of functions, assuming others when performing their roles⁽¹²⁾.

Regarding this issue, I believe that units such as emergency health care centers should provide correct instructions to patients with diabetes and their relatives, founded on establishing attachment with professionals and the service center, which could improve treatment adherence, in addition to informing them about general diabetes care and, specifically, foot care⁽¹⁴⁾.

In the Heideggeriana reflection, in the world, considering one landscape of everyday human life, situations emerge and destroy all private things that surround them, directing to an emptiness⁽³⁾. In this context, I observed that Saturn demonstrated his perplexity in view of the attitudes of neglect and disregard towards his feelings regarding the possibility of the dusk of amputation, because for the doctor is was simply one more procedure to be performed.

[...] The doctor said he had to amputate my leg, but he looked at me from far away, the guy working on the dressing opened it and the doctor didn't even come close, because it was late, like six o'clock. He looked at me and said: "We will amputate your leg, close to the knee, so it will end the problem", and left[...]. And explained [...] the workers put a black bag on my foot, it would stay on all day long, so it made my foot even more rotten. [...] I went three days without them changing my dressing. Can you picture the smell, the foot is not well, and with the bag?... No one could even come near the room [...].

By stating these words, Saturn expresses his resentment towards the workers' attitudes, because they did not worry about taking care of his wounded limb. The respondent moves on in his statement, describing the time experienced at the hospital waiting for the surgery.

[...] My saddest day at the hospital in Bandeirantes was when they took me to an isolated room. I really felt shaken that time. They told me that I should stay there. My foot was really smelling bad. But when I got there I felt desperate, Gosh, that was my last step. [...] But thank God we overcome anything. When they threw me in that room I felt there was no more chance of cure and they were trying to minimize a situation that had no return. Think about it, never in my life had I been in a hospital. Then I arrived there got into a room and nothing worked. In the afternoon they take you to be alone in another room, that smell. I thought that besides the wound there was some other disease, I don't know! I felt it was my last stop. Yesterday I was going to have my leg amputated and today they isolate me in here, they come in and close the door. I felt I had hit rock bottom, if there is such a thing, now I'm isolated, with nobody to talk to, and my foot smelling worse and worse [...].

With these words, I understood that Saturn expresses his sadness not only because of the physical pain, but also because of the neglect form the workers and, mainly, for feeling a part of his body is rotting and he sees himself alone in the world, stuck to a bed. In this context, I agree with the following thought: when your life becomes limited by pain, suffering is expressed not only by perceiving pain itself, but mostly by the limitations that are forced to your life, as it becomes impossible for you to express your own feelings⁽¹⁵⁾.

Unauthenticity has a significant effect on the control of the encounter, because the other is not someone who is part of my care⁽³⁾. In this sense, I identified in the language of the present study participants that the health team hides among itself, escaping from its responsibilities of establishing an affective relationship with the patients. That identification may be represented through the statement by Pluto:

[...] instead of coming to have a talk with me, they guy comes and says to me straight that he's going to cut off my whole leg. I was already nervous, I said I had been waiting for a long time and I wanted to be seen by an expert. Then a stressed-out vascular doctor came in, and said he was going to amputate my leg. I said: go amputate you mother's leg, not mine! He was doing all the paper work for my admission, and I said I wasn't staying. He said he had more patients to see, and that I should wait outside, and that I should see him when I made up my mind. So I calmed down and went to get admitted, but this time they stalled my even more; so I decided to not admit myself. If it here on them, I would have been admitted and they would have amputated my leg, it is easier on them [...].

Affective tone or disposition is one of the three essential behaviors that the being-in-the -world uses to reveal himself to the world. Through disposition, man opens up to himself and to the world and permits that others come to his encounter. It is the condition of touching and being touched, of being able to share your feeling with a close one⁽³⁾.

Through this thought, I observed that Pluto seeks, a priori, to open up to himself, searching for the strength to stay firm and stand this new and unwanted condition of being-in-the-world with a foot complication. However, through his statement, I analyzed that this opening process in a second moment, makes him entwined in himself, because he does cannot share his opinion with the doctor. I examined, in this unit, the suffering that Pluto experienced when he understood that the doctor limited his work to solving the problem by amputating his leg, without considering his life history.

About this issue, they came close to me and spoke the following words:

Disease as to how people experience it has two aspects that should be taken into consideration. One has a structural and formal nature, which permits to understand the disease as to what it is in itself, any place in the current world. The other, of a material nature of a content that will express the concrete existential of the ill being, bearer of the disease and who presents himself through his corporeity, language, and his socioeconomic and cultural life, which differs from place to place, because they are attached to the particular historicity of each patient⁽⁴⁾.

According to the Heideggerian interpretation, the different forms of solicitude related with dehumanization, in a mass society, where the entire spiritual humanity is suppressed and the morbid irresponsibility and lack of affection arises. Hence, the ill being permits himself to be guided by the situation, by the care he receives from people around him, exempting himself from his responsibility. He makes no decision, and takes no initiative, because everything has been decided for him in his everyday life. Nevertheless, I noticed in Pluto's language, his need to be heard in his facticity and, especially, of participating in his own treatment.

The art of caring consists in finding a way to permit ill people to express their needs. Care givers are people capable of listening to ill people and meet their individuals expectations⁽⁴⁾.

In her statement, Earth also expresses the lack of solicitude from the health team, showing all her suffering when she discovered she would be admitted again. She reports how much suffering it was for her to be in a hospital and, especially, to deal with the imposition attitudes from the nurse:

[...] When the doctor said I would be admitted again, I would have given anything in the world so I didn't have to stay there. I'm terrified by hospitals. I can´t explain. I started to cry hard, I felt desperate and said I didn't want that hospital. I had to go to the bathroom on my own with my foot in that condition, I had to take a shower, but I didn't have even have strength enough to get off the toilet [...] Anything I would eat, my stomach would reject. There was a nurse who would say I was playing around, but I don't stress out. I was really feeling sick to my stomach, so the food they would set on my table would just stay there. I ate a piece of fruit and the nurse at the hospital got angry with me. I ate a pear, and they she went on saying that I didn't eat the food because I was eating in secret. It because I felt like eating cold food so it wouldn't upset my stomach [...].

The respondent also shows her dissatisfaction with the worker's service, who, concerned exclusively with the routines of the institution, forgot to see the patient as a human being with particular needs, prohibiting her from eating foods that would give her comfort. The following words enrich this interpretation:

Taking care of someone is giving them our time, our attention, our empathy and any social help we can to make their situation bearable, and if not bearable, at least make sure it will never lead to abandonment⁽¹⁶⁾.

The search for understanding the facticity of the lives of human beings, from an existential perspective, permits health professionals to discover other therapeutic forms, of which reference is the being and their relationships with the world, valuing subjectivity and intersubjectivity, besides technical-scientific knowledge⁽¹⁷⁾.

FINAL CONSIDERATIONS

Before presenting some thoughts about the present study findings, I would like to reinforce that the theme The Being-there and the unauthentic care represents one of the three themes that emerged from the feelings experienced by the patients with a diabetic foot, extracted from my Master's dissertation. I considered important to develop this theme first, which is an invitation to all of those involving in the care to this specific population to reflect on the paradigm of health care, as it evinced characteristics that originate in the biological health-disease model. Hence, I sought to find, in philosophy and my professional experience, considerations to recover holistic care in nursing for these beings.

Through this study I understood that patients seek care not only with their disease, but also with their physical body; they expect to see solicitude that contemplates their being-in-the-world with a diabetic foot; however, according to the respondents' conceptions, that care should not be provided as isolated techniques, rather, is should be engaged in a relationship of being-with-the-other in an authentic form, considering the uniqueness of each patient.

During their stay at the hospital, some respondents reported having experienced an unauthentic being with the team, i.e., a relationship modeled by the deficient ways of society that permeate the institutional norms. In their reports, they express their suffering because of the lack of care and attention from the health team in providing them with clear instructions about the procedures that would be performed. I also highlight that through their relationship with others around them, they seek to understand their own situation. I learned that the hospitalization period should not represent, for the Being, a moment of complete rupture with their everyday familiarity. In this respect, their ways of caring for themselves at home should be respected, and, thus, incorporated to this world that is presented to them so abruptly.

Through their statements, patients express an apparently isolated life while in hospital, i.e., in an existential-ontological sense. That is observed in the study when the interviewees refer feeling close and distant, at the same time, from the health team. Form the respondents' perspective, those professionals hide from themselves, escaping from their responsibilities of establishing an affective relationship with them.

Health professionals often report that the lack of time accounts for their not sharing the experiences of beings with diabetes mellitus. Sorbs I think about time, which is often the health professionals' excuse to hide from their own power-of-being, i.e., a Being of and for care. Health professionals report not having the time to talk to the diabetic beings, to touch them, and especially, listen to their everyday talk about their facticities. They forget that the same time that the patient, sometimes, needs, is the time that the professional has to justify their suffering in view of the domination of a system fills nurses with bureaucratic demands - such as reports- thus moving them away from care. That time could be extremely important for the Being bearing a diabetic foot if the health professional shows attitudes of care and knows how to administrate; if he can dedicate at least 15 minutes of exclusive attention to that patient, showing that attitude not only physically, but with the presence of their soul. This is the time to be-with-the-other, working with what you have in mind and, especially, with what is in your heart.

Finally, new possibilities of care emerged with the completion of this study. I am not hesitative in recommending: when working on the dressing, do it with love; when instructing patients, do so with joy, patience and concern; when entering the ward room, wear a smile on your face and remember that that room (the bed, the nightstand, the steps to the bed, the shoes on the bedside, and everything else) is an extension of their own body; and, most of all, when entering their world, do so with your soul wide open to find the understanding of the Being experiencing a foot complication, shedding light on your thoughts so they guide your attitudes towards the being-with-the-other.

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Correspondência:

Catarina Aparecida Sales

Rua Bragança, 630 - Apto. 501

CEP 87020-220 - Maringá, PR, Brasil

*

Extraído da dissertação "O cuidado de enfermagem para com o ser que vivencia uma complicação podológica decorrente do Diabetes Mellitus: um enfoque fenomenológico", Programa Mestrado em Enfermagem da Universidade Estadual de Maringá, 2007.

Publication Dates

• Publication in this collection
  15 Dec 2010
• Date of issue
  Dec 2010

History

• Received
  20 Jan 2009
• Accepted
  07 Dec 2009