ENTRAR            

TEORETHICAL

The interface between phenomenology and nursing care

Genival Fernandes de Freitas,¹ Miriam Aparecida Barbosa Merighi,² Maria de Fátima Prado Fernandes^3
1Enfermeiro. Professor Doutor do Departamento de Orientação Profissional da Escola de Enfermagem da USP, São Paulo, Brasil. ²Enfermeira. Professor Livre - docente do Departamento de Materno Infantil e Psiquiátrica da Escola de Enfermagem da USP, São Paulo, Brasil. ³Enfermeira. Professor Doutor do Departamento de Orientação Profissional da Escola de Enfermagem da USP, São Paulo, Brasil

Mail delivery: Genival Fernandes de Freitas. Av. Dr. Enéas de Carvalho Aguiar, 419 - CEP 05403-000 - Cerqueira César - São Paulo - Brasil

Manuscript received by 09.05.2007
Manuscript accepted by 09.08.2007

Index de Enfermería [Index Enferm] 2007; 58: 55-58

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Abstract

This study aims to reflect on the importance of phenomenology in the nursing area, as a possibility of opening up spaces to think about care based on the existential understanding of man, contemplating the human dimension beyond the technical-scientific perspective. Thus, the authors discuss nursing's tendency, focusing on care from a phenomenological approach.
Key-words: Nursing. Phenomenology. Care. Cultura.

Introduction

    We have been nurses for more than twenty years and our education was more focused on the disease, on the pathology and, at most, on the patients, attempting to interpret them in the light of theoretical models, constructed in accordance with our world. In our Undergraduate Nursing course, we had contact with basic subjects in the biological and human areas. This knowledge is necessary to support basic education and includes the following subjects: fundamental, medical and surgical nursing, pediatrics, gynecology, obstetrics, mental health and administration applied to nursing. In view of this fragmented teaching, compartmentalized by the "division" itself of knowledge, we may say that our nursing education was guided by the positivist natural science model, focusing on the human being's biological condition and on the technical procedures for nursing practice.
    This model lasted some time in our professional life. Care was focused on as a nursing activity directed at therapeutic pathologies and nursing techniques, distancing us from the dimension of being-with-the-other and bringing us closer to "technical practice", in the acquisition of verticalized knowledge on biological sciences, covering therapeutics and surgical technologies, to the detriment of human sciences.
    During our professional experience, we have perceived that nursing also includes other perspectives. One of them is being-with-the-other, that is, understanding the person in his/her situation of being ill, in his/her human dimension. In 1987, we had the opportunity to participate in Research Methodology seminars with a phenomenological focus, looking towards a new horizon in terms of care. Since then, we have gradually acquired a new perception of the nurse's way of being.
    In the 1990's, we became affiliated with the graduate program through courses, specific readings and study groups, thus having closer contact with the theoretical and philosophical premises of phenomenology. This allowed us to elaborate our doctoral dissertation and, from this point onwards, create new research spaces within this branch. When thinking about nursing in the light of phenomenology, nurses can look at their questions, their senses, their conducts, and interpret the care world from another viewpoint, given by our own way of being and that of sick persons.

Phenomenological thinking and nursing

    In the 1970's, in Brazil, a research approach emerges whose characteristics distinguish it from studies carried out until then. This research approaches the qualitative methodology which, in its holistic, descriptive and meaning-based nature, emphasizes the importance of getting to know, understanding and interpreting the meanings and events, without taking into account the past or present time they occur in. Its practice favors a more in-depth look at the meaning of the beliefs and values people experience in their existence. Through a bibliographic study of nursing research carried out in Brazil which approached phenomenology, we found that the 1980's marked the start of nursing production on phenomenological bases. In the 1990's, the interest in the application of this methodology to nursing research increased. This applied science has attempted to understand the meaning of experiences related to the health-disease process, experienced in the different stages of the life cycle, in hospital, outpatient and community care as well as in the family context.¹
    The phenomenological movement was born in reaction to positivism, which only considered the empirically examined and measured phenomenon as valid, while phenomenology aims for direct investigation and the description of phenomena that are experienced by conscience, without theories about the causal explanation and as free as possible from prejudices.² Phenomenology refers to the endless ways of being, articulated with the existential sphere. This is not about a theory, it is an attitude, a posture, a way of understanding the world.³ The phenomenological attitude invites us to let things appear with their own characteristics, as they are, letting the essence manifest itself in the subject's awareness, so as not to transform, not to change the originality of phenomena.⁴
    The phenomenological method has increasingly conquered recognition in qualitative research, mainly in health and particularly nursing. The phenomenological reference framework looks for the meaning of experiences, contributes in the search to understand man, the subject of care and, therefore, is in line with the goals of nursing.^5,6 Existential and ontological phenomenology is a way of conscience, a way of being and looking, which assumes the commitment to reinterpret all knowledge as expressions o four experiences -the meaning of the human being.
    Essentially, thinking does not mean constructing theories, surveying scientific data and developing intervention techniques in health, but a phenomenological act. It means discovering or rediscovering the meaning existentially in what used to be given as theory, concept, quantifications, definitions, pre-established procedures, cause-and-effect relations, hypotheses, conjectures, among others. Thinking means founding what is phenomenologically manifested, looking for meaning and essence in the way they are shown.⁷
    Studies have revealed that the "way of care delivery" in nursing can appear differently in the eyes of who delivers care, i.e. the health professionals, and in the eyes of who receives care, that is, the client/patient or user. Concepts like health, disease, care, cure, treatment are part of an intelligence or a reason that proceeds abstractly in relation to the existential conditions, which can be reconsidered phenomenologically. A new meaning can be attributed to disease and care, in their various aspects, from the perspective of existential phenomenology. They can be phenomenologically understood from the viewpoint of who experiences these phenomena.
    The disease in the way people experience it presents two aspects: one formal, structural aspect, which makes it possible to understand it as it is, in itself, in any space and time; and another material or content aspect, which expresses the ill being's concrete existential situation. This existential condition appears in his/her corporeity, and also through his/her language, socioeconomic and cultural life and linked up with the historicity that is characteristic of each sick person's way of being.

Care in a phenomenological perspective

    The current and future tendency of nursing is to consider man as a whole and no longer isolatedly, in parts. Based on this premise, other care modalities emerged and brought a new understanding for nursing. Hence, it can be affirmed that it approaches, consciously or not, human sciences and the way of care guided by the phenomenological course. Thus, the health-disease phenomenon can no longer be analyzed isolatedly from the person who is living this phenomenon in practice. In care delivery, nurses need to look at the people in their existential totality, examining the disease as it is lived by the being who gets ill, contextualizing the historical, cultural and social conditions (s)he is part of.
    When interacting with ill persons, in their actions and values, nursing professionals should prioritize respect for their feelings and commit themselves to the well-being of the persons who receive care. Thus, they can establish a more authentic relation, being-with-the-other, looking for new meanings on the basis of the sick person's experience. As nursing involves "people who take care of people" and highlights the importance of intersubjectivity in human relations, it approaches existential phenomenology, represented by Martin Heidegger.
    Heidegger emphasizes care as an existential condition - a way of being in the world. Care is a source of the Being itself, and the essence of man is to take care of oneself. The meaning of care inserts the manifestation of the Being as a way of care that is characteristic of existence, as it is by leaving room for the other person to transform himself that man can manage to transform his own being, in the search for his essentialization.⁸ In taking care of a person, conditions should be offered to allow that person to manifest him-/herself as a Being. This way of being includes the caregiver's allowing that person to open up his/her presence based on the being itself.⁹ Ands his/her look to see things the way that they show themselves.
    The Being-nurse unveils him-/herself in care experiences, of which we believe that they manifest themselves in care-of and care-with. According to Heidegger,⁹ at least two ways of care can be visualized, both of which naturally vary. We understand the first way as care-of, which is frequently developed when nurses adopt the biomedical model as a reference. It means doing for the person what (s)he him-/herself is capable of doing, which may involve manipulation, even if in a subtle way. This attitude refers to a form of care-of, in the way a non-nurse being takes care of a sick person. We consider the other way as care-with, which means allowing the person to assume his/her own courses, to grow, to mature, to face oneself. Such an attitude implies being authentically as a nurse, unveiled in care with. Through these experiences, the nurse-being, together with the ill person-Being, can transcend the challenges of becoming-with-the-others-in-the-world. Thus, the nurse-being's actual existence is only expressed in being-with the ill person, in the coexistence to become-and-live-healthily-with-the-others and with-the-world.
    According to Heidegger,¹⁰ the human being is a being-in-the-world and lives inseparably from existence in everyday life, through the levels of experience that include conscience, the way of living in the world and the state itself of care for the Being. Man as a subject in the world can live existence as care, manifestation and understanding and, in this experience, can transcend the conditions of daily existence, unveiling the Being itself as opening to the possibilities of the world.
    According to the same author, man not only exists for himself (awareness of himself), but also for the others (awareness of other people's awareness). Thus, his existence is inseparable from the others' existence - both are interwoven. Man is responsible for the choices of his existence, as a being that experiences the world. All of these aspects support nursing care as a process inherent in the process of delivering care and existing.

Final Considerations

    Reflecting on care from the phenomenological perspective made us look at care in an existential condition, bringing us closer to the understanding of the phenomenological encounter between the person who receives care and the caregiver.
    Nowadays, our way of experiencing nursing is guided by the search to understand the phenomenon, which shows us the meaning of care in the world the nurses live and these professionals' need to deepen their knowledge of human sciences. In this perspective, phenomenology helped us to develop an internal attitude, based on a further understanding of human existence and of the nurse-being.
    In view of our professional trajectory, our attitude towards fragmented care has changed. We believe that nursing professionals can deliver care phenomenologically, granting meaning to themselves and the people they take care of on the basis of the experienced world. In care delivery, they can experience unique situations through intersubjectivity, thus establishing an authentic relation. This way, they open up conditions to understand man in his existential wholeness, in a given society whose history is inserted in a situated culture.
    To act in a phenomenological way, nurses should value subjectivity and intersubjectivity. This implies that the care act appears articulated with interpersonal relations, that is, adding care actions in nursing, committing oneself to the other person.¹¹
    Care is inseparable from understanding and, as understanding, it should be symmetric: listening to the other person, listening to ourselves, taking care of the other and taking care of ourselves. Nurses should develop abilities to listen and respond to the expectations of the persons they deliver care to, considering their individuality. On the other hand, it should be taken into account that the act of comforting itself is inherent in the care process, that it is valuable for caregivers and receivers and should offer both the opportunity to grow.
    All of the situations nurses experience: interest, dedication, commitment, respect for other people, as well as distancing, competition and accommodation can be analyzed from a phenomenological focus. In this sense, the application of phenomenology will depend on professionals' joint actions and interests, with a view to the team's development as a whole.
    In itself, this condition already represents a great challenge, mainly because care is inserted in the dimension of existing in a world that is at the same time complex and singular, so that "the ways of delivering care" are not exhausted.
    Nurses are not finished beings and have a lot to learn and to develop in different knowledge areas. They should practice humility, tolerance, patience, solidarity, availability, reciprocity, courage, confidence, responsibility, action-reflection-action and citizenship and, thus, transform their practice conscientiously.
    In the nursing world, all of us nursing professionals have a lot to unveil about care, and we should expand our knowledge every day, so as to increasingly approach care by delivering care to the others in all dimensions of existence.

References

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