THE CAREGI VI NG PROCESS I N THE VULNERABI LI TY PERSPECTI VE
Ver a Regina Waldow1
Rosália Figueir ó Bor ges2
Waldow VR, Borges RF. The caregiving process in t he vulnerabilit y perspect ive. Rev Lat ino- am Enferm agem
2008 j ulho- agost o; 16( 4) : 765- 71.
This t heor et ical ar t icle deals w it h t he pr ocess of car egiv ing in t he v ulner abilit y per spect iv e, w hose condit ion
leads t o t he need for care. The t ext analyzes t his process, which is charact erized by t he encount er bet ween t he
car eg iv er an d t h e car e r eceiv er . Th e h osp it alized p at ien t is an ex t r em ely v u ln er ab le b ein g , ex p er ien cin g
som et hing unique. The caregiver plays a very im port ant role in reducing t his sit uat ion and preserving his or her
aut onom y and dignit y .
DESCRI PTORS: v u ln er abilit y ; pr ofession al au t on om y
EL PROCESSO DE CUI DAR SEGÚN LA PERSPECTI VA DE LA VULNERABI LI DAD
El present e art ículo de nat uraleza t eórica, aborda el proceso del cuidar baj o la perspect iva de la vulnerabilidad,
cuya condición lleva a la necesidad de cuidado. El t ext o analiza est e pr oceso, que t iene com o car act er íst ica la
conj unción ent re el ser que cuida y el ser cuidado. El pacient e hospit alizado es un ser bast ant e vulnerable que
pasa por u n a ex per ien cia sin gu lar . Por ot r o lado, la cu idador a t ien e u n r ol f u n dam en t al par a r edu cir est a
sit uación y m ant ener su aut onom ía y dignidad.
DESCRI PTORES: v u ln er abilidad; au t on om ía pr ofesion al
O PROCESSO DE CUI DAR SOB A PERSPECTI VA DA VULNERABI LI DADE
O pr esent e ar t igo, de nat ur eza t eór ica, t r at a do pr ocesso de cuidar sob a per spect iva da vulner abilidade, cuj a
condição lev a à necessidade do cuidado. O t ex t o analisa esse pr ocesso, o qual se car act er iza pelo encont r o
en t r e o ser q u e cu id a e o ser cu id ad o. O p acien t e h osp it alizad o é u m ser ex t r em am en t e v u ln er áv el q u e
v iv en cia ex per iên cia ím par e a cu idador a ex er ce papel f u n dam en t al n o sen t ido de r edu zir essa sit u ação e
m ant er sua aut onom ia e dignidade.
DESCRI TORES: v u ln er abilidade; au t on om ia pr ofission al
1 Ph.D. in Educat ion, Ret ired Professor, School of Nursing, Rio Grande do Sul Federal Universit y, Brazil, e- m ail: waldowvr@port oweb.com .br; 2 Faculty,
UNI LASALLE de Canoas, Brazil.
I NTRODUCTI ON
C
ar egiv ing is a pr ocess under st ood as t he consideration of how caring happens, or how it should happen. This process, t o be briefly described in t his t ext , deals wit h t he encount er bet ween t he caregiver an d t h e car e r eceiv er. Tor r alba com m en t s on t h is encounter: “ The encounter of two personal universes, two free worlds, two consciences, two unique destinies in hist ory is produced by t he act ion of caring for a hum an being”( 1). The relations of care that are sharedbet ween t he prot agonist s occur during t he encount er nam ed m om ent of caring. This m om ent of caring is fully concret ized when bonds of t rust are est ablished f r om t h e car ed f or t o t h e car eg iv er, an d w h o, in pr in ciple, sh ou ld sh ow r espon sibilit y, com pet en ce, respect and sensit ivit y t o arouse t his t rust . I t is also under st ood t hat t he car ed for, in t he cont ex t of a hospit al organizat ion, is a vulnerable being.
Therefore, t his t ext aim s at analyzing, in a t h eor et ical w ay, a few im por t an t poin t s abou t t h e caring process. I n this process, the caregiver and the t h e car ed f or ar e em ph asized, sin ce bot h liv e an experience – t he m om ent of caring – charact erized as t he encount er of car e. This car e is visualized in t he vulnerabilit y perspect ive, which is represent ed in the present text by the disease and by hospitalization, i.e. t he condit ion of being ill and being hospit alized.
CARI NG: PHI LOSOPHI C I NTERPRETATI ON
Caring is a way of being Man; it has m eanings t hat com e fr om Man him self. I t includes behavior s, at t it udes, values and principles t hat are experienced daily by people in cert ain circum st ances; however, it p r i m ar i l y r eg ar d s b ei n g or, as San t i n p r ef er s, i t regards Man( 2).
The hum an being is born with the potential of caring, which m eans t hat everybody is able t o care. Evidently, this capacity will be m ore or less developed according to the circum stances it is exerted in during t he st ages of life.
The hum an being is a caring being; it is his essence. I t exists before the being itself, it is a priori,
“ it is in the frontal root of the constitution of the hum an being”( 3). I t is in car ing t hat t he
et h os needed for
hum an sociabilit y and ident ificat ion of t he essence of being is found.
I t is known t hat hum an beings need care t o dev elop; in higher degr ees in childhood and in t he lat e st ages of old age, when t hey show dependence for t he ex ecut ion of bot h t heir phy sical- social and m ent al daily act ivit ies.
Disease, disabilit y and suffering are som e of the circum stances that confer a state of vulnerability, as well as those m entioned before, from childhood to old age, and which are condit ions t hat m ake caring possible( 4).
The caregiver should be sensitive and skilled t o help and support in circum st ances of vulnerabilit y and, t herefore, caregiving has it s point of m axim um im por t ance, since t he effor t s in seeking r est or at ion go beyond t he phy sical or der, r epr esent ing suppor t and allowing the other, the cared for, to be by him self, in his own specificity, in his uniqueness. The caregiver u lt im at ely seek s t o p r eser v e t h e in t eg r it y of t h e v ulner able being, r egar dless of w hat his condit ion results in, whether it is healing or relief at a term inal st age. Help is m anifest ed in dealing w it h suffer ing, disabilit y and lim it at ions, or even in cases of support in states of fear and anxiety, am ong other conditions. The caring process com prehends, m ore t han t ech n i cal p r o ced u r es an d act i v i t i es, act i o n s an d behaviors t hat favor not only st ay ing w it h, but also
being wit h. Better yet, it is believed that procedures,
in t er v en t ion s an d t ech n iq u es p er f or m ed w it h t h e pat ient ar e only char act er ized as car e at m om ent s when caring behaviors are identified, such as: respect, considerat ion, kindness, at t ent ion, solidarit y, int erest , com passion, et c. Caring is an int eract ive process. I t only occurs in relation to the other. The way of caring does not involve a subj ect- obj ect relation, but one of subj ect- subj ect. I n the context of the caring process, this relation is characterized as a professional relation, subj ect - ot her, based on r espect and, if it falls int o obj ect ificat ion, it would be seen as a relat ion of not -caring( 5).
Today, t here is a redefinit ion of t he m eaning of caring, which com prehends, as m ent ioned before, a m uch m ore widespread and integralizing dim ension. I t includes, m ore widely, a philosophic- anthropological com plex it y.
Sev er al au t h or s p oin t t o r esp on sib ilit y in caring – responsibility and com m itm ent with the other, an d i t r ep r esen t s t h e et h i cal d i m en si o n( 1 , 4 , 6 ). I n Noddings, this dim ension is also found: The response t o t h e i m p u l se o f ca r i n g r e su l t s i n a n a ct o f com m it m ent and com poses an et hical ideal( 7).
V U LN ER A BI LI T Y I N T H E SU BJECT ’ S
PERSPECTI VE
Vulnerability is directly associated with caring, as previously m entioned in a form er item , as well as t he idea of responsibilit y. Som e of Francesc Torralba y Roselló’s ideas will be borrowed to analyze the issue of vulnerabilit y, expressed by t he following t opics.
Ever y hum an being is vulner able, in all his dim ensions, i.e. he is physically vulnerable because he is subj ect t o falling ill, suffer ing fr om pain and d isab ilit y an d , f or all t h at , h e n eed s car e; h e is psychologically vulnerable because his m ind is fragile, needing at t ent ion and care; he is socially vulnerable because, as a social agent, he is susceptible to stress an d social in j u st ice; h e is sp ir it u ally v u ln er ab le, m eaning t hat his inner self m ay be obj ect of sect ary instrum entalizations( 4). I n fact, the pluridim ensionality
of bein g, t h e r elat ion al w or ld, lif e, w or k , act ion s, t hought s, feelings, even fant asies, all are vulnerable. Therefore, it can be said that the hum an being is m ore vulnerable t han m any ot her living beings. How ever, h u m a n s h a v e a b e t t e r ca p a ci t y o f p r o t e ct i n g t h em selv es.
I n t he present t ext , t he int erest s cover t he analysis of the vulnerability experienced by the hum an being – disease – w hich is char act er ized by being one of t he m ore ext rem e t ypes, and which dem ands car e.
To r r a l b a a l so r e l a t e s p h i l o so p h y a n d v ulner abilit y in t he sense t hat , w hen ex per iencing v u l n er a b i l i t y, t h e b ei n g t r i g g er s a p h i l o so p h i ca l process( 4). I n other words, when suffering from som e
illness, the hum an being philosophizes, because there is the need to find m eaning in the suffering, in falling i l l , i n d e a t h ; i t i s a w a y o f r e sp o n d i n g t o h i s vulnerabilit y. I n t his way of t hinking, philosophizing and caring are very sim ilar act ions, one working at t h e i n t e l l e ct u a l l e v e l a n d t h e o t h e r d e v e l o p i n g fundam ent ally at t he level of pr ax is.
Ph en o m en o l o g i ca l l y, o n t o l o g i ca l , et h i ca l , social, n at u r al an d cu lt u r al v u ln er ab ilit ies can b e
dist inguished. The ont ological t ype present s dist inct levels; t he first , regarding t he being, it s ont ological const it ut ion: a vulnerable being is not an absolut e, self- sufficient being. The hum an being is a dependent being, lim it ed and r adically det er m ined by his ow n finit ude.
Et hical vulnerabilit y m ay present it self in t he m eaning of em ot ional inst abilit y, which is t he being’s capacit y of succum bing, failing, since he is a finit e structure. On the other hand, there is the capacity of acting in the m oral sense, protecting the weaker and needy being, and this is related with the other, who in turn is also related with care, as in putting oneself in the place of the other, supporting him . I t is an ethical im perative, i.e. a kind of m oral duty towards the next-of- k in.
Natural vulnerability m eans the surroundings, t h e en v ir on m en t of t h e h u m an b ein g , su b j ect t o ch a n g es a n d t r a n sf o r m a t i o n s. Na t u r e i s f r a g i l e, esp ecially con sid er in g t h e t ech n ical act ion of t h e hum an being. The int ervent ion in t he environm ent is directly reflected in the being and the outcom e of his freedom . That is why nature should be well- cared for; det er ior at ion of t he nat ur al r ealit y ser iously affect s the personal structure of being, as well as his way of living, working and loving.
Social vulnerability is about the hum an being’s sociabilit y – he is inevit ably a relat ional being. The in t er per son al r elat ion m ay dev elop at t h e lev el of fr iendship, lov e, r espect and cont em plat ion; it can a l so d e v e l o p a t t h e l e v e l o f v i o l e n ce a n d inst rum ent alit y. Social vulnerabilit y, t herefore, is t he possibility that the being has of being obj ect of violence at t he heart of society, of losing his social safety.
I nform ation should be related to the patient’s concept ions of healt h and disease and, t herefore, it i s sa i d t h a t t h e p r o f essi o n a l i s a l so v u l n er a b l e, b e ca u se h e sh o u l d o v e r co m e h i s o w n cu l t u r a l vulnerabilit y t hrough an individualized knowledge of t he pat ient , which will allow t reat m ent t o go on wit h dignit y.
When the being falls ill, when he is not capable of developing his usual pace of day- t o- day act ivit ies, b e ca u se o f so m a t i c, so ci a l o r p sy ch o l o g i ca l p a t h o l o g i e s, h e e m p a t h i ca l l y p e r ce i v e s t h e v u ln er ab ilit y of h is ow n b ein g . Per h ap s, in t h ese circum stances, the being has the m axim um perception of his own vulnerability. When becom ing aware of his sit uat ion, t he being accept s it m uch bet t er. On t he ot her hand, t he caregiver needs t o be aware of t he vulnerability of the other, i.e. its extension and nature, and t hen m ake effort s t o help and care. I n order t o m ake effort s t o prom ot e care, t he caregiver should becom e involved in the working process of healthcare organizat ions, so t hat she can seek and perform not on ly w h at is h er r esp on sib ilit y, b u t also w h at is idealized in nursing. Care is insert ed in t he everyday w or k ing act iv it ies of nur sing, because it r epr esent s t he cor e of t he t r ansfor m at ion pr ocesses of hum an beings’ healt h- disease sit uat ions, i.e. it is t he final product( 8).
CH ARACTERI ZATI ON OF TH E CARI N G
PROCESS
Th e ca r i n g p r o ce ss o ccu r s w i t h i n t h e or ganizat ional cult ur e of a hospit al, w hich pr esent s variable com ponent s t hat can be visualized according t o w h at is descr ibed an d gr aph ically pr esen t ed in Waldow( 9). Am ong t he com ponent s, t he environm ent
is highlight ed, w hich in t ur n includes t he phy sical, adm inist rat ive, social and t echnological environm ent . These com ponent s will not be analyzed in t his t ext , since it favors t he encount er bet ween t he caregiver and t he cared for, alt hough it should be m ent ioned t hat t hey play a fundam ent al r ole in a sat isfact or y car in g pr ocess. Th e af or em en t ion ed en v ir on m en t s m ak e up t he nur sing scene. I n her adm inist r at iv e function, she is responsible for the activities of caring, b esid es ed u cat ion al, or g an izat ion al, p lan n in g an d
ev aluat ion act ions, w hich cov er hum an int er act ions am ong different cult ures, feelings and knowledge.
I t is consider ed t hat t he m om ent of car ing has a transform ing character, in which both the cared for and caregiver grow, in t he sense t hat t he form er present s a m ore posit ive and serene at t it ude in t he face of his experience wit h t he illness, disabilit y and even death, the result of a calm and friendly relation of t rust wit h his caregivers.
When the patient is considered and respected as a unique person, it is im port ant t hat all quest ions about his situation can be clarified. I t is also im portant for him to increase his knowledge of him self, his illness, his exist ent ial condit ion of t he m om ent , so t hat he can ser en ely u se st r at egies t o f ace t h e obst acles present ed and engender plans for t he fut ure.
Th e k n o w l e d g e a b o u t h i m se l f, h i s cir cum st ances, lim it at ions and pot ent ialit ies w ill aid h im in h is self - est eem an d t r u st in h is sit u at ion , preserving his identity and courage. On the other hand, at t h e p h y sical an d em ot ion al lev els, p ain r elief, com fort, tranquility, relaxation and well- being, am ong o t h e r s, ca n b e m e n t i o n e d . Fe e l i n g w e l co m e d , protected and well- cared for will considerably influence t he pat ient ’s experience so t hat it becom es as m ild as possible.
Regarding t he caregiver, growt h is t ranslat ed i n t o sa t i sf a ct i o n , se n se o f a cco m p l i sh m e n t , ach iev em en t , im p r ov em en t of self - est eem , m or e safety and trust, besides pleasure and well- being. The experience acquired with each new situation and each new encount er adds know ledge t o t he professional. Ev er y n ew life h ist or y an d t h e ex per ien ces of t h e pat ient help t o k now people bet t er, as w ell as t he caregiver herself; her ways of caring becom e richer with her experiences with the patients, allowing them t o ev olv e personally and professionally.
THE EXPERI ENCE OF THE CARED FOR
The patient, when receiving care, experiences som et hing unique, regarding bot h his illness and his h osp it alizat ion * . Feelin g ill or b ein g ill cau ses a disruption in the relation of the hum an being with the w o r l d . He f a ces a t h r ea t ( o f d i sea se, su f f er i n g , disabilit y and deat h) , t he unknown ( his sit uat ion, his dest iny, a st range environm ent , st range people) and
with a tem porary or definitive lack of structure, called on t olog ical cr isis b y Pelleg r in o, w h ich af f ect s t h e individual as a whole in the physical and psychological, social and spirit ual sense( 10).
Al l t h e se a sp e ct s e x p o se t h e p a t i e n t ’ s vulnerability, m aking him m ore fragile. His experience of living is int errupt ed, disart iculat ed, brought out of t he regular rhyt hm . The relat ion of t he pat ient wit h t h e ot h er s is also com pr om ised; h is in t im acy, h is privacy are invaded. His social world is m odified and t h e p a t i e n t f e e l s o p p r e sse d , r e st r a i n e d i n h i s m ovem ent s and t hought s, hum iliat ed and dependent . I t i s co m m o n t o v er i f y a r ed ef i n i t i o n o f v alues; t he pat ient r ev iew s w hat and how he w as, and what and how he is now, and quest ions him self about the future, about how and what could happen. There is a reflection about the m eaning of life and the pr ior it ies.
Se v e r a l q u e st i o n s o ccu r b e ca u se o f t h e disease, during hospit alizat ion and during t he caring process, such as: what is happening to m e? What are t hey doing / will t hey do t o m e? Will it hurt ? Am I going t o die? Ar e t hese people com pet ent , do t hey know what t hey are doing? Will t hey be able t o help m e? And so on.
When he becom es aware of his situation, the pat ient m ay accept care or not . However, as a rule, he subm its to the m edical authority in relation to his diagnosis and treatm ent, and puts him self in the hands of the physician, also accepting and subm itting to the o t h e r ca r e g i v e r s a n d t h e i r ca r e . Acce p t i n g a n d collab or at in g ar e closely r elat ed t o sev er al it em s descr ibed by Pellegr in o an d an aly zed by Fr an cesc Torralba, regarding the principle of autonom y that will be present ed next .
To accep t an d collab or at e w it h car e, it is i n d i sp e n sa b l e t o t r u st t h e ca r e g i v e r s a n d t h e knowledge, i.e. how im port ant t he pat ient is, aware of what is happening with him . He will respond to the t r eat m ent and car e as t he afor em ent ioned t r ust is pr eser v ed, and t his cor r esponds t o being aw ar e of the com petence, responsibility and attention given by t he caregiver. An at t ent ive, int erest ed and respect ive a p p r o a ch i s t h e k ey f o r t h e p a t i en t t o r esp o n d posit ively, and t his includes t ranquilit y and securit y.
Th e se a n sw e r s ca n b e v e r i f i e d t h r o u g h several signs, either by expressing doubts, com plaints, even silence. Obj ective answers can be detected, such as: r elax at ion, r educt ion of pain, fev er, st able v it al
signs, added t o dat a per ceived by t he car egiver as ot h er s m en t ion ed b ef or e, su ch as at t it u d e, f acial ex pr essions, am ong ot her s.
THE AUTONOMY I SSUE
Caring for som eone m eans watching over his autonom y, developing his capacities and not opposing or g o ag ain st h is f r ee an d r esp on sib le d ecision s. However, t here are circum st ances like t hose relat ed t o t he need for care, because t he aut onom y of t he b e i n g i s a l so f o u n d t o b e v u l n e r a b l e . Th e se cir cu m st an ces r eq u ir e an an aly sis of t h e r elat ion between the act of caring and the lim its of the person’s autonom y, because this autonom y is not unlim ited, it p r e se n t s d i st i n ct d e g r e e s a n d d e v e l o p m e n t a l regist ries. I t is, t herefore, dynam ic and concret e( 1).
Still using Torralba’s ideas, in a bioethical and p h i l o so p h i ca l p e r sp e ct i v e , t h e r e a r e w a y s t o u n d e r st a n d a u t o n o m y, a n d , a cco r d i n g t o h i m , “Autonom y is said of a reality that is ruled by certain law s, dist inct fr om ot her law s, but not necessar ily incom pat ible wit h t hem ”( 1).
Au t on om y h as n o dir ect ion , differ in g fr om freedom , which is fundam entally oriented towards the good. I t also differ s fr om fr ee w ill, because t his is r elat ed t o t he hum an capacit y of choosing am ong several opt ions. This capacit y, however, m ay not be autonom ous, m ay be totally determ ined or conditioned b y e x o g e n o u s e l e m e n t s o f su b j e ct i v i t y i t se l f . Autonom y occurs in the absence of coercion and ability to clarify the presented alternatives. From autonom y’s internal point of view, it refers to a deep desire that is ex p r essed t h r ou g h on e’s d ecision s, m ed iat ed b y crit ical reflect ion.
The autonom y of the being who receives care presents lim its. These lim its m ay be m edical, because of uncertainty about his pathological condition; it m ay be r elat ed t o t h e sit u at ion of u r gen cy ; it m ay be lim ited in function of fam ily power; and also because of econom ic factors, besides the lim its im posed by law. Anot her aspect about t his t opic t hat should be rem inded is that the principle of autonom y should not be understood in an isolated way, separately from the principles of dignity, integrity and vulnerability. I t should also be visualized in close connection with the principle of responsibility. I n this sense, it is said that it is a t y pe of aut onom y w it hout r esponsibilit y or, better yet, a decision without responsibility that is not able to assum e and prevent the consequences of such a decision cannot be considered as aut onom y, in it s m or al sense.
The t hem e aut onom y does not only refer t o t h e sco p e o f t h e ca r ed f o r, b u t a l so t o w h a t i s considered as being part of the responsibilities of the caregiving professionals. I n t he field of healt h, it is r elat ed t o t he issue of com pet ences, being a w ide and com plex subj ect that will not be addressed here.
THE CAREGI VER
I t is im portant for the caregiver to be aware of what is happening, or what m ay happen wit h t he p at i en t s ( b ei n g s ex p er i en ci n g a ci r cu m st an ce o f v ulner abilit y ) and, t her efor e, not only pr ofessional co m p e t e n ce i s r e q u i r e d , b u t a l so se n si t i v i t y, discernm ent and int uit ion.
Kn o w i n g t h e p a t i e n t , h i s h i st o r y, h i s biography, his for m er ex per iences, his m ot iv at ion, expectation, rituals of care and degree of vulnerability will be of great help in t he caring process. Knowing t he pat ient allows for t he prom pt er ident ificat ion and com prehension of his react ions. Being available not only for the patient, but for his fam ily is also a valuable f a ct o r. Th e i n f o r m e d f a m i l y, w e l l ca r e d f o r a n d support ed, can great ly collaborat e in t he care.
A study reveals that, in the view of the nurse responsible for the coordination and planning of care, t he concept of caring was perceived as t he essence and integrality in the relation with the being, and this especially involves support ing t he fam ily( 8).
The caregiver should be receptive and aware of what it m eans to be a patient, to be cared for, to be
sick, t o be hospit alized, as well as being sensit ive t o fears, anxieties and insecurities he and his fam ily m ay present . She should be prepared t o help t he pat ient t o deal wit h his new sit uat ion, t hat of being sick, of b ein g h osp it alized an d n eed in g h elp ; sh e sh ou ld ult im at ely at t em pt t o keep his ident it y and preserve his int egrit y.
During the caring process, the caregiver m ust br in g t o pr act ice h er abilit y t o t h in k cr it ically. All t h r o u g h t h i s p r o ce ss, r e f l e ct i o n s a b o u t w h a t i s happening, what is being done and how she should act always need to be present. At each new encounter, she should ev aluat e t he pat ient and his sit uat ion, seei n g h i m as a w h ol e. Sev er al h y p ot h eses an d quest ions will be concoct ed, such as: What sit uat ion is t his? Who is t his pat ient ? How v ulner able is he? How can I help him ? What do I need t o know about h im ? Wh at do I n eed t o k n ow abou t h im an d h is sit uat ion? Am ong m any ot hers.
When identifying what is happening and what the patient needs, the caregiver verifies the available m eans, so t hat care can be perform ed as prom pt ly and adequately as possible. The actions should always b e f ollow ed b y in t er act ion , i. e. t alk in g , list en in g , t o u ch i n g , e x p r e ssi n g i n t e r e st , a v a i l a b i l i t y a n d accep t an ce. At t it u d e, f acial an d b od y ex p r ession , t ou ch in g an d look s ar e in d icat or s of su ch it em s. Therefore, the patient m ay, in turn, detect when these b eh a v i o r s a r e g en u i n e a n d l o se a l l t r u st i n t h e car egiv er an d h er car e w h en t h ese ar e absen t or m ism at ched. St aying wit h and being wit h t he ot her, t he genuine presence, is fundam ent al* .
During and aft er t he act ions or procedures, t he behaviors of caring should becom e explicit . The actions at all m om ents suffer a process of evaluation, su ch a s h o w t h e a ct i o n w a s p e r f o r m e d , w h o perform ed it, whether there is the need to reform ulate or provide som ething else for the next tim e, whether t h e m at er i al an d en v i r o n m en t al co n d i t i o n s w er e adequate, and so forth. On the other hand, reflection about her feelings and values is suggest ed, as well as about the m eaning of the experience in relation to t he experienced sit uat ion, as well as reflect ion about how she perceived t he response of t he pat ient and his fam ily during the encounter. This reflection aids in the caregiver’s learning, so that she can always refine her care, providing t he pat ient wit h well- being.
The evaluat ion, t herefore, is bot h subj ect ive and obj ective. The caregiver will m onitor the patient’s
physical- chem ical responses and, vital signs. She can also verify t he pat ient ’s react ions, his behavior, if he is m ore or less relaxed, apprehensive, t ense, am ong ot h er it em s. Am on g t h e car egiv er ’s v ar iables, h er m ot iv at ion, ex per ience, k now ledge, t echnical sk ills, capacity of learning and critical thinking are noteworthy. Therefore, t he caregiver, when caring in it s t ruest sense, int eract s wit h t he pat ient , put t ing her knowledge, t echnical skills and sensit ivit y in pract ice, helping him grow. The patient, in turn, in his genuine experience, shares his own being, experience, rit uals of care, charact erist ics t hat will cont ribut e posit ively to the caring process. I t is good to highlight that both, car eg iv er an d car ed f or, sh ou ld b en ef it f r om t h e m om ent of caring.
FI NAL CONSI DERATI ONS
According to the above, it is verified that care, although necessary in all the stages of life and for all types of life on the planet, is fundam ental when there is vulnerabilit y. The com pulsion t o care is highlight ed every t im e t he ot her being present s it self in a st at e of vulnerabilit y. The pat ient , due t o his illness, is a vulnerable being; hospit alizat ion, in t urn, aggravat es this state of vulnerability, which, as m entioned before,
m akes caring possible. During the caring process, the encounter between the caregiver and those cared for is of m axim um relevance because, depending on how t he relat ion is init iat ed, t he experience m ay becom e less t raum at ic.
I t is also prim ordial, during t he m om ent of caring, for truth to be established between the cared for with the nurses and all other caregivers; the form er will feel safer and calm er, extracting com fort and well-being, and t he lat t er will feel accom plished, grat eful and will ext ract m ore knowledge, because each new en co u n t er en r i ch es b o t h b ei n g s i n v o l v ed i n t h i s relation. The role of caregiver is fundam ental to reduce t h e v u l n e r a b i l i t y a n d t o p r e se r v e t h e p a t i e n t ’ s au t on om y an d dign it y. I n t h is sen se, t h e n u r sin g professional, in part icular, is responsible for obtaining an environm ent of care, and this involves actions that m obilize bot h hum an r esour ces, in t heir m ax im um possibilit y of r elat ing, and m at er ial r esour ces. The hum an dim ension favored by t he act of caring has a charact er of t ransform at ion, of int egrat ing t he world, t he environm ent and t he people.
I t is thought that the review proposed in this t ext can cont ribut e t o som e reflect ions, focusing on t he im por t ance of t he ex per iences of t he car egiv er and t he car ed for dur ing t he car ing pr ocess in t he v u ln er ab ilit y p er sp ect iv e – a con d it ion t h at calls f or car in g.
REFERENCES
1 . Tor r alba FR Ét ica del cu idar : fu n dam en t os, con t ex t os y p r ob lem as. Mad r id : I n st it u t Bor j a d e Bioét ica/ Fu n d acion Mapfr e Medicina; 2002.
2. Sant in S. Cuidado e/ ou confor t o: um par adigm a par a a enferm agem . Text o Cont ext o Enferm 1998 m arço; 7( 2) : 111-3 2 .
3. Boff L. Ét ica e eco- espirit ualidade. Cam pinas( SP) : Verus; 2 0 0 3 .
4. Torralba FR. Ant ropologia del cuidar. Madrid: I nst it ut Borj a de Bioét ica/ Fundación Mapfr e Medicina; 1998.
5. Waldow VR. O cuidado na saúde: as relações ent re o eu, o out ro e o cosm o. Pet rópolis ( RJ) : Vozes; 2004.
6. Lévinas E. Tot alidade e infinit o. Lisboa ( PT) : Edições 70; 2 0 0 0 .
7. Noddings N. O cuidado: um a abordagem fem inina à ét ica e à educação m oral. São Leopoldo ( RS) : Unisinos; 2003. 8. Borges RF. Hum anização da rede pública de Port o Alegre: b a se s e e st r a t é g i a s d a s g e r ê n ci a s d e e n f e r m a g e m n o d e se n v o l v i m e n t o d o cu i d a d o h u m a n o . [ D i sse r t a çã o d e Mest r ad o] . Can oas ( RS) : Pr og r am a d e Pós Gr ad u ação em Saú de Colet iv a/ ULBRA; 2 0 0 6 .
9 . W a l d o w VR. Cu i d a r : e x p r e ssã o h u m a n i za d o r a d a enfer m agem . Pet r ópolis( RJ) : Vozes; 2006.
10.Torralba FR. Filosofia de la Medicina; em torno de la obra d e E. D. Pelleg r in o. Mad r id : I n st it u t Bor j a d e Bioét ica/ Fundación Mapfr e Medicina; 2001.
