The experience of a woman working in nursing suffering from De Quervain's disease

Abstracts

El presente es un estudio de caso cualitativo fenomenológico sobre la experiencia de una mujer trabajadora portadora de la Lesión De Quervain, un disturbio osteomuscular relacionado al trabajo. Siendo el objetivo comprender como es el ser una mujer trabajadora de enfermería dentro del Centro de Material y Esterilización de un hospital particular con un disturbio osteo-muscular relacionado al trabajo. Se utilizó el referencial filosófico de Martín Heidegger para el análisis comprensivo de la entrevista. El análisis mostró que el proceso fisiopatológico originó cambios en su vida, caracterizados por las manifestaciones dolorosas y especialmente por limitaciones físicas, lo que generó una multiplicidad de sentimientos. La angustia esta presente dentro del proceso de aceptación de la enfermedad, momento en el cual, la trabajadora percibe la fragilidad de su existencia y se reconoce como responsable de su cuidado, alcanzando la autenticidad y transcendiendo la enfermedad.

trastornos por traumas acumulados; salud de las mujeres; investigación cualitativa

Trata-se de um estudo de caso qualitativo de abordagem fenomenológica sobre a experiência de uma mulher trabalhadora de enfermagem portadora de Lesão De Quervain, um distúrbio osteomuscular relacionado ao trabalho. Objetivou-se compreender como é ser mulher trabalhadora de enfermagem, estando doente por um distúrbio osteomuscular relacionado ao trabalho, por meio de uma trabalhadora do Centro de Material e Esterilização de um hospital particular. Utilizou-se o referencial filosófico de Martin Heidegger para análise compreensiva do depoimento em questão. A análise revelou que o processo fisiopatológico da Lesão de De Quervain desencadeou mudanças na vida da trabalhadora, caracterizadas pelas manifestações dolorosas e especialmente pelas limitações físicas, gerando, assim, uma multiplicidade de sentimentos. A angústia se fez presente no processo de aceitação da doença, momento em que a trabalhadora percebe a fragilidade de sua existência e se reconhece como responsável pelo seu autocuidado, alcançando a autenticidade e transcendendo a doença.

transtornos traumáticos cumulativos; saúde da mulher; pesquisa cualitativa

ORIGINAL ARTICLE

The experience of a woman working in nursing suffering from De Quervain's disease

Patricia Campos Leite^I; Miriam Aparecida Barbosa Merighi^II; Arlete Silva^III

^IDoctoral student, Professor at University Center Nove de Julho, e-mail: [e-mail]

^IIFree Lecturer at University of São Paulo College of Nursing, e-mail: [e-mail]

^IIIRN, Full Professor I at University of Guarulhos, e-mail: [e-mail]

ABSTRACT

This is a case study with a phenomenological approach on the experience of a woman who works in nursing and suffers from the de Quervain's disease, an osteo-muscular disorder related to working conditions. This study aimed to understand what means to be a woman working in nursing and suffering from an osteo-muscular disorder related to working conditions through a worker of the Material and Sterilization Center of a private hospital. The philosophical referential from Martin Heidegger was used for the comprehensive analysis of the statement in question. The analysis revealed that the physiopathological process of the de Quervain's disease caused changes in the worker's life, characterized by painful manifestations and especially by physical limitations, which generate a multiplicity of feelings. Anguish is present in the process of accepting the disease, when the worker perceives the fragility of her existence and recognizes herself as the one responsible for her own care, reaching authenticity and transcending the disease.

Descriptors: cumulative trauma disorders; women's health; qualitative research

INTRODUCTION

In our professional experience, we have perceived that the reality of nursing workers has been marked by daily activities loaded with bad work conditions, caused not only by a lack of human and material resources, but also by the stress inherent in hospital activity.

Most hospital institutions have a highly complex and diverse service structure. However, this does not reduce the workers' exposure to countless problems⁽¹⁾.

The work conditions offered by hospitals and the peculiarities of nursing work, associated with the difficulties in the health sector, contextualize nursing professionals' work situation in different countries⁽²⁾.

Despite the whole beneficial dimension attributed to work, it is known that, in nursing, various experts have looked at the exhaustion, discouragement, frustration and desire to give up the profession^(3-5).

As nursing professionals are predominantly women, a differentiated look on these workers is needed, who mostly work a double or triple journey and is responsible not only for housework, but also for professional activities.

This fact causes countless health problems, when even affect official mortality and morbidity statistics between the two genders, with higher morbidity rates among women and higher mortality rates among men⁽⁶⁾.

In the context of female nursing workers' illnesses, Work Related Musculoskeletal Disorders (WMSD) stand out. This name includes a group of illnesses, such as tenosynovites, tendinites, De Quervain's disease, synovites, and peripheral nerve compression syndromes, besides more disseminated symptoms, such as myofascial syndrome, fibromyalgia and reflex sympathetic dystrophy⁽⁷⁾.

De Quervain injury is also known as tenosynovitis of the radial styloid, resulting from the constriction of the common sheath of the long abductor and short extensor tendons of the thumb. It mainly affects women over 40, and is associated with occupational exposures that require repetitive thumb movements, pinching of the thumb with flexion, extension, rotation or repeated ulnar deviation of the carpus and use of scissors for long periods. The clinical picture is characterized by projected pain in the styloid process of the radial nerve with or without irradiation in radial projection until the shoulder and which increases through active radial abduction of the thumb. Tumors may appear in the painful regions⁽⁸⁾.

In most cases, the symptoms initially appear insidiously and are more predominant towards the end or produce peaks, with rest giving some relief. However, over time, the symptoms can become frequent during work and even affect the worker's extra-occupational activities⁽⁹⁾.

Due to the countless symptoms included in WMSD, some diffuse and others well delimited in anatomical and/or physiological terms, diagnosing and proving the disease is not always easy, which turns the process of looking for adequate treatment even slower⁽¹⁰⁾.

Thus, our concerns with the increased incidence of musculoskeletal problems in nursing workers, associated with the lack of studies about WMSD specifically in this professional group, lead us to the theme of this study, which attempted to understand what it is like to be a woman who suffers from a work-related musculoskeletal disorder De Quervain injury, through the experience of a nursing worker.

METHODOLOGICAL TRAJECTORY

We carried out a case study from an existential phenomenology approach, about the experience of a 40-year-old nursing worker, who is married and mother of two children, has been professionally active at a Material and Sterilization Center for 12 years and suffers from De Quervain disease, a WMSD.

In order to understand what it is like to be a woman who suffers from a work-related musculoskeletal disorder De Quervain injury, through the experience of a nursing worker, we considered the qualitative methodology as more coherent with our goals. Thus, we used the comprehensive approach of Martin Heidegger's existential phenomenology to analyze the nursing worker's discourse, presented here as a case study, which constituted the guideline to analyze the testimony under study.

As a study method, phenomenological research allows the researcher to access the human conscience and go back to things themselves, to the essentials. It is a method to approach the phenomenon, considered as anything that shows itself, manifests itself, appears to a conscience that questions it, giving up prejudices and premises⁽¹¹⁾.

Heidegger's thinking is about an awakening based on the question of the meaning of being, seeking to unveil its comprehension, considering phenomenology as a way to access the understanding of human existence^{(12- 13)}.

The human being's basic way of existence is "being-in-the-world", in which man is understood based on the world he is in and how he relates to it, to objects and people, opening up to himself and the world⁽¹⁴⁾.

In this context, the nursing worker who experiences the disease process can, to the extent that she opens up to herself and the world, question herself about her own existence in the world, perceiving the fragility of her existence brought about by the WMSD symptoms. Thus, another ontological characteristic defined by Heidegger is the anguish that emerges when the human being becomes aware of his existential instability. Moreover, according to this philosopher, it is also when acknowledging herself as a being-for-death that this being can find her authenticity, a moment when this woman can transcend the disease^(15).

As described above, we used Heidegger's existentialist reference framework, in the belief that the structures the author proposed could serve as a mark in the comprehensive analysis of this nursing worker's testimony, who is experiencing a work related musculoskeletal disorder (WMSD).

The interview was held in July 2004 at the worker's home, in São Paulo City and took 42 minutes. It was tape-recorded with the woman's authorization, through the Free and Informed Consent Term. To conduct the interview, we used the following guiding question: What is it like for you to be a female nursing worker and live with a WMSD? The aim of this question was to guide us to this woman's world-life, based on her own experiences, considering that the phenomenon of being-a-female-nursing-worker living with a WMSD can only be unveiled when starting from the subject who experiences the disease, the pain and the suffering caused by the WMSD.

It should be emphasized that, before holding the interview, this study was assessed and approved by the Research Ethics Committee at the University of São Paulo College of Nursing (EEUSP).

CONSTRUCTING THE RESULTS

After the interview, we transcribed the collected discourse in full. Next, we read and reread the transcriptions to find units of meaning, that is, significant extracts of discourse, in view of Martin Heidegger's propositions. The following step was to group the units of meaning according to similarities, which gave rise to themes that constituted the Ontological Unifications⁽¹⁶⁾.

We present the ONTOLOGICAL UNIFICATIONS identified in the discourse of the female nursing workers who suffers from De Quervain's disease, which revealed the being a female nursing worker living with the WMSD:

Being-in-the-world living with the WMSD

Considering that man is understood based on the world he lives in and how he relates to this world, being a woman in the world, working in the nursing team, living with a WMSD is much more that experiencing pain and professional difficulties. It also includes living a daily reality of impossibilities to perform even simple daily tasks, as presented in the discourse extract below:

...and at my house too I couldn't do anything anymore, I couldn't even manage to pull up the blanket to cover me... (Marília)

In daily life, the meaning of many things only appears to the human being when something is missing, that is, the experience of a loss or limitation evidences the meanings that had been hidden or ignored until then⁽¹⁴⁾.

The female nursing worker starts a process of perceiving herself in the world as she is, living with her different impossibilities, considering the many modifications in her physical abilities that disable her not only for work, but also to perform simpler activities related to her own self-care.

The nursing worker's testimony reveals that, despite the pain, the limitation, she continues working and insisting, resisting her intense pain and making efforts not to take leave from her professional activities:

...and after the injury established here, you know, I couldn't do hardly anything anymore, I couldn't take a box, take down boxes from the shelf...I couldn't do almost anything at the Material Central...So I arrived, I choose the shift that was possible for that day, but sometimes I couldn't work until the end of the shift...(Marília)

We can perceive that the worsening of the disease tends to cause a series of physical and mental alterations and that the worker is aware of her limitations for work. However, for her, taking leave from work means much more than acknowledging her disease, it means accepting and turning her disability public, as evidenced by the following discourse:

...I'm not going back home, I want to see until what point I manage to work, you know.... (Marília)

The nursing worker still performs her professional activities, attempting to prove to herself that she is still able, although this often represents the most relevant factor for the worsening of her injury. Her being-in-the-world is intensely modified through the alterations resulting from the WMSD, as these manifestations unavoidably occur and this woman finds herself obliged to live with the changes because, although she is ill, she still lives with herself and the world, establishing simple relations of existing in the world, suffering from the pain and her limitations.

The nursing worker living the ambiguity of solicitude

The nursing worker living with the WMSD can experience other people's concern about her and her health condition. This concern is based on the ontological constitution of the pre-sence as being-with, guided by consideration and tolerance or patience towards the other, the so-called solicitude⁽¹⁴⁾.

...in this interval, I found a doctor who took care of me and said you have to take leave, you know, this arm has to rest... (Marília)

When reporting on this professional's solicitude, she reveals her gratitude for the fact that he warned her about her actual situation and the need to grant importance to her own illness, which allowed her to open up to being-able-to-be herself, living with the truth.

Unfortunately, the worker reports that it was difficult for professionals to give this support, neither professionals involved in occupational health care nor her nursing team colleagues. The feeling of disdain or lack of care, greatly present in the work environment, configured the distancing from the being-with as, according to Heidegger, we are essentially relation and, in this relation, concern about the other, that is, "solicitude" becomes the essence of our existence⁽¹⁴⁾.

...in fact, I didn't feel that they were taking me seriously... I felt that he didn't believe in my pain, you know, that it was that intense...a kind of disdain... (Marília)

Marília's statement demonstrates that she felt that the occupational health care professionals did not accord due importance to her complaints. This impersonality in the context of the doctor-patient relation accuses this woman's need for solicitude since, at that moment, what she most needed was to feel heard about her pain, about her suffering.

The impersonal is present all over, in which the whole world is the other and nobody is himself and this experience totally dissolves the person's own pre-sence in the way of being-with the others, in a way that the others disappear even more in their possibility⁽¹⁴⁾.

Besides this difficult observation, there is the nursing workers' hidden prejudice:

I ended up being negatively considered, you know, by my colleagues, I ended up with a bad image in the sector, today, I say to my psychotherapist like this, I… I feel what black people feel (crying)... (Marília)

The prejudice and discrimination also extend to her nursing team colleagues, evidencing neglect in daily relations. This situation tends to generate even more suffering in the worker as, although the world is shared, the experience of being a WMSD patient is individual.

The anguish of living with a WMSD

In the context of acquiring a WMSD, it should be emphasized that many modifications result from the physiopathological process. Considering that, in most cases, women are responsible for home and professional activities, the new situation, marked by painful manifestations, decreased muscle strength and restrictions to perform many activities, this obliged the nursing worker to become aware of the fact that her life changed, that the transformations caused by the disease already established themselves and that her future is uncertain.

We observe that uncertainties about her physical abilities, commitments and response to treatments made her experience anguish:

...you start like that, when you have this kind of injury, in your hand, right hand, when my hand was immobilized I couldn't do anything with my left hand, I wanted to die...(Marília)

Marília's statement reveals that her world-life was intensely modified because of the disease. When she talks about "right hand", it is evidenced that, in her relation with the world and its things, she perceives her disability and starts to question her existence, in which "wanting to die" seems to be the end of everything, the end of getting confronted with such an and personal fragility. This exposes the worker's anguish, who perceives herself as a being-for-death.

Death is the most personal, most singular of the possibilities of being-there, and that is exactly the source of anguish. In this aspect, when thinking about her limitations, the female nursing worker who lives with the WMSD approaches her finiteness, where she'll be able to live either authentically, opening up to herself, or inauthentically, in function of the fear of getting confronted with herself and with her being-towards-the-end⁽¹⁴⁾.

Moreover, the worsening of the disease gives rise to the feeling that she could never practice her profession again, which created an enormous feeling of incapacity. In this phase of the disease, the anguish this worker experienced was so intense that it exerted a decisive influence on her treatment, in which she acknowledged the need to invest in psychotherapy, as revealed by the following statement:

...at some moments, I thought I could not even work any longer, and then I started an intense psychotherapy treatment... I really needed that (crying, silence) (Marília).

It is when acknowledging the possibility of death that the human being finds his authenticity, as death is an unconditional and insurmountable possibility. Therefore, for the author, anguish is a kind of ontological nausea that invades the human being when he is close to understanding the uncertainty of his existence⁽¹⁴⁾.

In this aspect, when confronted with her reality in view of her finiteness, the woman decides to face her new life situation. At this moment, she starts to live in her authenticity.

The transcendence of the nursing worker living with the WMSD

In experiencing the difficulties inherent in the process of catching the WMSD, the woman lived feelings of loss, revolt, sadness. However, when she acknowledged her disease and her new conditions, she embraced new objectives, granting a new meaning to her existence.

...then I went back there and I did well, like, I really managed to do very well...like, today I manage, not for them, for myself I managed to achieve, arrive where I wanted...in this one year she saw my work, you know, she has complimented me... (Marília)

Her testimony evidences that, in her new situation, she has gone back to work and believes that she has been successful, because her boss compliments her and, in fact, she established some goals for herself, which she reached, allowing her to transcend her disease and feeling accomplished.

Therefore, transcendence occurs when the worker acknowledges her actual situation, and nevertheless sets goals and finds a meaning in her existence.

In this aspect, the phenomenologist describes that it is only through the opening of the pre-sence that the most original phenomenon of truth is reached, and that the pre-sence exists in the truth⁽¹⁴⁾.

The course the nursing worker followed made her perceive her own participation in the recovery process because, while she requests support at first and shares her complaints, expecting a lot from other people, over time, she starts to act in defense of herself, investing in her treatments and self-care:

...I took time to perceive, if you're sick, you're going to handle it, you're going to apply a compress... (Marília)

Marília's discourse demonstrates that, in transcending the disease, she acknowledges the symptoms and gets to know ways to relieve her pains, allowing her to establish self-care means, instead of waiting for solutions from other people.

In creating awareness of herself, her limitations and fragility, the ontological-existential condition remains of the possibility of being free for the actually existential possibilities⁽¹⁴⁾.

Thus, her experience of living with the WMSD allowed for the possibility of being-herself, with her limitations and commitments, facing her truth and history, acknowledging her fragility as well as her possibilities in the world.

FINAL CONSIDERATIONS

In understanding the phenomenon of being-a-female-nursing worker living with De Quervain's disease, we could understand that, in getting confronted with the disease process, this woman experiences a multiplicity of feelings.

The worker revealed that living with the WMSD, or being-in-the-world living with the WMSD inserts her into a daily reality that is characterized by pain and many limitations, which causes physical and mental suffering. The fact that she is often obliged to take leave from work arouses the feeling of incapacity and unproductivity in this woman, as it is through work that she becomes a relation, exercises her knowledge and feels valued.

She has experienced the solicitude of a health professional who, as her discourse evidenced, seems to have been responsible for warning her about her real situation. However, unfortunately, the neglect stands out which she mentioned about occupational health professionals as well as her own colleagues, groups that are so close to daily life and, at a fragile moment, revealed such an impersonal attitude towards her suffering.

Anguish is part of the feelings the nursing worker in this study experienced, especially because she perceived herself in a new life context, being aware of her fragility as a being in the world. However, despite experiencing all of the difficulties deriving from the physiopathological process, it was evidenced in her discourse that this woman faced the new reality, discovered her role as a caregiver for herself, to the extent that she accepts herself with the disease, gets back to work, re-elaborating her functions, transcending the disease, finding herself in the new life context and attributing a real meaning to her existence.

Recebido em: 25.1.2006

Aprovado em: 10.11.2006

• 1. Gurgueira GP, Alexandre NM, Correa HR Filho. Prevalência de sintomas músculo-esqueléticos em trabalhadoras de enfermagem. Rev Latino-am Enfermagem 2005;11(5):608-13.
• 2. Royas ADV, Marziale MHP. A situação de trabalho do pessoal de enfermagem no contexto de um hospital argentino: um estudo sob a ótica da ergonomia. Rev Latino-am Enfermagem 2001; 9(1):102-8.
• 3. Santos SR, Rodrigues J Filho. Enfermagem: fatores de satisfação. Rev Bras Enfermagem 1995; 48(3):242-50.
• 4. Lautert L. O desgaste profissional: estudo empírico com enfermeiras que trabalham em hospitais. Rev Gaúch Enfermagem 1997; 18(2):133-44.
• 5. Beck CL, Budó MD, Gonzales RMB. A qualidade de vida na concepção de professoras de enfermagem-elementos para reflexão. Rev Esc Enfermagem USP 1999; 33:348-54.
• 6. Gomes KRO. Morbidade referida por mulheres em idade fértil, uso dos serviços e qualidade da assistência: estudo da região sul do município de São Paulo. [Tese] São Paulo: Faculdade de Saúde Publica da Universidade de São Paulo;1998.
• 7. Ministério da Saúde (BR). Secretaria de Políticas de Saúde. Departamento de Ações Programáticas e Estratégicas. Área Técnica de Saúde do Trabalhador. Lesões por Esforços Repetitivos (LER) e Distúrbios Osteomusculares Relacionados ao Trabalho (DORT). Brasília (DF): MS; 2001. (Série A. Normas e Manuais Técnicos, 103).
• 8. Ministério da saúde (BR). Doenças relacionadas ao trabalho: manual de procedimentos para os serviços de saúde Brasília (DF): MS; 2001. (Série A. Normas e Manuais Técnicos, 114).
• 9. Oliveira RMR A abordagem das lesões por esforços repetitivos/ Distúrbios osteomusculares relacionados ao trabalho - LER/DORT no centro de referência em saúde do trabalhador do Espírito Santo. [Dissertação]. Rio de Janeiro: Escola Nacional de Saúde Pública; 2001.
• 10. Santos SB, Barreto SM. Algumas considerações metodológicas sobre os estudos epidemiológicos das lesões por esforços repetitivos (LER). Cad Saúde Pública 1998; 14(3):555-63.
• 11. Merighi, MAB. Fenomenologia In: Merighi MAB, Praça NS. Abordagens teórico-metodológicas qualitativas : a vivência da mulher no período reprodutivo Rio de Janeiro (RJ): Guanabara Koogan; 2003. p.31-8.
• 12. Rée J. Heidegger. História e verdade em Ser e Tempo. São Paulo (SP):UNESP; 2000.
• 13. Silva ARB. Convivendo com o câncer ginecológico avançado: em foco a mulher e seus familiares [Doutorado]. São Paulo: Escola de Enfermagem da Universidade de São Paulo; 2002.
• 14. Heidegger M. Ser e Tempo. 13. ed. Petrópolis (RJ): Vozes; 2004.
• 15. Josgrilberg RS. O método fenomenológico e as Ciências Humanas In: Castro DSP Fenomenologia e análise do existir. São Paulo: Universidade Metodista de São Paulo; 2000. p.44-68.

Publication Dates

• Publication in this collection
  29 May 2007
• Date of issue
  Apr 2007

History

• Accepted
  10 Nov 2006
• Received
  25 Jan 2006