The senses of being an enterostomal therapist nurse: complexities involved in the specialty

1.Universidade do Estado do Rio de Janeiro – Departamento de Enfermagem Médico-Cirúrgica – Rio de Janeiro (RJ), Brasil. 2.Universidade Federal do Rio de Janeiro – Instituto de Doenças do Tórax – Rio de Janeiro (RJ), Brasil. *Autora correspondente: carolcuerj@hotmail.com Recebido: Nov. 21, 2019 | Aceito: Abr. 6, 2020 ABSTRACT Objective: To describe the meanings of being an enterostomal therapist considering the complexity of the process of caring for people with wounds, stomas and incontinence. Method: A qualitative, descriptive-exploratory study, conducted through a semistructured interview, between the months of January to April 2018, with 22 graduates from a specialization course in Nursing in Enterostomal Therapy from a public university in the Southeast region, following the snowball technique. Documental research was also carried out in order to complement the data analysis. Results: The interviewed graduates reported that being an enterostomal therapist is taking care of people who have a wound, stoma and/or incontinence, which means they recognized the essence of the specialty. They emphasized that being an enterostomal therapist is to care for people who may be marginalized/stigmatized by society, to work with a focus on the patient’s rehabilitation, seeking social reintegration and independence, and to know how to be an entrepreneur. Conclusion: The meaning of being an enterostomal therapist involves being inserted in a specialty that provides flexibility in the job market and an entrepreneurial character, which gives professional recognition and even financial satisfaction. It is suggested, therefore, that further studies be carried out in this area, contributing to the fields of assistance, teaching, research and extension.


INTRODUCTION
It is important to emphasize that sense is understood as personal production, the fruit of the individual apprehension of collective meanings in daily experiences.
It is important to emphasize that sense is understood as personal production, the fruit of the individual apprehension of collective meanings in daily experiences.
The analysis of the senses produced by people should consider the relationships with collectively constructed meanings and vice versa 1 .
The introduction of new technologies in the world of health has changed its workforce in this sector, creating the need to hire more and more qualified professionals for innovations in diagnostic and therapeutic methods.
This phenomenon is expanding to the nursing field, as an increasing number of nurses have been seeking constant improvement and specialization through postgraduate courses 2 .
The moment of choosing a specialty involves many symbolisms and individual and collective meanings, which is not an easy task, as believed in common sense.
It is multidimensional, complex and multidetermined by personal, social, philosophical, political and economic factors, among others 2 .
From this perspective, a peculiar phenomenon that is characterized by the increasing demand for enterostomal therapy as a specialization of newly graduated nurses becomes evident. It is worth noting that this specialty is complex as it involves a multidisciplinary activity, the use of various technologies and the provision of care in its biopsychosocial dimension 2,3 . Therefore, it is necessary to develop unique and special skills and competences to act with safety and excellence, thus guaranteeing quality of life to the people assisted.
Enterostomal therapy is an exclusive specialty of nurses whose focus is the care of people with stomata, fistulas, tubes, drains, acute and chronic wounds, and anal and urinary incontinence. It is also intended for preventive, therapeutic and rehabilitative activities and strategies, with a view to improving the quality of life of assisted clients 2,3 .
It can be seen that this specialty is in national expansion, since it is present in several fields of nursing, overcoming the assistance activities by permeating teaching, research, administration, advisory and consulting areas. The enterostomal therapist can work in public and private services, outpatients, clinics, offices specialized pela sociedade, é trabalhar com foco na reabilitação do paciente, buscando sua reintegração social e independência e é saber ser empreendedor. Conclusão: O sentido de ser estomaterapeuta envolve inserir-se em uma especialidade que confere flexibilidade de atuação no mercado de trabalho e caráter empreendedor, o qual confere reconhecimento profissional e até satisfação financeira. Sugere-se, assim, que novos estudos sejam realizados nessa área, contribuindo para os campos da assistência, ensino, pesquisa e extensão.
in stomatherapy and home care, in addition to the possibility of carrying out his own enterprise 4 , gaining increasing prominence in the context of health work.
In order to consolidate itself in the area of enterostomal therapy and have satisfaction and effectiveness in the work process, one of the most important pillars is the exercise of autonomy, which is essential in the labor market, due to the transformations that have occurred with nursing work in the globalized world. Thus, the enterostomal therapist needs autonomy to manage creativity and resolution, which generates professional

OBJECTIVE
To describe the senses of being an enterostomal therapist considering the complexity of the process of caring for people with wounds, stomata and incontinence.

METHODS
This is a qualitative, descriptive-exploratory research.

RESULTS
The results treated a differentiated care of the enterostomal therapist from a holistic approach. In addition, another theme that emerged from the interviews was the meaning/sense of being an enterostomal therapist and his differentiated training. The participants also highlighted the rehabilitative character of the specialty and the experience with stigmatized patients, as well as the responsibility of the enterostomal therapist to deconstruct stigmas. It was also noted in the interviews the entrepreneurial nature of enterostomal therapists. The par ticipants emphasiz ed that to be an enterostomal therapist is to take care of patients who present some wound, stoma and/or incontinence, that is, they recognized the essence of the specialty: The senses of being an enterostomal therapist nurse: complexities involved in the specialty "To be an enterostomal therapist is to encompass wounds, stomata, incontinence. I consider myself an expert in this area, effective, and that I can make a difference by being so specific." (E17) "To be an enterostomal therapist nurse is to be a specialist given to the nurse who wants to deepen in the area of wounds, stomata, incontinence and the choice of specialty, denotes very different meanings for being a nurse." (E21) It is reinforced that, during the process of documental analysis of memorandum books of the aforementioned specialization course, it was identified the concern to approach the three areas of knowledge that involve enterostomal therapy in a consistent and effective way, which favors the process of training the future specialist,

DISCUSSION
The essence of the work of the nurse and nursing is care, which promotes closer contact with the client in relation to their own health needs, encompassing acts, behaviors and attitudes, which are often the result of the relationships established between the patient and the professional. In addition, it is an action that includes an attentive look, the perception of the various feelings and attitudes of attention, zeal and responsibility towards the client involved in the care process 11,12 .
From this perspective, the humanization of health care has been a subject highly valued by institutions and the academic universe, since there is a concern to offer integral care to clients, considering them in their entirety. Care takes on a broader dimension, emphasizing emotional, psychological, social and spiritual biological needs, which favors the holistic care landscape 13 .
The process of caring meets the commitment to maintain the uniqueness of being cared for, since it is a moment of concern, sensitivity and interest, where respect and ethics become differentials. Awareness of care must encompass decision-making ability and critical-reflexive thinking, to differentiate care from simply performing technical procedures 14 .
The holistic look at the care process was highlighted in the statements of the interviewees, when the sense of being an enterostomal therapist was questioned. This is because it is known that the enterostomal therapist nurse must lead holistic and interdisciplinary care, prioritizing differentiated quality care that brings together knowledge constantly updated and based on scientific evidence, focused on the client's needs 15 .
As the enterostomal therapist cares for clients who experience innumerable doubts, insecurities and fears in face of a new life condition, which may be temporary or not, besides the possible presence of lesions, which often take years to heal, this professional must be attentive to offer a care that goes beyond the stoma, wound or incontinence complaint, covering the understanding of the whole biopsychosocial process 15 .
For this reason, the enterostomal therapist uses various alternatives of care to properly assist people, since they require physical support and also psychosocial, because many of the interventions can be definitive and even compromise the quality of life 15 .
The person who presents a stoma (temporary or definitive), skin lesions, incontinence and/or fistulas requires differentiated care and needs to be seen as a unique, dynamic and complex human being who needs support that goes beyond the traditional interventions, which concern the performance of techniques only. It should be noted that there is a close association between the issue of social exclusion and the person with stoma, one of the pillars of the care process related to enterostomal therapy. Thus, it is known that many people with stoma have a tendency to isolation, as they prefer to keep their health condition a secret and, for this reason, they distance themselves from family and friends, and even from the work environment, due to the stigma caused by the presence of the stoma 19 . In their statements, the interviewees highlighted that being an enterostomal therapist is also entrepreneurial.
Entrepreneurship can be understood as the creation or improvement of something, with the intention of providing benefits to individuals and society, having advanced in recent decades as a result of economic changes, technological innovations and globalization 22 .
Entrepreneurship stands out in the nursing area as a career option, since nurses need to know its various competencies, dare to explore opportunities and reach innovative spaces, becoming a protagonist of new fields and practices of professional performance 23 .
Thus, a different look is added to the production of new services, enabling nurses to sell their services and innovate their activities in any scenario of performance, renewing the "being" nurse, providing, most of the time, the muchdesired professional recognition and financial satisfaction 24 .
It is worth noting that, for many years in Brazil, the fact of concluding only the undergraduate course already carried the guarantee of employment and financial stability, since there was no competition and competitiveness, due to the lack of professionals and the level of demand of the labor market which were lower than nowadays 24 .
This context has been changing, given that the population has had more access to information, and the demand for health services has not only been in search of a cure, but also as a prevention strategy. This means that professionals have to keep up to date and start reinventing themselves within their profession. That is why nurses have invested in specializations for the development and increment of their career, which generates competition and competitiveness in the labor market, which, depending on the region, is saturated 24 .
The entrepreneur is a leader who produces a vision of what is possible to achieve, seeking to attract people to act within that vision and turn it into reality. Brazil is pointed out as an enterprising country in the formation of specialists 24 , the enterostomal therapists among them, since they have transformed paradigms in assistance and teaching, due to their enterprising and innovative characteristics in the process of caring, having autonomy, respect for clients and satisfaction in exercising nursing with excellence.
As a specialist, the nurse has spread his professional practice through the assistance performed, scientific production, undergraduate and graduate teaching, and through the services and advisory/consultancy provided.
It should be noted that the area of technical consulting, especially with companies producing materials specialized in the area of enterostomal therapy, has been showing wide growth, in addition to the specialized audit.
The autonomous and enterprising activity has acquired greater amplitude in nursing practice with the emergence of the first nursing "offices and clinics", services that were created with the purpose of developing the care that can be carried out in extra-hospital environment 25 and even those related to specialized care, highlighting those who need specific knowledge and sometimes focused on aspects not so widely disseminated, such as enterostomal therapy.

CONCLUSIONS
This study made it possible to see the various senses of being an enterostomal therapist, considering the complexity of the process of caring for people with wounds, stomata and incontinence. It was identified that there is a sense of being a professional with a holistic perspective of the human being; that it has relevance in the deconstruction of the social stigma that these people experience; that one of the senses of their performance is the rehabilitation and social inclusion of the assisted clients.
It also emphasized a perspective that gives meaning to an autonomous specialty and that allows for home care, enabling a new field of action for the specialist. Therefore, the meaning of being an enterostomal therapist involves inserting oneself in a specialty that provides flexibility in the labor market. Another outstanding issue was the entrepreneurial character of the specialty, giving professional recognition and even financial satisfaction.
It is understood as one of the limitations of this study that it is restricted to the reality of a specialization course, but it is already possible to realize the need for new research involving graduates of other enterostomal therapy courses, not exhausting the discussions here.
The authors believe that this study will boost the emergence of other researches, contributing even more to the fields of assistance, teaching, research and extension, from the discussions that translate the sense of being an enterostomal therapist, with the purpose of valuing this specialty, which is growing.