Report of the Experience of Living with High Blood Pressure in Light of the Theory of Caring

Abstract Objective. To analyze the report of the experience of the person with high blood pressure, in light of the theory proposed by Kristen Swanson, Methods. This was a qualitative research with autobiographical-type narrative design. To collect and analyze the information, the work used open in-depth interview with 12 individuals, participant observation, and field notes. Results. The study recognized the beliefs, customs, and cultural practices of the person living with high blood pressure and identified the care needs. The participants shared their feelings, finding that each confronts this disease differently and learns to care for themselves in particular manner. Conclusion. In the analysis of the narratives of the experience of people with high blood pressure, five care processes by Swanson were recognized: maintaining the beliefs, knowing, being with, doing for, and permitting.


Introduction
C urrently, high blood pressure (HBP) has become one of the first causes of morbidity and mortality globally. According to the WHO, in the world there are 1.130-billion people with this disease. By 2015, one in every four 4 men and one in every five women had hypertension; the purpose is to reduce HBP prevalence by 25% by 2025. (1) Due to the high number of patients and its complications that can cause death, the pathology is considered a public health problem throughout the world, becoming a risk factor for high-cost chronic and degenerative diseases, like cerebrovascular, cardiac, arteriosclerosis, and renal diseases, among others. (1) High blood pressure demands strict regular and constant compliance with the therapeutic regime, which implies changes in life habits because the treatment has a pharmacological component and a nonpharmacological one (diet, physical activity, stress management). However, most patients abandon the recommendations from the health staff as of the first year after being diagnosed because they believe they are feeling better, forget to take the tablets, or get tired with the treatment. (2) Also, health professionals and the very health system face the problematic of the lack of adherence to the treatment. (3) Knowledge patients have acquired about the disease and treatment lets them act consciously, (4) bearing in mind the characteristics, effects, risks, and adequate behaviors to manage HBP. The selection of the diet (5)(6)(7) in elderly adults is of great importance for the patients' care, given that it permits their obtaining a balance in their health status to avoid complications. Regarding the perception of life of the patient with HBP, it changes upon knowing of their diagnosis; at the start, the reaction tends to be of rejection and resistance to adopting other eating habits and lifestyle; (2) thereafter, they reflect and know they will have to care for themselves for the disease not to cause complications. (4) However, there are patients who do not modify living conditions. (6) From the emotional sphere, diverse feelings are experienced that often the health professional is not capable of understanding; each being is unique and must be cared for independently. (7) Beliefs with respect to managing the disease play an important role when establishing care guidelines, as well as the culture with the life habits. (8) In nursing, theoretical referents exist that are part of the essential component of the discipline, one of them is the theory of caring by Kristen Swanson, (9) which represents care based on the maintaining belief in patients, anchored on knowing the reality of the other, transmitted through being with, and enacted by doing and enabling.
It was deemed pertinent to use this theory in the research, given its relevance for the nursing discipline and thinking on the wellbeing of the individual with HBP to achieve manifesting their feelings, thoughts, and behaviors. Additionally, using this theory will permit moving toward taking care actions in this type of individuals, starting from the fact that they tend to have difficulties in finding the relationship between the theoretical referents and the practice. The study sought to analyze the report of the experience of the person with high blood pressure in light of the theory of caring.

Methods
This was a qualitative research with autobiographical narrative-type design, (10) applying the theory of caring. This project was carried out from June to August 2018 in the San Vicente de Ramiriquí Hospital in Boyacá, Colombia. The sequence of actions considered to approach the narrative study was thus: (i) Election of the context and participants: these were contacted with the database provided by the manager at the San Vicente de Ramiriquí Hospital, in the municipality of Ramiriquí in the department of Boyacá (Colombia); (ii) Immersion to the field was conducted through recognition and subsequent revision of the site to recreate the life history, experiences, and events; (iii) The Selection of participants agreed on attending the meeting of the Program of caring for chronic patients held once a month in the health institution. The research objective and the guarantee of confidentiality of the information shared were explained. The work also consulted the clinical histories to enrich the study; (iv) Application of the theory by Kristen Swanson, explored the meaning of the experiences narrated and documented. The first story was developed to collate and cross it with sources from the theory, verifying the facts and perspectives from the different participants; and (v) Units, categories and themes of the narratives, establishing coherence between that said in the interview and how it was said through observation and field notes.
The report was made, then these results were revised by experts in qualitative research and who have applied theories; thereafter, it was returned to the participants to introduce the definitive version. The sampling was selective, judgmental, or intentional because it offered indepth and detailed information on the purpose of this research. Inclusion criteria considered elderly adult patients diagnosed with HBP for at least six months prior to conducting this study, who voluntarily participated in the research. Some were approached personally, after attending the scheduled medical control and others via telephone. Initially, fifteen patients were summoned, two of which did not accept to participate due to work occupations and one withdrew during the middle of the study due to personal reasons. With this group, the first interview exercise was begun. The narratives were transcribed exactly as the person expressed them, in maximum spontaneity, giving as much freedom as possible. To preserve the identities of the participants and give the reports poetic nature, their names were changed for those of some flowers.
To gather and analyze the information, which were conducted simultaneously, the open, indepth interview, participant observation, and field notes were used. The hospital director provided a room for the meetings with the participants; it was a place with privacy and tranquility for the participants. During the interview, the researchers supported on their experience, carried out several extensive sessions (on average, three meetings with each person) and detailed, starting with guiding questions, like: How do you care for yourself since you were diagnosed with HBP?, Do you know what is the cause of your disease? According to the answer, new questions were made. These were recorded and transcribed textually with prior signing of the informed consent, agreeing on the meeting with the participants. Three meetings took place, in each of them the story was again addressed and progress was made in the depth of the story. The interview lasted from 30 to 60 minutes. A conscious position was assumed, placing trust on the person telling the story.
The techniques and analytic procedures mentioned permitted the researchers to develop a substantive theory, compatible with the phenomenon observed. The analysis was a cyclical, flexible, dynamic and creative process, while systematic. The concepts were denominated and categories defined, through the constant comparative method. Coding was performed at three levels: (i) Open coding: this level performed an initial descriptive analysis of the codes (specific words of the participants) and of line by line and phrase by phrase, looking for words to generate codes and define categories. The data were compared and each interview with the previous, underscoring relevant words and phrases that expressed aspects of the phenomenon under study; (ii) Axial coding: this level identified, the relationships between the codes and categories. Hence, the data was again joined through induction and abstraction to establish connections between codes and categories, similar categories were grouped and new data with emerging codes to construct initial relationships; and (iii) Selective coding: this level integrated the categories, in search of a central one, to construct a larger theoretical scheme. Triangulation of information was carried out when calling on other informants, databases from the health institution, and personal documents, like clinical history, in search of the confirmation.
To grant validity to the research, rigorous methodological criteria were kept in mind during the research, such as credibility, dependency or consistency, and confirmability. The research was approved by the ethics committee at the San Vicente Hospital in Ramiriquí, dated 20 June 2018. Ethical principles were kept in mind with the signing of the informed consent.

Results
This study had the participation of 12 patients (7 men and 5 women), ages ranged between 50 and 91 years. Nine of them have endured the disease for over five years; 40% live with their children; 35% live with their spouse and children; and 25% with other relatives. The following will describe the principal research results, according to the five caring processes proposed by Swanson. (9)

Maintaining Belief
The orientation of caring for patients with HBP stems from a fundamental belief in them and their capacity to overcome obstacles imposed by the disease. Elderly adults tend to have physical and emotional changes in their health status; the fact of living with HBP faces them with challenges they must confront to learn to assimilate the disease. Among the caring beliefs, they recognize those of religious type and others that have been passed on from generation to generation from home practices:

Knowing
Understanding the patients' lives permits recognizing knowing their care needs, which have to do with the lack of information about the disease and its treatment, as well as the importance of comprehending and respecting the eating habits and benefits generated by complying with the medical prescription and recommendations offered by the health staff. This is a compromise between the care giver and the subject of care: For me, going to the hospital is a routine procedure, they care for me, give me a prescription, I claim the medications and leave to continue with my tasks. I prefer not to ask so that I am not kept late, that is why I really do not know what is the cause of this disease and why they give me so many medications (Clavel, male, 51 years); They always make me arrive 10

Being with
The participants managed to share some feelings and trust was generated with the researchers who understood their specific situation. Certain fears were highlighted, especially that of death as something unexpected for some and predictable for others.

Enabling
This process was evaluated from two aspects; on the one hand, self-care actions were discovered and on the other hand, it favored the expression of opinions regarding the disease: I know I should take the medications for life and at the time indicated by the physician; on the contrary, this disease will worsen and I can die. I also stopped eating so much salt, I

Discussion
Through Swanson's theory, the human is perceived as a unique person, manifested through feelings, thoughts, behaviors, and life experiences. (9) According with the testimonies presented in each process, it should be highlighted that Maintaining beliefs occurs through religious practices and use of traditional medicine with home treatments to control blood pressure. (11) The population in Boyacá has strong cultural roots that could cause lack of adherence to the pharmacological treatment. This concept coincides with the results in the study by García, R et al., which found big benefits in using natural remedies compared with the pharmacological treatment, in addition to being safer because they do no harm in the organism. (12) Another recommended use also accepted by the participants in the research is garlic to diminish blood pressure. (13,14) However, the effect changes according to how it is taken, the best way is in extract because it increases the concentration of S-allyl-cysteine that is tolerable and functional; rather, when eating it whole, one of its components denominated Allicin, is volatile and unavailable. (14) According to the aforementioned, it is possible to state that people's beliefs along with the biological, cultural, and family factors are important to assimilate the treatment, hence, the importance of establishing agreements between the patient and the health staff about the treatment's parameters. (15) Regarding Knowing, patients state that they have little information about the disease and the reason for the treatment, but try to comply with it; this coincides with García et al., and Ried, F, who conclude that users try to obey the medical prescription even if they do not strictly follow the indications, (12,16) or as stated by a participant, they take the medications only in case they have any symptom (dizziness or headache) or when they have high blood pressure. (17) Learning to eat without salt has been a difficult habit to acquire, is one of the testimonies in this study that coincides with Negreiros and Asakura who report the low-sodium diet as one of the practices with greatest inconvenience to follow the treatment. (18) Literature reports the benefits related to physical activity; (19) however, in this study it was not found practiced by all the participants.
Listening and sharing the individual's feelings of concern and sadness are included in Being for, which reported fear of death and the worry caused by having a serious disease. The affliction, suffering and fear of having BPH are also expressed as a threat to life that leads to suffering with resignation. (5,17) Doing for was manifested through consolation and support from the family, neighbors, and friends. This coincides with Moura et al., regarding support from relatives and friends complying a role in adapting to new habits in hypertensive patients, thereby, strong commitment is required from everyone. (20,21) The analysis of the concept of Enabling described the self-care actions; one of them is to walk every day. This practice is considered as low-cost and minimum-risk physical activity that most humans can perform. Evidence shows that it offers positive effects in lowering systolic pressure, diastolic pressure or both. (22) The participants expressed their opinions to protect health, with diminished intake of salt and fats and moderate practice of physical activity. It is necessary to participate self-care to comply with the treatment, (23) some of the practices include diminished salt intake, increased intake of fruits and vegetables, and enhanced physical activity. (24)(25)(26) Many patients have modified their eating habits by following the recommendations by the health staff, in spite of not agreeing and that it is not pleasant to their taste; the changes consist principally in diminishing intake of fried foods, sugar, and salt and adding fruits; the whole family joins these new habits. (7) This study concludes that in the analysis of narratives of the experience of patients with high blood pressure, the five caring processes by Swanson were recognized. The integral assessment nursing makes of these individuals is fundamental, respecting their beliefs, learning to know it, sharing their feelings and fears as fundamental concepts of care and, thus, permitting to advance in the disciplinary development.