The scientific nursing production about the clinic: an integrativa review

Abstracts

O estudo objetivou conhecer a produção de conhecimento da Enfermagem brasileira atrelada à temática da clínica. Trata-se de uma pesquisa qualitativa operacionalizada por meio de uma revisão integrativa. Os dados foram coletados na base de dados SciELO através das palavras-chave enfermagem e clínica, presentes no resumo dos artigos. Verificou-se que a clínica é concebida como um instrumento atuante na construção de nexos entre a pesquisa e o cuidado em enfermagem, exercendo um constante movimento de construção e desconstrução de saberes e práticas. Os resultados do estudo podem contribuir para a produção de pesquisas e conhecimentos em Enfermagem, proporcionando subsídios para a melhoria dos cuidados de enfermagem, nos quais as práticas e os saberes biológicos e não biológicos interagem.

Enfermagem; Cuidados de enfermagem; Pesquisa em enfermagem clínica; Competência clínica

ORIGINAL ARTICLE

The scientific nursing production about the clinic: an integrative review

La producción científica de enfermería acerca de la clínica: una revisión integradora

Lenice Dutra de Sousa^I; Wilson Danilo Lunardi Filho^II; Valéria Lerch Lunardi^III; Silvana Sidney Costa Santos^IV; Cristiano Pinto dos Santos^V

^IRN. M.Sc. in Nursing. Ph.D. student, Graduate Nursing Program at Universidade Federal do Rio Grande. Faculty, School of Nursing, Universidade Federal do Rio Grande. Rio Grande, RS, Brazil. [e-mail]

^IIRN. Ph.D. in Nursing. Faculty, School of Nursing and Graduate Nursing Program at Universidade Federal do Rio Grande. Rio Grande, RS, Brazil. [e-mail]

^IIIRN. Ph.D. in Nursing. Faculty, School of Nursing and Graduate Nursing Program at Universidade Federal do Rio Grande. Rio Grande, RS, Brazil. [e-mail]

^IVRN. Ph.D. in Nursing. Faculty, School of Nursing and Graduate Nursing Program at Universidade Federal do Rio Grande. Rio Grande, RS, Brazil. [e-mail]

^V RN. Master's student, Graduate Nursing Program at Universidade Federal do Rio Grande. CAPES grantee. Rio Grande, RS, Brazil. [e-mail]

Correspondence addressed to

ABSTRACT

The objective of this study was to learn about the production of nursing knowledge in Brazil associated with the clinic theme. This is a qualitative study performed by means of an integrative review. Data collection was performed on the SciELO database using the keywords nursing and clinic, present in the abstracts of articles. It was found that the clinic is seen as an instrument used to establish connections between research and nursing care, having a constant movement of constructing and deconstructing knowledge and practices. The study results may contribute with the production of research and knowledge in nursing, providing elements to subsidize improvements in nursing care, in which there is an interaction between practice and biological and non-biological knowledge.

Keywords: Nursing; Nursing care; Clinical nursing research; Clinical competence.

RESUMEN

El estudio objetivó conocer la producción de conocimiento de la Enfermería brasileña vinculado a la temática clínica. Investigación cualitativa operada a través de revisión integradora. Los datos fueron recolectados en la base SciELO, usando las palabras-clave enfermería y clínica, presentes en el resumen de los artículos. Se verificó que la clínica es concebida como un instrumento que actúa en la construcción de nexos entre la investigación y el cuidado de enfermería, ejerciendo un constante movimiento de construcción y desconstruc-ción de conocimientos y prácticas. Los resultados del estudio pueden contribuir en generar investigaciones y conocimientos en Enfermería, proporcionando ayudas para la mejora de los cuidados de enfermería, en los cuales las prácticas y los saberes biológicos interactúan.

Descriptores: Enfermería; Atención de enfermería ; Investigación en enfermería clínica; Competencia clínica.

INTRODUCTION

The clinical model has been attributed with an essentially biological focus, arousing different forms of criticism against the way it is being put in practice and developed in health services. In this sense, across its historical trajectory, Nursing, aiming for comprehensive care delivery to human beings, has enhanced its distancing from the clinical model, with a view to covering all aspects that involve life, health, living and being healthy.

At its core, however, the clinical model displays knowledge that needs to be recognized and valued, due to its importance for health practices. Hence, clinical Nursing itself is neither fragmenting, nor should it be perceived as a mere part of what is visible⁽¹⁾. On the opposite, it is a field in which biopsychosocial practices and knowledge interact in a circular way, reflecting a way to promote new syntheses and ways of acting in health on professionals and their care objects⁽²⁾.

Thus, clinical Nursing is considered a knowledge framework that supports Nursing work. It seems to be little explored, however, in Nursing teaching, clinical practice and research. This research derived from concerns with valuing this knowledge, which is part of health production processes and constitutes an important work instrument.

OBJECTIVE

The goal of this study was to get to know Brazilian nursing knowledge production on clinical practice through an integrative review.

LITERATURE REVIEW

Initially, clinical knowledge was not defined as the field that mainly addressed the visible, as it referred to the investigation of animal economy, ranging from elementary biological structure until the complex phenomena of the organism and life and efforts to show in what relations live bodies interacted with all components of nature⁽¹⁾. Hence, at bottom, clinical practice aims for the articulation between the body’s exteriority/interiority and the psychosocial aspects that indissociably interfere in the health-disease processes.

The process of living covers different knowledge dimensions and, likewise, human health aspects meet in the multiple spaces of subject areas, denying linear constitutions. The understanding of care as a result of multiple human interactions is associated not only with social, economic and political macro-results, but also with the demands of the micro-spaces related with daily hospital reality⁽³⁾.

Hospital nursing care can and should be understood as a product and service in its multiple dimensions/relations/spaces, that is, as a personified and distinguished service production system capable of providing adequate care⁽³⁾. In this sense, by joining psychobiological aspects, clinical practice can be relevant for the identification and comprehension of the multiple factors characteristic of the health and Nursing care production processes.

METHOD

To achieve the research goal, an integrative review was carried out, involving the following steps: problem formulation, data collection, data assessment, data analysis and interpretation and results⁽⁴⁾. In the integrative review, experimental and semi-experimental research can be included simultaneously, providing a more complete understanding of the research focus of interest. Also, the review can be directed at concept definition, theoretical review and methodological analysis. Besides, it provides important data that can be directly interconnected with professional or clinical practice.

Furthermore, the integrative review permits knowledge dissemination, as one single review provides readers with various research results⁽⁵⁾. The question that guided this review was: how has Brazilian Nursing addressed the Clinical practice theme in knowledge production?

Data were collected in July 2009. Articles were included that were published between 2005 and 2009, indexed in the Scientific Electronic Library On-line (SciELO), through the following keywords contained in the abstracts: enfermagem and clínica, separated by the Boolean operator and. This database was chosen because it is an electronic library supported by the Latin American and Caribbean Center on Health Sciences Information (Bireme) and because it includes a large collection of Brazilian journals whose full text is available on-line. This research did not require Ethics approval, as data were available for public access and did not demand ethical secrecy.

The search resulted in 65 (sixty-five) publications, available in Portuguese and English. Departing from the focus on clinical practice in Nursing knowledge production, abstracts of these papers were read, seeking approximations with the clinical practice theme. After the reading, the presence of the keywords prática clínica in the papers’ abstract was established as the inclusion criterion, resulting in 16 (sixteen) publications for analysis.

Two authors independently located the articles that constituted the corpus of this review, as a strategy to guarantee the legitimacy of content analysis ⁽⁶⁾. For data collection, an instrument was elaborated with the following items: title of the publication, journal, year of publication, type of article, author(s), study aim and focus on clinical practice in the selected article.

Textual analysis was used to analyze the data, which is a way to deepen and dive into discursive processes, with a view to reaching knowledge in the form of reconstructed understanding about the discourse. This analysis method permits identifying and isolating statements from the contents submitted to this method, categorizing these statements and producing tests, to achieve interaction between description and interpretation. Textual analysis used the category system, the corpus – set of texts submitted to appreciation, as the basis for its construction, representing the multiplicity of the subjects’ worldviews on the research phenomenon⁽⁷⁾.

RESULTS

The results will be presented in three phases. Initially, Table 1 shows the variables involved in the identified articles. Next, Table 2 shows the foci on clinical practice in these papers. Finally, the foci on clinical practice in the selected articles were emphasized through categorization in two axes, which guided Nursing knowledge production in Brazilian publications on the clinical practice theme.

The 16 articles selected were distributed among the following journals: Latin American Journal of Nursing (four), Acta Paulista de Enfermagem (four), Revista da Escola de Enfermagem da USP (three), Texto & Contexto Enfermagem (two), Revista Brasileira de Enfermagem (two) and Revista Brasileira de Saúde Materno-Infantil (one). As for the type of publication, seven were reviews, five research articles, two reflections, one experience report and one update.

The number of authors per article ranged between one and five, totaling 38 (thirty-eight) authors, only two of whom were present in more than one publication: Galvão CM was an author for three articles and Sawada NO for two.

As for the publications’ aims, most addressed concepts, methods, Nursing diagnoses, treatment, Nursing interventions and the relation between knowledge and practice in Nursing. However, great diversity was verified among the proposed aims. Next, Table 1 displays some of the study variables and the results presented so far, for the sake of clarification.

In the research results, some clinical practice foci were also identified as part of the themes the different authors addressed in the papers under analysis, as presented in Table 2.

Hence, 11 (eleven) papers were located that focused on the link between scientific knowledge and clinical practice; 03 (three) linked with the valuation of research associated with clinical practice as a tool for Nursing care and 03 (three) linked with clinical practice and Nursing diagnoses. Also, 02 (two) papers were associated with clinical practice, addressing psychosocial and educational aspects, 02 (two) related to difficulties to incorporate scientific knowledge into clinical practice, one focusing on clinical practice knowledge as a mechanism for decision making and one linked with clinical practice as a source for Nursing research.

According to the knowledge area for health and care production, clinical practice was not addressed as the central theme in any of the papers under analysis, but seemed to be a secondary object in Brazilian Nursing publications. The study results indicate, however, that despite the range of themes found in the publications, a conception predominates that associates scientific knowledge with clinical practice, intrinsically appointing the valuation of clinical practice for nursing work.

Data analysis permitted the identification of two axes that guided Nursing knowledge production in Brazilian publication on clinical practice. Hence, two categories emerged from the review, which address clinical practice as an instrument to construct links between Nursing research and care. These categories are presented next.

DISCUSSION

Clinical research supporting Nursing care

Evidence-Based Practice (EBP), mentioned in articles I, VI, VIII and IX, shows to be valued in the construction of support for Nursing care. EBP is a process of discovering, assessing and applying scientific evidence to health treatment and management⁽⁸⁾. Hence, studies using the integrative research method join previously constructed knowledge and can collaborate to consolidate knowledge and offer elements for the elaboration of Nursing interventions. Besides, they can enhance the incorporation and applicability of little used practices in care production.

Evidence-based Nursing emphasizes the use of research to guide clinical decision making and can thus be defined as the conscious, explicit and judicious use of information deriving from research⁽⁹⁾. Articles X and XII, however, mention difficulties to accomplish this incorporation into Nursing care in nurses’ daily practice.

Nursing students present difficulties to articulate theoretical contents with applicability in practical classes, which can consequently entail future harm for clinical practice⁽¹⁰⁾. A range of factors can enhance the existing gap between the knowledge science produces and its application in clinical Nursing practice, such as the insufficient recognition of the importance of knowledge deriving from qualitative research⁽¹¹⁾.

Similarly, articles IV and VIII mentioned difficulties to effectively connect certain Nursing diagnoses with clinical practice. Hence, it is observed that, even for acknowledgedly consolidated and established knowledge in Nursing care production, weaknesses still exist, which indicate the need for further research to consolidate Nursing care technologies.

The subjectivity attached to the different aspects that constitute sources for the establishment of Nursing diagnoses can be the main origin of the difficulties nurses face. Thus, the defining characteristics can be mixed up and associated with mistaken diagnoses, as there tends to be little or no more concrete evidence for the elaboration of a consistent data collection (Nursing history) instrument.

Due to its identification with the Social Sciences, however, Hermeneutics – the subject area that deals with the necessarily hidden in-depth meaning of the subject, but which is accessible to interpretation⁽¹²⁾ – serves as a valuable tool for Nursing to understand subjective processes. Likewise, qualitative research is related with the meanings people attribute to their experiences in the social world and how they understand the world⁽¹³⁾. Hence, Nursing can answer questions on distinct health conditions, disease and life experiences, through different existing qualitative designs⁽¹⁴⁾.

From this perspective, the integrative review is an approach that enhances knowledge and knowledge systemization through research development or application to professional practice⁽⁹⁾. Thus, a qualitative study that adopts this research method can collaborate towards greater approximation between Nursing theory and practice, as it can minimize conceptual discrepancies, besides contributing to knowledge condensation on different biopsychosocial phenomena. Therefore, the integrative review can be a route to achieve evidence-based practice in Nursing.

Nursing care offering elements for clinical research

Through the study results, it was verified that article III appoints the dynamics of Nursing knowledge and, like article V, considers clinical practice as an assessment instrument that supports both care and research. Thus, the peculiar characteristics of care comprehensiveness and contextualization contribute with important concerns clinical Nursing research needs to answer.

Articles V and XIV highlight human multidimensionality in clinical practice, evidencing the importance of the connection with the psychosocial aspects that comprise the process of living. Hence, Nursing care gains political, social and cultural competency, contributing for clinical research in Nursing to seek, in the understanding of disease processes, contextualized identification and applications of more problem-solving conducts⁽²⁾.

The different psychosocial aspects that contextualize biological processes should not be ignored, but visualized in a horizontal structure, avoiding that the materiality of the body be minimized. Therefore, the implications between science and technique need to be minimized, thinking and acting for both to progressively intermingle and show their ability to solve any kind of problems⁽¹⁵⁾.

Nursing’s distancing from the clinical model, however, may have weakened nurses’ theoretical knowledge on clinical practice as instrumental to accomplish the Nursing work process and, hence, constitutes an aspect that inhibits the identification of different elements for clinical research. In this sense, a route of knowledge construction and skills development may be necessary to enable nurses to act as parameters of consistent and reliable evidence. Hence, the quality of higher education at undergraduate and graduate level and the scientific opportunities of professional life can be determinant factors⁽¹⁶⁾.

Based on the listed premises, article XIII appoints that nurses need to display and develop competencies for the identification of clinical evidence present in their professional practice. Similarly, article VII acknowledges that clinical knowledge is important to equip professionals in Nursing decision making, collaborating in health/care production. Therefore, it is fundamental to strengthen knowledge based on clinical practice to accomplish effective care and identify elements guiding Nursing research.

In Brazil, scientific and technological development has been mainly assessed through clinical, biomedical and public health research⁽¹⁷⁾. Thus, the valuation of clinical research and the incorporation of the produced knowledge in nursing work can contribute in the interrelations with the multidisciplinary team, minimizing disparities in attitudes and power relations in the work environment.

Historically, clinical knowledge has enhanced a reorganization of the hospital domain, in which the physician took power, which imposed an unjustifiable hierarchical ranking(1). There are still remnants of this heritage of domination, however. Thus, clinical Nursing research can contribute to unveil the continuing irreversible power relations in the multidisciplinary team. Thus, clinical knowledge production and consumption by Nursing research can act as an instrument of social valuation.

CONCLUSION

The research goals were achieved, as knowledge was obtained on Brazilian Nursing knowledge production about clinical nursing, reflecting on the main variables involved in the study and identifying two axes that guided Brazilian publications: clinical research supporting Nursing care; and Nursing care offering elements for clinical research. This information demonstrates that clinical practice is conceived as an instrument to construct links between Nursing research and care, in a constant construction and deconstruction movement of knowledge and practices.

The use of the integrative review method was relevant to achieve the goal and identify gaps that reveal the need for research designs to develop evidence related to the research theme. These studies can contribute to Nursing research and knowledge production, supporting the improvement of Nursing care, in which biological and non-biological practices and knowledge interact.

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Correspondência:

Lenice Dutra de Sousa

Av. Itália, 2111 - Bloco 18A - Apto. 103 - Bairro Trevo

CEP 96203-000 - Rio Grande, RS, Brasil

Publication Dates

• Publication in this collection
  26 May 2011
• Date of issue
  Apr 2011

History

• Received
  16 Mar 2010
• Accepted
  14 Aug 2010