The importance of civilian nursing organizations: integrative literature review Importancia de las organizaciones civiles de enfermería: revisión integrativa de la literatura

Objective: to identify and analyze evidence from studies about the importance of civilian nursing organizations. Method: an integrative literature review, for which searches were conducted in the databases LILACS, PubMed/MEDLINE, SciELO, BDENF, and Scopus. Results: sixteen articles published between the years 2004-2013 were selected, 68.75% of which were sourced from Brazilian journals and 31.25% from American journals. Conclusion: civilian nursing organizations are important and necessary, because they have collaborated decisively in nursing struggles in favor of the working class and society in general, and these contributions infl uence different axes of professional performance. Descriptors: Nursing; Nursing societies; History of Nursing; Professional Associations; Social organization. RESUMEN Objetivo: identifi car y analizar las evidencias expresadas por estudios sobre la importancia de las organizaciones civiles de enfermería. Método: se trata de una revisión integrativa de la literatura, en la cual fueron realizadas búsquedas en los bancos de datos LILACS, PubMed/MEDLINE, SciELO, BDENF y Scopus. Resultados: fueron seleccionados 16 artículos publicados entre los años 2004 y 2013, resultando que el 68,75% de los mismos fueron realizados en Brasil, y el 31,25% en los Estados Unidos. Importância das organizações civis de enfermagem: revisão integrativa da literatura The importance of civilian nursing organizations: integrative literature review Importancia de las organizaciones civiles de enfermería: revisión integrativa de la literatura Importância das organizações civis de enfermagem: revisão integrativa da literatura 611 Rev Bras Enferm [Internet]. 2016 mai-jun;69(3):610-8. James Farley Estevam dos Santos E-mail: jamesfarleyestevam@yahoo.com.br AUTOR CORRESPONDENTE


INTRODUCTION
Analysis of the socio-historical context of Brazil demonstrates that social and political participation by popular sectors of society has been achieved through confrontation with hegemonic groups in a conjuncture where political, social, and economic contradictions are the object of important struggles for the realization of basic rights, democratic representation, and overcoming social inequalities arising from the system of capital accumulation (1) .
With regard to the political organization of nursing in Brazil, there are few records in the literature on this subject and, amid advances and setbacks, the sector's political participation remains incipient.This is because it lacks a political and social project built by different sectors of the working class that expresses the interests of the profession and society in general, and that is able to guide actions and interventions in spaces of deliberation and power, both within and outside the field of nursing (2) .
Despite the challenges, since the birth of modern nursing in Brazil the commitment and organizational capacity of nurses was immediately expressed.Soon after the first class of nurses received their degrees in 1925 from the (then) School of Nursing of the National Department of Public Health (EE/DNSP) in Rio de Janeiro now known as the Anna Nery School of Nursing (ANSN) of the Federal University of Rio de Janeiro the National Association of Registered Nurses (ANED) (currently the Brazilian Association of Nursing -ABEn) was founded in 1926 as a civil nursing organization with the mission to bring nursing professionals together and develop the profession in its various lines of action (3) .
For nearly 50 years, ABEn was the only entity to fight for the professional category of nursing in the country and, since its inception, has consistently worked in favor of the technical, scientific, political, and cultural development of the profession, "seeking to implement new strategies aimed at problem solving, and has been fighting continuously, through its members, for a broad social and economic order that is more fair and in solidarity and cooperation with organized civil society" (4) .Today the Association is present in all states of Brazil, and has focused its efforts on uniting the forces of professional organizations to make demands of interest to nurses in the spheres of labor, education, research, and nursing care (5) .
Given the above, an integrative literature review was performed, and the evidence presented here can support nursing professionals to think and rethink their organizational practice to support the causes of nursing in Brazil.These would include its technical, scientific, political, and cultural development; the struggle for greater visibility and recognition of the work developed by nursing staff in terms of its social impacts in improving people's living conditions; and the promotion of consolidation of the public Unified Health System, sustained on the principles of fairness, integrity and universality.Thus, this study aimed to identify and analyze the evidence put forth by studies on the importance of civilian nursing organizations.

METHOD
This was an integrative literature review, using a research method that, based on the synthesis of multiple studies, allows identification of the state of knowledge of a particular subject as well as gaps that need to be filled with new research, thereby enabling obtaining more general conclusions about a particular area of knowledge (6)(7) .
To guide development of this integrative review, the following guiding question was formulated: What is the evidence put forth by published studies about the importance of civilian nursing organizations?Searches for articles took place in the fourth quarter of 2014, and the databases used were: the Latin American and Caribbean Center on Health Sciences (LILACS); the Scientific Electronic Library Online (SciELO); and the Nursing Database (BDENF).The following search terms and combinations in Portuguese were used: "nursing societies"; "professional associations" and "nursing"; and "social organization" and "nursing."The following two strategies were used in the databases PubMed/ MEDLINE (US National Library of Medicine/International Literature on Health Sciences) and the Scopus Database (Subject Areas: Health Sciences): "societies, nursing;" and "American Nurses' Association".
The titles and abstracts of the 725 articles found were read.The selection process was guided by the following inclusion criteria: articles available in full online; and published since 2000 in Portuguese, English, or Spanish since.This timeframe is justified by the expansion of graduate courses and the consolidation of research groups since 2000, which has quantitatively and qualitatively increased scientific production in nursing (8) .Publications that were excluded were editorials, biographies, letters to the reader, and similar publications.Sixteen studies were included in the sample of this literature review, which were submitted to external and internal analysis and are presented in Box 1.

Historical social
Analyzes the position of ABEn in the field of higher education in nursing, and discusses strategies for struggle undertaken by spokespersons for higher education in nursing based on the guidelines of the LDB/96.Strategies for struggle adopted by nursing agents occurred from political-expansionist, politicallegal, and political-organizational policies, which contributed to the reconfiguration of the field of higher education in nursing.
To be continued

RESULTS
The first variable analyzed was the year of release, and it was verified that 50.00% of the articles were published in the years 2012 and 2013, while the others were published between 2004 and 2010; 62.50% of the studies were published in Portuguese and only 6.25% in Spanish, and it is important to note the amount of research published in English (31.25%).In addition, 68.75% of the selected works were sourced from Brazil, and 31.25% were from research in the United States.There were no works from other sources, probably due to the search criteria used and the characteristics of the consulted databases.
Analysis of the publishing vehicle showed that 62.50% were published in the Revista Brasileira de Enfermagem (RE-BEn); 12.50% in the Journal of American Critical Care; 6.25% in the Revista de Pesquisa: cuidado é fundamental; 6.25% in the Oncology Nursing Forum; 6.25% in the Journal of Oncology Practice; and 6.25% in the Online Journal of Issues in Nursing (OJIN).Thus, 68.75% of the studies were published in national journals, and 31.25% in international journals.
These data enabled finding the Qualis of the publications, considering "nursing" as the area of evaluation and the updated Qualis of the periodical (2014), in which 75.00% of the articles fell into strata A1 and A2, while only 6.25% were in stratum B2.It should be noted that 18.75% of the studies had a Qualis of "not evaluated," meaning that although they had been assessed in their countries, they were not yet assessed in Brazil.
Qualification of the authors was analyzed by counting their number in the 16 selected studies, which was 61, and then excluding repetitions; 53 authors remained.Querying the metadata available in the articles and the authors' curricula enabled identification of the highest professional ranking of 43 of them: 76.74% had a doctoral degree; 11.63% had a master's degree; and 11.63% had completed their undergraduate degree, mostly in nursing.
It was found that all of the articles stated their aim explicitly, and a total of 26 aims were counted; of these, 42.32% were descriptive and only 15.38% were analytical.However, it is interesting to note that 26.92% of the aims indicated an interest to discuss/reflect on issues related to civil organizations.Furthermore, 73.68% of the findings of the articles confirmed the idea that civil nursing organizations have decisively contributed to the development of the profession in the spheres of education, research, professional practice, and social movement, including preserving the historical memory of the profession and its professional and institutional identity.For example, 15.79% of the articles argued the need to strengthen and integrate the organizations, including proposing to create a project in which civil organizations assume the role of monitoring the profession, and 10.53% affirmed the importance of the participation of nursing professionals in civil organizations.

DISCUSSION
Most of the publishing vehicles had high Qualis, which positively conveys the quality of work.It is possible that this finding is related to the categorization of the authors, who were mostly graduate students at the master's and doctoral levels, and therefore well versed in the science of nursing.Furthermore, there is the fact that they retain ties with strictu sensu graduate programs, with the responsibility to publish the results of their research and theoretical reflections (8) .
Also considering the subject of this review and the data presented on the categorization of the authors, the results revealed that qualified nurses are interested in the subject, and therefore it is important to emphasize that a portion of the authors were people who had experience with nursing associations, were involved with these organizations, and were dedicated to the "ethical intentionality of the mystique of nursing" and to the values and objectives of associative participation and social commitment (9) .
Considering the time frame of this study, it was found that only from the second decade of the 2000s was there a progressive increase in the number of publications on civil nursing organizations, highlighting the years 2012 and 2013.It is interesting to note that of the eight publications from this period, three are from the U.S.; this may be associated with the social organization of the country, which is strongly based on social representation (9)(10) .On the other hand, the number of Brazilian articles shows that the nursing community in Brazil maintains a growing pace of publications on the subject, which may contribute to increase records about its political organization.
As for the journal of publication, most were linked to civil organizations such as REBEn in Brazil and U.S. journals such as OJIN of the American Nurses Association (ANA).It seems reasonable to assert that these organizations have used their publication vehicles to ensure nursing communities a space for discussion about issues that affect them, and subsequently publish studies on social, political, and historical phenomena and their effect on work in nursing (9)(10)(11)(12) .In this sense, this can be a powerful strategy to strengthen the commitment of members associated with organizations and the profession, uniting collaborative efforts for the achievement of common goals and dissemination of issues of interest to nursing students and professionals (9)(10)(11)(12) .
In the Brazilian context, REBEn and the Jornal da ABEn deserve mention as ABEn's official publications (9,(11)(12)(13) .REBEn was created by the Association in 1932 with the title Annaes de Enfermagem, as a scientific journal whose founding was directly linked to Edith de Magalhães Fraenkel and Rachel Haddock Lobo, respectively president of the organization and director of the Ana Nery School of Nursing at the time (9,11,13) .The goal was to develop a new area of research in nursing, in order to assure Brazilian nurses a space to publicize their research experiences, thereby promoting the growth of knowledge of nursing and preserving the memory of the profession (9,11,13) .Since its inception, the journal has been developing and meeting requirements of the contemporary world, including adhering to increasingly strict publication criteria.
The Jornal da ABEn was established in 1958 under the title Boletim Informativo, with the mission "to keep members aware of the most significant news about the profession" (12) .Starting with Volume 45 in 2003, the journal adopted its current name, and not only currently consists of a news bulletin, but contributes to the political and ideological development of its readers (12) .
Analyzing the objects of study of the selected articles, it was found that, in the Brazilian context, ABEn was the focus of most of the studies, perhaps because it is the oldest nursing organization in the country, and even acts as an umbrella organization for other municipal, union, and scientific nursing organizations in Brazil (9,11,14) .It seems that, in a way, all of the articles addressed the contributions of the Association to the world of nursing, especially in the areas of education (15)(16) , care and professional practice (14,(17)(18) , political participation (19) , and preservation of the memory of the profession (13) .It is noteworthy that there was mention of unions, specialties, and supervisory bodies of professional nursing practice during the joint work developed by these institutions in favor of the demands of the field of nursing.
One article specifically addressed the Pan-American Federation of Nursing Professionals (FEPPEN), which was founded in November 1970 as a private, nonprofit, non-governmental organization made up of national professional nursing organizations in Latin America and the Caribbean (11,20) .In Brazil, FEPPEN is represented by ABEn, which was also a founding member of the organization (11) .This research sought to demonstrate, in a prospective vision for the 21 st century, the Federation's commitment to scientific, political, economic, and social development of the nursing profession and workers of each region, based on a definition of guidelines, aims and targets that encouraged solidarity, cooperative work, and defense of the right to health and social security in member countries (20) .
The articles published in English shared the characteristic of treating the achievements of scientific organizations of nursing experts for the improvement of care and research practices, including in partnership with other entities, demonstrating that associations seek to positively influence the improvement of care provided by articulating the development of care protocols and disseminating evidence to support care (21)(22)(23)(24) .However, among the studies, one described the mobilization activities of professional nursing organizations, emphasizing the role of ANA and the International Council of Nurses (ICN) (10) .
ANA was established in 1896 under the name Associated Alumnae of Trained Nurses of the United States and Canada, but assumed its current name in 1911 (10) .This organization represents the interests of more than three million nurses in the U.S., and has been busy raising the standards of nursing practice and promoting the rights of nurses in the workplace, including in conjunction with other institutions (10) .The ICN is a federation of more than 130 professional nursing associations, representing over 13 million workers worldwide (10) .It was founded in 1899 as the first and most comprehensive international organization managed by nurses, assuming the task of representing nursing worldwide, advancing the profession and influencing health policy (9)(10) .
In this sense, it seems that the selected studies bring with them a concern to make public the contributions of civil nursing organizations in Brazil and abroad.To this end, the associations adopted their own publication vehicles, giving evidence that they (the organizations) have been making collective efforts, including working together with other institutions within and outside the profession, to overcome the problems that affect it, as well as to build relevant achievements for the profession and society in general (9)(10)(11)(12)20) .
Analyzing all of the proposed objectives and methodological approaches used together, it was possible to perceive that the selected articles sought mainly to describe the contributions of the organizations to the development of the profession.As such, the descriptive methodology, historical and social studies, and theoretical reflective discursive studies were those best adapted to this purpose (9)(10)(11)(13)(14)(15)(17)(18)(19)(20) . This is possily because these types of research enable description of objects of study related to the phenomenon of the social and political participation of nursing, as well as discussing their situational aspects.
The presence of historical studies in the sample of this review is quite interesting, as the sources consulted explained that this type of study can awaken in nurses a sense of belonging to the profession, and an enduring commitment to it and to the training of a professional identity (9,11,13,25) .These aspects are very important, especially considering the challenges that nursing faces at this historic moment, in a conjuncture strongly influenced by the principles of wealth accumulation, entrepreneurship, and free competition that require the expropriation of labor rights from the working class, and that are manifesting in the social, economic, and political realms of provision of health care services.
These aspects are essential in the struggle for the social recognition of the work carried out by nursing professionals, for better training and qualification, and greater representation in spaces of power in a manner coherent with its quantitative expression of workers and the great responsibility they assume in the provision of nursing care (9)(10)(11)20) .
As for the conclusions of the studies included in the present review, the evidence is that civil nursing organizations contribute to the development of the profession in its various areas of work (9)(10)(11)20) , in which professional training and care for human beings are the most discussed (15)(16)(17)(18)(21)(22)(23)(24) . In egard to professional practice and political participation in social movements, the need to strengthen and integrate such organizations is highlighted, along with the importance of participation of the working class in these associations (9)(10)(11)(12)19,20) .
In the Brazilian context, the studies conclude that, since its inception, ABEn has always been vigilant in monitoring all proposals and actions that relate to nursing education opining, reflecting, building, and intervening competently and consistently with the social mandate that it assumes with nursing professionals and society (9,11,(15)(16) .
In this trajectory of work, the creation of the Education Committee in 1939, through participation in formulation of Law No. 775 of 1949, and the minimum curricula of 1962, 1972, and 1994 stand out.In addition, there is the initiative to create the National Seminar on Guidelines for Nursing Education (SENADEn) as a space for discussion on the subject, whose proposals influenced the National Curriculum Guidelines for Undergraduate Nursing Education in 2001, as well as dissemination and promotion of adherence to these guidelines by nursing schools throughout the country (9,11,(15)(16) .
Thus, ABEn has played an important role in the process of developing nursing education in Brazil, articulating and mediating strategies collectively built with other entities such as the Rede Unida [United Network], the National Federation of Nurses of Brazil, the Brazilian Association of Medical Education, and sectors of the ministries of education and health, to promote change in institutions that provide education and health services, bringing together the voices of students and professionals in favor of an educational project that meets the needs of the population (15)(16) .
Regarding the development and growth of research, the creation of the Center of Studies and Research in Nursing (CEPEn) in 1971 is highlighted, which aims to "encourage the development and dissemination of nursing research, organize and preserve historical professional documents" (11) .In this same area, since 1979 ABEn has held the National Seminar on Nursing Research (SENPE), a biannual event that brings together: "students, teachers and researchers, with presentations reports and shows setting up research projects and results of specific advancements and outstanding achievements to the domain of professional knowledge" (9) .
With regard to professional practice and provision of health care to populations, the Association has always been attentive, and participated in discussions and the development of legal instruments of regulation of nursing practice.This was the case with Decree No. 20,109/31, which provided the first legal provision of this nature; Law No. 2,604/1955 and then Law No. 7,498/1986, which regulate professional nursing practice and Law No. 5,905/73, which deals with the creation of a system for monitoring professional practice (9,11,14) that influences the quality of care provided by workers.
Moreover, ABEn is concerned with the work environment and situation of nursing professionals, considering that a significant portion of these individuals work in inadequate settings, with compensation far short of the social responsibility they assume, with multiple work shifts lacking proper protection of their own health and, in many cases, under the constraint of harassment, as well as having to deal with the exhausting process of the health system and job insecurity (11) .To engender changes in this scenario, the Association has been interacting with other entities seeking to ensure the consolidation of the Brazilian Public Unified Health System, as it believes that only a single equitable, universal, and comprehensive health system can alleviate the situation of social inequality to which the population is subjected (11) .
On this point, the significant contributions of ABEn to the dissemination of the International Classification for Nursing Practice (CIPE ® ) stands out, along with its intensive work for the inclusion of terms related to public health, which were included in the International Classification for Nursing Practice in Public Health (CIPESC) (11,26) .
Within the scope of political participation, in analyzing the historical background of ABEn one article referred to the Participation Movement as a social movement of nursing in Brazil, made up of nursing professionals and students who shared the understanding that ABEn should be a democratic organization, strengthened to participate in the general struggles of society and to act autonomously and independently that is, without suffering constraints by the state, political parties, and/or multinational corporations operating in the health care sector and that it was the interlocutor of the nursing profession in favor of the interests of its members (19) .
On this issue, it should be emphasized that, on the part of the leadership in the profession, there has always been a concern to ensure spaces for organization and training, with a view toward strengthening the purposeful action of the organization and, when necessary, to ensure the democratization of the spaces conquered, especially in the 1980s.This constituted the Participation Movement, from which the organization's guidelines were reorganized (19) .
According to this article, among the proposals of the Participation Movement in some Brazilian states (that were not the consensus among Movement members nationwide) was the construction of a unitary entity, that is, an organization that "exceeds the current reality that separates nurses from other nursing professionals, and that separates political, associative and scientific organization from labor union organization and monitoring professional practice" (19) .The authors explain that this proposal has not yet been put into discussion in ABEn, but suggest, considering the discussions to date, that ABEn take the initiative by changing its legal status, thereby enabling it to also assume these functions (19) .

CONCLUSION
This review aimed to identify and analyze the contributions of 16 articles selected from major databases of national and international literature.It was found that these articles were mainly published in journals of civil organizations, which were well sought after by qualified authors and linked to strictu sensu graduate programs to disseminate the results of their research.
Regarding the types of studies that have addressed the issue, it was noted that the socio-historical articles helped to contextualize the circumstances of establishment and operation of organizations representative of nursing, as well as to report achievements in the development of the profession.Another finding, found in 10 national articles, is that ABEn has provided important services to nursing and to Brazilian health, among other things, in order to keep a journal classified by CAPES with a Qualis A2, and to organize national and international events that discuss and interfere with the educational policies and research in nursing and health.Similarly, other articles attribute similar importance to ANA, FEPPEN, and the ICN in defending the interests of nursing.
All of the articles identified the fact that nursing organizations are important and necessary, as they have contributed decisively in the struggles of the profession in favor of the working class and society in general.The most significant evidence found was that these contributions are levied on the various axes of professional practice, and that they seek to defend a political project of professional training and qualification that is consistent with the interests of the working class and social demands, as well as to ensure spaces for the dissemination of studies on the phenomena that are of interest to professionals in the field.All of this has the perspective to mature a critical mass of knowledge to serve to support the demands of nursing and improve its standards, based on the defense of decent working conditions, and dissemination of research to promote positive changes in services and consolidate health systems guided by the principles of equality, integrity, and resolution, in order to reduce social inequalities.
From the foregoing, we can concluded that the objectives were achieved and the results, considering the current social, economic, and political context, allow for the recommendation to nursing communities in Brazil and other countries to continue studying and publishing on the subject from a perspective of the ideological direction of the association's members and the preservation of the collective memory of the profession, generating evidence of the social importance of the work of the directors of the civil organizations of the profession.

Box 1 -
Distribution of articles selected according to title, year of publication, country, study design, interventions and outcomes, Maceió, Alagoas, Brazil, 2015