Systematization of nursing care and the formation of professional identity

The aim of this study is to explore arguments that broaden the understanding of possible links between the organization of nursing care and the structuring of professional identity. For that purpose, some aspects related to these themes are addressed, highlighting issues regarding differences in the concepts of the organization of nursing care and the nursing process, as well as the performance of this activity and its possible impact on the establishment of its relationship with the professional identity. Emphasis is given to the need to stimulate the debate on the subject by nursing professionals involved in the training of human resources and the provision of care, as well as in class entities, in order to deepen understanding of these concepts as signifi cant elements for strengthening our professional identity. Descriptors: Nursing; Nursing Process; Occupations; Professional Competence; Socialization. RESUMO O objetivo do presente artigo é explorar os argumentos que ampliem a compreensão dos possíveis nexos entre a sistematização da assistência de enfermagem e a formação da identidade profi ssional. Para tanto, abordam-se alguns aspectos relacionados a esses temas, destacando questões referentes às diferenças na concepção da sistematização da assistência de enfermagem e do processo de enfermagem, bem como na prática dessa atividade e sua possível repercussão no estabelecimento de sua relação com a identidade profi ssional. Enfatiza-se a necessidade de estimular o debate a respeito do assunto entre os profi ssionais de enfermagem envolvidos na formação de recursos humanos e na prestação da assistência, bem como das entidades de classe, de modo a aprofundar a compreensão desses conceitos como elementos signifi cativos para o fortalecimento de nossa identidade profi ssional. Descritores: Enfermagem; Processos de Enfermagem; Profi ssão; Competência Profi ssional; Socialização. RESUMEN El objetivo del presente artículo es explorar los argumentos que amplíen la comprensión de los posibles nexos entre la sistematización de la atención de enfermería y la formación de la identidad profesional. Para tanto, son abordados algunos aspectos sobre esos temas, destacando cuestiones referentes a las diferencias en la concepción de la sistematización de la atención de enfermería y del proceso de enfermería, así como en la práctica de esa actividad y su posible repercusión en el establecimiento de su relación con la identidad profesional. Se da énfasis a la necesidad de estimular la discusión sobre el asunto entre los profesionales de enfermería involucrados en la formación de recursos humanos y en la atención de enfermería, bien como de las entidades de clase, de modo a profundizar la comprensión de esos conceptos como elementos signifi cativos para el fortalecimiento de nuestra identidad profesional. Descriptores: Enfermería; Procesos de Enfermería; Profesión; Competencia Profesional; Socialización. Systematization of nursing care and the formation of professional identity Sistematização da Assistência de Enfermagem e a formação da identidade profi ssional Sistematización de la Atención de Enfermería y formación de la identidad profesional REFLEXTION Maria Gaby Rivero de Gutiérrez E-mail: gaby.gutierrez@unifesp.br CORRESPONDING AUTHOR


INTRODUCTION
This reflection was presented in a lecture entitled Systematization of Nursing Care and the Formation of Professional Identity during the 12 th National Symposium on Nursing Diagnosis (SINADEn), which took place in Recife, Pernambuco, in July 2016.The referred topic posed a great challenge because of its complexity and many possible ways to address it.Extensive literature was made available for both topics, but not dealing with the specific focus that this conference required, regardless of the relationship between the Systematization of Nursing Care (SNC) and the formation of professional identity.
Therefore, the initial challenge was to define which direction to take to tackle the proposed topic, in such way that the arguments that could lead to the establishment of possible links between both mentioned aspects could be explored.The first thought was to carry out a study with nursing professors and assistants, including conducting a test pilot based on the key question, but several reasons made this proposal unfeasible.However, the discussion on the issue that should guide the interview with nursing professionals, as well as the answers obtained with the first contact, provided valuable clues to support our reflection on the topic.
Therefore, the content of this presentation represents the reflective effort of two nurses who, drawn upon their own view of the world and nursing and what had been produced on both topics contained in the proposal, tried to capitalize their generational and cultural differences to better understand something they have in common -nursing and nursing care.
While considering several analyses that were carried out on SNC, it became clear that, despite the qualities attributed in terms of benefits for the quality of the provided care, the scientific breakthrough in the area, and professional autonomy (1)(2)(3) , recurring conceptual, operational, organizational, and political issues involved in this activity (1,(4)(5) were still subject of discussion; thus, highlighting that it was a controversial and multifaceted topic that requires investments in the category so it can be better comprehended.Looking at SNC through this lens, the question raised was whether it would be possible for the SNC to become a significant element for the construction of a professional identity.What are the elements contained in it that are responsible for the construction of professional identity of the nurse?
Seeking answers for these issues, and many other questions that emerged over the course of the preparation of this presentation, the researchers decided to start their analysis with a discussion on some concepts about identity and professional identity construction and its relationship with SNC.

IDENTITY CONSTRUCTION
Identity construction has been the subject of study of researchers in the fields of sociology, social psychology, anthropology, and philosophy.Among varied theoretical and conceptual approaches to this process, the emphasis is put on some authors that conceive them as a historical, social, cultural, political, and relational construction consisting of material and symbolic elements (6)(7) .Within this perspective, the work of Castells (7) defines identity as follows: It is the process of construction of meaning on the basis of a cultural attribute or a related set of cultural attributes, that is/are given priority over other sources of meaning, however there may be multiple identities within one individual or a group.
According to Castells (7) , identities are sources of meaning for the actors themselves, constructed through a process of identification, and could be the source of changes translated into wishes, struggles, new paths, and other routes.He argues that only through the internalization of this identity and the construction of its meanings that the actions of individuals or actors could be guided, because they are responsible for the construction of representations that place them within a group, giving meaning to "what they are and what they could be" (7) .
The concepts between identity and roles are also distinguished.For the author, identities organize meanings, whereas roles organize functions.In other words, identity guides the social roles performed by social actors (7) .He understands meaning as "the symbolic identification by a social actor of the purpose of his/her action" (7) .He also proposes that meaning is organized around a primary identity that is self-sustainable over time and space.
This perspective on the historical and procedural nature of identity construction is emphasized by Cruz (8) , when he claims that: [...] the concept of identity must not be confused with the ideas of originality, tradition, nor authenticity, since identification processes and sense of belonging are constituted by traditions (roots, heritage, background, memories) and translations (strategies for the future, "paths", "routes", and projects).Identity is not limited to the question of "who we are", but also to "who we could become" […] the construction of identities has to do with "roots" (being), but also with "paths" and "routes" (to become, to come into being) (8) .
Thus, the ideas emphasized by Cruz (8) convey that, although identity construction also contains elements related to tradition, the meanings and senses of this "how, from what, by whom, and for what" construction will guide the actions of each group, which organizes the meaning according to social trends and projects rooted in the social structure, as well as in their view of space and time.The dynamic nature of identity construction is also highlighted by Almeida (9) , who reassures its relationship with social and historical processes.
Whether these arguments take us to consider that SNC would represent one of the translations of our collective identity, they also served as a source of new questions, among them: the teaching and practice of SNC would be contributing to the internalization of meanings that could set boundaries or guide our professional actions; in other words, would they be contributing to the consolidation of our professional identity?This question led us to reflect on the formation of professional identity, on which some considerations were made.
Systematization of nursing care and the formation of professional identity Gutiérrez MGR, Morais SCRV.

PROFESSIONAL IDENTITY CONSTRUCTION
To address this aspect of our discussion, two authors cited by Santos (10) , who presented different approaches on professional identity, were taken as reference.Initially they explain the concept of profession as a historically built social process and product.Drawn from this concept, they take on the construction of professional identity.
For one of the authors, Dubar (6,11) , the formation of the professional identity is a complex phenomenon, a product of secondary socialization mechanisms of the individual, and which presents continuities and discontinuities.The author claims that it is forged in a game of social interactions where the organizational context, the biographical characteristics of the individual, and his/her formation courses play an essential role.
For the other author, Blin (12) , the social context where a given profession is performed is fundamental for the consolidation of the professional identity and is related to professional practices and knowledge.He also states that more than the biographical aspects of the individual, what matters is to analyze, describe, and understand the organizational elements that are present.Therefore, elements such as formation, organizational characteristics, knowledge, and specific practices emerge as determining factors for the consolidation of an individual's professional identity.
The author also takes into account that the sense of belonging to a professional group constitutes an essential consolidating mechanism of professional identity.The sharing of values and spaces by a group of actors, as well as the relational game that emerges in this context, has a direct relationship with the construction and consolidation of a reasonable professional identity for the individual and for the group, since it is something socially constructed and, consequently, socially accepted (12) .
The elements pointed out by both authors contribute to the construction and consolidation of professional identity and are consistent with the dialectical perspective between the historical and social context, as well as with the intrinsic mechanisms of the identity process.The authors take into consideration not only the collective aspects inherent in the organizational world and in the reference processes related to the construction of the professional identity, but they also claim that similarly it is a product of individual characteristics, aspects and biographical experiences that distinguishes the subject as a single being that will act in a unique way, in the same organizational context and in the same process of secondary socialization.Therefore, professional identity is consolidated in an intervening context that requires a specific professional performance, observing the unifying matrix that allows someone to distinguish himself/herself from other professional groups.
The unifying matrix of the professional group encompasses the functional aspects of career, their goals, ethical and legal principles, and set of actors that shares a common reference and that demands from the individual the appropriation of these values as someone who belongs to a specific professional group (10) .They conclude claiming that career and professional identity are constituted by a set of knowledge and practices of a given social group.
In the case of Brazilian nursing, it relies on a vast production on the professionalization process and on the construction of the professional identity.Most of the authors (13)(14)(15)(16)(17)(18)(19) substantiate their analyses on the sociological theory of professions and in a historical framework.All studies consulted highlighted the historical and social nature of nursing professionalization and work and the attributes that define it as a profession and a scientific discipline, which have care as the subject of study and work.Among various constructive features of a profession, it is worth noting the questions related to the development of specific knowledge, scientifically documented and aimed at the collectivity, and the working process specificities in nursing carried out by different professional categories, and by the profession self-employment and self-regulation.
In this process of ongoing construction and reconstruction of their knowledge and practices, the authors point to many challenges faced by nursing to establish itself as a socially recognized and valued profession, but also emphasize its changing potential to grow and be further strengthened as such.For this purpose, the need for "generating meetings and discussions among individuals, health/service professionals, users, and the population" stand out (18) .
In the context of these studies, the SNC is addressed in order to guarantee the profession identity, its autonomy, authority, and responsibility; in other words, to confirm its status of a scientific discipline (18) .
It is also worth noting that the establishment of a specific knowledge that could delimit the essentiality of the profession and an appropriate space of power is crucial for professional autonomy (20) .Regarding this aspect, there are controversies whether the knowledge constructed by nursing would lead to sufficient specificity to achieve the necessary identity for delimiting an appropriate space of power and, consequently, professional autonomy (13,21) .However, the angle of our analysis will not address this issue.
As previously mentioned at the beginning of this presentation, since we tried to find the fundamentals that would allow us to establish the links between SNC and the formation of the professional identity, we ran into more questions than answers.Therefore, the considerations made by consulting different authors regarding professional identity motivated the emergence of a new question: Are nurses and other nursing team members sharing the concept of SNC as a common and constructive reference of their professional identity?

SYSTEMATIZATION OF NURSING CARE AND THE FORMATION OF PROFESSIONAL IDENTITY
If we take into consideration that the existence of rules and regulations that guide professional work is one of the attributes of the career status, then SNC is included in this context.Since the 1970's, Brazilian nursing has considered SNC as a specific know-how of the profession, turning it into a legal and mandatory requirement after publication by the National Council of Nursing, on Resolution 272 of 2002, repealed by Resolution 358 of 2009.This law determines the implementation of SNC and the Nursing Process (NP) in public and private settings where nursing care is delivered (22) .
For COFEN (Federal Nursing Council), the SNC "organizes the professional work according to method, personnel, and instruments, enabling the operationalization of Nursing Process stages" (22) .This, in turn, covers the key elements of our healthcare practice, of which nursing diagnosis and prescription of interventions are the exclusive competence of nurses.It also determines that it must be based on "theoretical support to guide data collection, the establishment of nursing diagnosis, and nursing action and intervention planning; and that could provide the basis for evaluating the results achieved" (22) .Accordingly, the NP represents the way nursing professionals act and think, and allow the organization of the necessary conditions for carrying out the care and documentation of the professional practice, which must be deliberately and systematically conducted (2) .
For these reasons, the importance attributed to the SNC concept, by our regulatory agency and by some nursing specialists (2,23) , is broader than the NP, and this is one of its components.In this context, when analyzing the SNC definition, it should take into consideration that it constitutes a tool for care management, since it involves aspects that go beyond direct care, allowing the evaluation of the efficiency and efficacy of the activities carried out, contributing to managerial and political decision making, and aiming at excellence in care (24)(25) .
However, what national publications on the subject (2,5) have shown, including practical experience, is that this conception is still not comprehensively internalized by the category.The terminologies SNC and NP have been used as synonyms.Authors have raised the possibility that the term SNC has been adopted in Brazil because of the definition that Horta (26) assigned to NP as the "dynamics of systematized and inter-related actions, aiming at caring for the human being" (4) .
Thus, the equivalence attributed to SNC and NP (4) contributes to the lack of consensus on the concept of these two key components for the nursing practice, with corresponding impacts on the formation of the professional identity.
When reflecting on some of these arguments raised by one of the authors mentioned in this presentation on the construction of identities (8,12) , the emphasis put on the internalization of the identity and on the meaning that social actors and individuals attribute to it becomes evident, in a sense of orienting their actions.They also argue that the meaning is organized around a primary identity, self-sustainable over time and space.
Assuming that our primary identity is nursing care, the above considerations take us to new questionings: Are we teaching and practicing SNC around a primary identity?Or are we emphasizing operational, bureaucratic, and function planning aspects instead of our primary identity that organizes the meaning?
Reading several articles on the shortcomings found in SNC teaching and practice, which in our view refers to the NP, it can be seen that most of them deal with the operational aspects involved in the execution, such as: amount of time required for carrying out the nursing process, lack of time, instruments too lengthy, and too much time spent on filling out all the required documentation.Some also refer to problems related to professional limitations regarding the development of required skills for implementing each one of the NP stages (deficit of semiology knowledge and basic techniques for performing physical exam, for developing precise clinical and therapeutic reasoning, for using communication and information technology, among others) (1,(27)(28)(29) .
However, little has been discussed on the impacts related to the construction of genuine nursing knowledge and, consequently, our professional identity, and low use of nursing theoretical frameworks that guide the use of this tool for providing care.Another aspect that receives little attention is the lack of credibility the nursing categories have manifested regarding the use of this technology, as the promoter of care quality and professional autonomy.We believe these aspects deserve special attention by the leadership of our profession, taking into account that the sharing of beliefs, values, knowledge, and practices is fundamental to the construction and reconstruction of professional identity.In this context, an instigating editorial was written by Herdman (30) , who raised the following question: "What is lacking in the nursing process?"The author says that she believes that "we did not incorporate what it seemed obvious, and it got lost now" -care (bold added).She also points out that we forgot that the process is based on a solid foundation of nursing knowledge, upon which the teaching and practice of the profession must be the focus.Only when we incorporate this understanding, we will be capable of implementing the process in a way that it would make sense (30) .
According to the references used in this presentation, only when the meaning is attributed to what we know and what we do, we will be able to include it as something pertaining to our professional identity.Thus, another reflection emerged: To what extent the conformation of the nursing team that includes members with different levels of education and competences (roles) related to the NP would constitute an aggregating and empowering factor for professional identity?
If our profession is centered in care and the NP is the way of giving scientific rationality to it in order to make the specificity of our know-how evident, we believe that all components of the nursing team should have the required knowledge from all the stages that enables the participation in the construction and consolidation of the sense of belonging to a professional group.According to Dubar (11) , they are " the activities that hold the symbolic dimension in terms of selfactualization and social recognition that would allow them to be identified by their work and, consequently, to become recognized".Therefore, we agree with the argument made by Salvador (31) that this is a serious issue because, "as long as knowledge on the NP is limited to nurses, it is unlikely that other nursing team categories contribute to its recognition" as something meaningful to qualify care.

FINAL CONSIDERATIONS
The authors recognize that the establishment of a relationship between SNC or NP and professional identity is not a simple task to be analyzed, because it is a professional practice that presents a series of ambiguities and strains, resulting Systematization of nursing care and the formation of professional identity Gutiérrez MGR, Morais SCRV. in a know-how constructed not only by difficulties, but also and mostly by potentialities in order to consolidate itself as the generator and organizer of our care practices, the reference of identity of our profession.
These paths and routes have been thought and constructed with the participation of all those involved in the care process, nursing professionals, class representative entities, and healthcare system users.