Productivity of subjectivity and autonomy of nursing professionals in Pediatrics

Rev Bras Enferm [Internet]. 2019;72(Suppl 1):41-8. http://dx.doi.org/10.1590/0034-7167-2017-0591 ABSTRACT Objective: To know the aspects involved in the production of subjectivity and autonomy of nursing professionals working in Pediatric Units. Method: An exploratory and descriptive study, with a qualitative approach, performed with users, professionals and nursing managers, totaling 44 participants. Data collection took place in the pediatric hospitalization units of two University Hospitals through semi-structured interviews, organized and treated by Nvivo 10 software and then submitted to content analysis. Results: The production of subjectivity and autonomy in nursing workers involves both the conditions of the work environment as the relation of the nursing team, the relation of hierarchy and the profile of the professional that works in the Pediatric Unit. Final considerations: The valorization path of the nursing profession emerges, whose knowledge and competence in the area of work contribute to the construction of autonomous subjectivities. Descriptors: Pediatrics; Child, Hospitalized; Family; Nursing; Professional Autonomy.


INTRODUCTION
The nurse in the Pediatric Unit, as a member of the health team and as a child care provider, often faces dilemmas related to inadequate space for care, lack of protocols, conflict over autonomy, among other factors that may hamper comprehensive and humanized care (1) . To change this situation, care needs to be taken as a process of participative construction whose relationship between managers and workers, between workers and those with patients is based on human values and principles.
However, the prevalence of relations of domination and subordination entails a process of subjection, which interferes with the decision of the nurse to allow or not to think, question, occupy the different spaces and exercise their autonomy as a subject. Also, it can be expressed by the patient and his/her family when the nurse, in the exercise of his/her autonomy, assumes an arbitrary position, placing them in a situation of submission, without considering the possibility of sharing decisions in the practice of care; (re)producing subjectivities that meet the "good patient" (2) .
To break this process of subjection, it is imperative to consider all forms of manifestation of subjectivity, enabling professionals to express and seek to realize their desires and desires. However, the singularities of nursing know-how are historically constructed in a network of power relations, in which the biomedical model decomposes care into diversified and isolated activities, reflected in discontinuous and fragmented care (3) .
Scholars show that fragmentation in child care "enables them to be identified in the health statistics of the population only according to their various illnesses and moments of exacerbation, making it difficult to recognize them in terms of comprehensiveness and the offer of health care with complexity and uniqueness of each child" (4) .
This form of assistance necessarily implies the reduction of subjectivity, since, in general, the professionals do not know the whole process, corroborating so that the health and nursing practices persist with "characteristics of the biologicist medical model, mechanistic, professional centered, which emphasizes the super-specialization to the detriment of a health action that is capable of apprehending the broader needs of the users and families, in a context that aims at the comprehensive care" (5) .
In this sense, a study aimed at identifying how undergraduate students in nursing perceive the comprehensiveness of child care in their learning process, showed that they perceive the concern, by parts of some professionals, for the accomplishment of tasks related to care as a fragmentation in caring mode. For students, the division of labor with the development of isolated tasks falls short of what is necessary to fully assist the child (6) .
This fragmentation of child care points to the risk of care if it is configured by performing tasks similar to an assembly line in which each professional performs a part of the work process without understanding it in a comprehensive way. The children, hospitalized in the pediatric unit, seem to circulate in the wake of the health assembly line, receiving from each member of the team parts of the care (1) .
When assistance does not enable professionals to express their creative capacities and restricts their possibilities of achievement and innovation, it ends up adding to the work the sense of destructive activity, which does not encourage or enhance the virtues of its workers (7) . In this sense, it emerges the importance of considering all forms of manifestation of subjectivity, enabling professionals to express their way of being in Nursing and in the health team, enhancing relationships and, consequently, transcending the traditional performance by category that fragments and distance from full care to the child.
To that end, the Pediatric Unit needs to be constituted in a space of interaction and interaction in which intersubjective relationships are established, enabling the nurses to appropriate space and (re)invention of the work environment, consequently, producing their subjectivity and autonomy (2) .

OBJECTIVE
To know the aspects involved in the production of subjectivity and autonomy of nursing professionals working in Pediatric Units.

Ethical aspects
In order to guarantee the ethical principles of research involving human beings, Resolution 466 of December 12, 2012 (8) was respected. To the participants, the objectives, the justification and the risks and benefits of the research were explained by signing the Free and Informed Consent Form, thus expressing knowledge and agreement to participate in the study. In order to preserve the anonymity of the participants, the letters U were used for the users, N for the nursing workers and M for the managers, followed by Arabic numerals that indicate the interview number. However, the environments investigated were identified as HA and HB.
The research project was submitted to the Brazil Platform and was approved by the Research Ethics Committee in the Health Area of the Universidade Federal do Rio Grande (FURG), through the Certificate of Presentation for Ethical Apreciation (Certificado de Apresentação para Apreciação Ética), receiving a favorable opinion under Protocol 033/2014.

Type of study
This is a descriptive, exploratory and qualitative research. This type of research is pertinent to the study of social relations, since it allows the analysis of concrete cases, starting from the expressions and activities of the people in their contexts (9) .

Study setting
The study was carried out in the pediatric hospitalization units of two University Hospitals. Both institutions are a reference in the service to the population of the micro and macro-region south of Rio Grande do Sul State, in addition, they have historical similarities in relation to the origin, involvement with teaching, research, extension and health care.

Study participants
The study participants were users, nursing professionals (with representatives of the different work shifts: morning, afternoon, night I, night II and night III) and managers. In all, there were 44 participants, defined by the saturation of the data, that is, when some redundancy or repetition was obtained, and it was not considered relevant to continue collecting data.
Study participants were selected according to the previously established inclusion criteria. For the professionals, the criteria were: to be a nurse, technician or auxiliary nurse, working in the pediatric unit for at least six months, and in the case of managers, to be working in nursing and management services in health/hospital institutions. For the users, the criteria were: to be at least 18 years of age, to be involved in the care of the hospitalized child and to be familiar with it. Nursing professionals and vacation or health leave managers were excluded from the study during the period of data collection. For the managers, the criteria were: to be a nurse and active in the management of nursing services for at least six months.

Collection and organization of data
Data collection occurred in the second half of 2014 through a semi-structured interview, guided by the following question: In the Pediatric Unit, what aspects influence how the team and nursing develop care? The interviews were carried out by a single researcher, Master in Nursing, trained for this purpose.
In order to guarantee the privacy of the participants, the unit's procedures room was used to conduct the interviews, respecting the availability of participants and the said room, in a way that did not interfere with the functioning of Pediatrics. The interviews were recorded and later transcribed. The Nvivo 10 software was used to organize and treat the data generated by the interviews, since it assists in the analysis of qualitative material through its tools of codification and storage of texts in specific categories (10) .

Data analysis
The data were submitted to the analysis of content understood as a set of methodological instruments constantly improved and applied to speeches, providing the researcher with the search for the latent, not apparent and hidden in the analyzed discourses. This method was implemented in three phases: pre-analysis, material exploration and, finally, treatment of results, inference and interpretation (11) .
The pre-analysis is constituted by the organization of the transcribed material with the purpose of systematizing the initial ideas, from the floating reading, allowing constituting a corpus. In the phase of exploration and analysis of the material, record units are extracted from the text for later codification of the data and their categorization (11) .

Characterization of participants
The study had the participation of 20 users, 20 nursing professionals and four managers, totaling 44 interviewees. The users were exclusively women, with 19 mothers and one hospitalized child aunt. The ages varied between 19 and 48 years, with predominance between 19 and 29 years (n= 12;60%). Ten reported being single, seven married and three divorced. With regard to schooling, ten had incomplete elementary education, four had completed high school, three had incomplete secondary education, two had completed higher education and one had completed elementary school. With regard to the work activity, 12 exercise some activity and eight are dedicated to domestic activities.
Nursing professionals are characterized by the preponderance of the female sex, with the participation of 18 women and two men; being ten nurses, five technicians and five nursing assistants, with a time of operation in the pediatric unit between six months and 23 years, with an average of seven years of operation. Their ages varied between 35 and 55 years, most between 45 and 55 years (n= 11; 55%). The managers are exclusively female, with ages between 40 and 55 years and academic training in Nursing. The time spent in management ranged from one to 20 years.
From the organization and analysis of the data, the following categories were relevant to the production of subjectivity and autonomy in the nursing professionals of the Pediatric Unit: working conditions, the nursing team relationship, hierarchy relations and professional profile.

Work conditions
The interviewees show that the production of subjectivity and autonomy of nursing workers is related to the working conditions offered by the Pediatric Unit whose lack of structure, material and human resources impose limits on the care provided, consequently generating sadness, irritation, stress and disillusionment, since it requires that the nursing team make efforts to obtain the means that they should have in the unit and that are necessary to assist the user. Over time, the inadequate conditions of the pediatric unit are absorbed as part of daily work and workers are subjected to the existing reality without expressing any suggestion of improvement even when they deem it necessary to do so. [ The need for adaptations in the physical area, such as the inclusion of space for workers to store their belongings and the expansion of the nursing station, makes the workers feel disrespected and unsupported in the development of this work, which sometimes discourages them.

Relationship among nursing workers
The interviewees understand that the production of subjectivity and autonomy in nursing is directly related to the way in which the relationships of the pediatric unit team develop. In this sense, the nursing professional needs to be understood as a relational being, who develops ties with his/her peers and, therefore, needs to be embraced, have a good relationship with the team, so that he feels confident and has the will to exercise his/her process and express their uniqueness, their way of caring, their way of practicing Nursing.. Team coordination is cited as a greater resource to address the existing inadequacies in the unit and to make the environment humanized for itself and for the user. Due to this, there is appreciation of all the people who make up the pediatric health team, encompassing academics and professionals from different areas, so as to integrate each one's contribution to improving the environment and child care. Each person here is valued, from the academic who is coming from a more initial series to the one that is graduating. All professionals are highly respected and valued, as each one has its contribution. (N1_HB) The multiprofessional team, all professions, each will contribute to a need. Nursing has its importance, Medicine, Psychology, Social Service, occupational therapist, physical educator, physiotherapist, so all these people actually living here and exchanging needs. (N8_HB) Nursing assumes a fundamental role in maintaining this multidisciplinary relationship, establishing links and integrating the various support sectors and their professionals in the care of the child.
Nursing is at the center of everything else. It is the nursing that makes the link between the laundry, the concierge, the physiotherapy, the nutrition. (N3_HB) I think a very positive signal is precisely these interpersonal relationships that exist between the team. It has cohesion. So, I guess you have to have a trait to work in the pediatric unit. (M2_ HB) In Pediatrics, the multidisciplinary issue is, has Nutrition, Psychology, Medicine, has Physical Education staff, everyone interacts, has good communication. The nurse went there, made the visit to the patient and saw that the mother is in need of clothes, that baby is wearing a little diaper, so she gets in touch with the social worker and the social worker sees that part. Oh, that mother is not very well, suddenly talk to psychology, then call the psychologist. I believe that the multidisciplinary issue within the hospital is well established, works well. (EM5_HA)

Hierarchy relationships
In the daily work in the Pediatric Unit, the nurse experiences relationships of (with) sharing of care to the child, emphasized mainly by the participation of the family and by medical professionals. While the family members assume activities already known and carried out in the daily care of the child, such as bathing and feeding, Nursing performs specific procedures and care based on specialized knowledge, which gives it the title of holders of scientific knowledge.
I think it's okay, everything is quiet too, all partnership. We take care of one side, the side of the bath, of feeding and they the side of science. (U10_HB) I think they need us here to help them and we need them to treat our son, because doctors do not always treat us. Most of the time, the people who treat them are nursing, they give medicine, everything is right. (U1_HB) However, the use and manifestation of nursing workers' science is still mediated by a historically constructed hierarchical relationship system, which attributes to the doctor the supreme power over therapeutics. This form of relationship between the different areas has consequences in the planning and exercise of nursing care, therefore, in the autonomy of the professional, since it is perceived as a barrier to the expression of their clinical and scientific knowledge and judgment. Thus, revealing that, even with caveats, the subjectivity of being a nurse is still permeated by the relation of submission to medical authority. On the other hand, the valorization process of the nursing profession emerges, whose knowledge and competence in the area of work contribute to the construction of subjectivities and autonomy. The knowledge and experience of the nursing professional are recognized by the managers, so that they understand that their role should be a facilitator, promoting conditions for nurses to constitute their subjectivity and exercise autonomy through the freedom to make claims in for the child and his/her family. I

Profile of the professional of nursing
Another aspect that influences the construction of the subjectivity of the nursing professional is the taste for the profession. For the users, liking what is done contributes to the development of humanized care, which, meeting the expectations of the children and their families, involves care, attention, education and patience. Therefore, the care that goes against what is expected by them is accomplished by workers who are not professionally performed, who do not like their doing.
We see a lot of care, but also see that there are some who are in that profession, but they do not like doing their work as it has to be done. (U3_HA) Similarly, the managers point out that Pediatrics is a singular unit whose object of care arouses the emotion of the worker and, for this reason, it is expected that the professional has a certain profile, which has not only the technical capacity, but also personal attitudes of sensibility which, consequently, will imply in their professional performance.
[...] we have the technical part and the personal part. It's no use getting a person to want her to take action if that's not part of her staff, so I need to identify the profile of the professional to put in the industry. This profile is how the person serves that child, not only technically, but overall, in the whole. We work a lot with emotion in Pediatrics. This is something that I consider quite important and that interferes with professional performance. (M1_HB) In addition to the taste for the profession, nurses must be psychologically prepared to experience daily work situations, which can positively affect when the child's clinical condition improves or, on the other hand, shake and de-structure the team due to feelings of impotence of the child's death.

DISCUSSION
The interviewees revealed that the production of subjectivity and autonomy is related to the working conditions offered by the Pediatric Unit. The nursing professional, when entering the workplace, believes that he will find subsidies that allow him/ her to do the same, such as the adequacy of human resources, materials and the establishment of favorable relations (12) .
Faced with the limitations imposed by the unit, nursing professionals experience a sense of sadness, irritation, stress and disillusionment because they do not have the necessary resources to assist their users. In this finding, researchers point out that, when subjects undergo their activities without the necessary and sufficient conditions, nursing professionals experience situations of suffering at work, remaining resigned to the way the service is organized and, sometimes, blaming themselves for institutional shortcomings or insecurity, as if they were responsible for the same (7) .
Thus, it is imperative that the design of the pediatric unit results from "the analysis of the processes that occur in the environment, generating a planning that perceives which interferences can compromise the actions, relating the built space, users, employees and the environment, integrating multidisciplinary competences" (13) . An Italian study that investigated the dimensions that have a greater impact on the perceptions of the organizational climate in pediatric wards, pointed out that for health workers the relationship with the leader and the cooperation with colleagues are the organizational dimensions that have a great influence on the satisfaction, cohesion and mutual trust between the leader and the group (14) .
In this sense, the results of the present study evidenced the importance of the relationships developed in the unit so that the nursing professional feels confident and at ease to exercise his work process and express his way of caring. Considering that work occupies a prominent place in the life of the people, it is essential to make it possible to express the subjectivity of workers and to boost their participation in the planning and organization of work (12) . Research with the objective of determining the level of autonomy that pediatric nurses perceive in their work found that the assistance tasks are developed with greater independence, especially the actions of education and health promotion, while in the development of the administrative functions are shown more dependents (15) .
It is emphasized that information sharing can bring professionals closer to the global knowledge of the work process, because by avoiding alienation and suffering, pleasure and well-being at work are potentiated (12) . Contributing to a "being" and "doing" in conscious and critical Nursing in the perspective of comprehensiveness and humanization (16) .
The National Humanization Policy (PNH -Política Nacional de Humanização) recommends the development of work processes that consider the knowledge and contribution of the different specialties, so that professionals can approach and develop exchanges, breaking with the traditional performance by category (17)(18) . In this sense, a study that examined the perceptions of autonomy and empowerment of nurses under the supervision of a doctor evidenced the increase in the promotion of power independently if the supervision adopted by him/her was of the facilitating or restrictive type. Thus, assuming that the opportunities for collaboration and interaction with doctors and other health professionals could facilitate the delegation of Nursing authority, optimizing their contribution in the assistance (19) .
The creation and adaptation of multifunctional or collective spaces destined to meetings, orientations, lectures, workshops and the like, emerge as a way to avoid sharing by specialties that consolidate real "fiefdoms" in the health services (20) . This means the possibility of connecting the different work processes, horizontalizing knowledge and power relations through the valorization of the knowledge of each professional that integrates the nursing and health team in search of solutions to the real problems encountered in daily life, in its multiple dimensions (16) .
In this sense, the present study pointed to the interaction of the team working in Pediatrics as the greatest resource to face the inadequacies of the unit and to make the environment humanized both for Nursing professionals and for the user. So that the diversity of professionals that could be a factor generating conflicts leads to discussions about the daily practice of care, and is an important means to raise awareness of the problems inherent in the work routine of the different professional categories, strengthening the capacity of the health team to know and recognize the peculiarities of the pediatric environment and, consequently, to solve and address the problems related to child care (21) .
On the other hand, the participants revealed that the subjectivity and autonomy of Nursing is still permeated by the relation of submission to medical authority. According to these findings, another study aimed at understanding the relationship between nurses' subjectivity production and decision-making in the care process indicated that dominance and subordination relations still prevail, which lead to a process of subjection that interferes in the decision of the nurse to allow or not to think, question, occupy the different spaces and exercise their autonomy, as subject (2) .
In a slope that is contrary to the nursing professional's assumption, the findings of the present study point to the path of valorization of the Nursing profession whose knowledge and competence in the area of performance contribute to the construction of subjectivities and autonomy. Similarly, research aimed at showing the construction of the professional autonomy through the Nursing Process (NP) evidenced that the application of such a process based on clinical judgment and proactive patient advocacy was the mainstay of nurses' autonomy in decision-making (22) . The implementation of the NP, by directing the organization of work according to the specific attributions of Nursing, provides nurses with greater personal and professional satisfaction (7) .
In view of these findings, it is important to emphasize the importance of establishing other forms of undervaluation that make it possible to overcome the submission posture and to enforce, in practice, autonomous nursing workers, committed to scientific evolution and to the principles of valorization of the profession (2) .
However, the last centuries have been characterized by the dictatorship of the way-to-be work as intervention, production and domination which, because it is salaried, is related to capital. As a consequence, the delivery of some nursing workers to the logic of the predatory work-mode is observed, which retracts it on its own horizon, resulting in a process of dehumanization and brutalization of relations (23) .
In this context, the great challenge of combining work with care emerges, since Pediatrics is a singular unit whose object of care arouses the emotion of the worker. For this reason, the participants of this research emphasize the need for the nursing professional to meet a certain profile, which reconciles technical capacity to personal attitudes of sensitivity. In order to uncover the elements of humanized care present in the encounter between nurse, family and child with cancer, some feelings need to be evident when care is given, such as caring, love and respect for the other and for the profession (24) . In this sense, care comes as concern and restlessness, but also as zeal, concern and kindness towards people and their vital and environmental environment (23) .
Complementing the profile of the nursing professional idealized by the participants to work in the Pediatric Unit, we highlight the psychological preparation to experience daily work situations, which can positively affect when the improvement of the clinical picture of the child occurs or, on the contrary, shake and disrupt the team by the sense of impotence felt before the death of the child. In this regard, research aimed at understanding the meanings attributed by the nursing team of a pediatric inpatient unit to their daily life found an ambiguity of feelings, since it now arouses emotions of joys, being gratifying, pleasurable, now, arousing sadness and concern (25) . It is often observed that the caring attitude that involves the health professional affectively and fills him/her with concerns about the patient is very demanding, especially if care is not a sporadic act but a permanent and conscious attitude (23) .

Study limitations
The study registers as a limitation the impossibility of generalization of its results for the entire population, since it was carried out in two university hospitals in the South of Brazil, thus representing characteristics and relationships existing at the local level.
Another limitation to be pointed out is the fact that the collection of data occurred at the place of care of users and the work of nursing professionals and managers, which may sometimes inhibit free expression about the phenomenon under study.

Contributions to the sector of Nursing
By presenting a multiple unveiling of the construction of subjectivity and autonomy of nursing professionals working in the Pediatric Unit, the results of this study make it possible to propose improvements and transformations in the work environment and in the relationship of the nursing team and other professionals who work in this unit, consequently, contributing to the construction of autonomous subjectivities.

FINAL CONSIDERATIONS
The results show that the production of subjectivity and autonomy in nursing workers involves both the conditions of the work environment as the relationship of the nursing team, the relationship of hierarchy with the health team and the profile of the professional who works in the Pediatric Unit , understanding that the relationships that the nursing team establishes with each other and with the other professionals converge to the line of comprehensive and shared care to the child, including overcoming inadequacies in the work environment.
It is imperative that hierarchical and subordination relationships be abolished, since they have consequences in the planning and exercise of nursing care, blocking the expression of clinical knowledge and judgment. On the other hand, the appreciation of the role of each one within the health team makes the nurse feel at ease to exercise their work process and express their uniqueness, their way of caring, their way of practicing nursing.
Given the results, the study registers the need for valorization and investment in the potential of the nursing team, since its integration, in addition to overcoming existing inadequacies in the Pediatric Unit, contributes to multidisciplinary integration, establishing links with the various support sectors and their professionals in child care. In addition, the valorization path of the nursing profession emerges whose knowledge and competence in the area of action contributes to the construction of autonomous subjectivities.