Environmental health: emancipatory care challenges and possibilities by the nurse

Objectives: to discuss challenges and possibilities for the construction of Environmental Health emancipatory care practices by the nurse. Methods: reflective analysis based on conceptual, theoretical, and methodological aspects of nursing care, under the emancipatory and critical perspective. Results: contemporary environmental issues involve complex determinants of the health-disease process. This fact requires the accomplishment of educative actions that encourage the change of environmental attitudes related to health-risk situations. In this sense, there are significant demands for emancipatory practices of primary care in Environmental Health by nurses, which need to be systematized by health and education institutions. Final considerations: the nurse, as an educator and social actor, should offer emancipatory practices of risk management, empowerment, and shared social and environmental responsibility, with a view to recovering an ecological well-being and social transformation, to improve environmental quality and human life.


INTRODUCTION
Environmental Health is a field of Public Health that has been producing demands for emancipatory practices of health care for nurses and Primary Health Care professionals (PHC), given the environmental and health risks to which populations are exposed and the proximity of practices of these professionals in the territories. Such practices are characterized in actions of environmental risk management and critical-reflectiveeducation, which should encourage citizenship and socio-environmental transformation (1) .
The actions developed under the emancipatory prism in health should provide means to increase political power and technical knowledge of individuals and social groups in conditions of inequality of decision, mediation, and interference on the quality of conditions and factors that influence health and human well-being (2) .
In this context, social, assistance, and scientific relevance of the nurses' insertion in spaces, sectors, and territories, where there is a production of situations related to health-related environmental hazards, becomes fundamental and visible. Nurses, as professionals sensitive to vulnerabilities and emerging health needs, play a significant role in the application of their knowledge to promote health and improve the environmental and life quality of individuals and communities (3) .
Based on these meanings, nurses' abilities and abilities to exercise care practices committed to maintaining good environmental conditions in places where people, families, and communities live and work need to be more evidenced, discussed, and legitimated, according to the scientific, social, and political perspective. Accordingly, there would be a better use and appreciation of its work process in this direction. In Brazil, care performed by the nurse in Environmental Health, even emerging as relevant, is still incipient. Currently, there is no specific scientific policy, consensus or consensus on this form of action.
In light of these considerations and the international insertion of nursing in global and local socio-environmental issues, there is a need to list and reflect on possibilities and challenges of high quality care by nurses in Environmental Health.

OBJECTIVES
To discuss challenges and possibilities for the construction of Environmental Health emancipatory care practices by the nurse.

EMANCIPATORY CARE PRACTICE CHALLENGES IN ENVI-RONMENTAL HEALTH BY THE NURSE
In Brazil, environmental and health risks are the most diverse, including remote problems ranging from inadequate basic sanitation to more recent technological factors, including the spread of radioactive and chemical agents (drug residues, pesticides, metals heavy, plastic, etc.) with crossings by distant directions and locations (1) .
Such complexity of the contemporary environmental problem requires the critical perception by nurses of environmental, life, and work conditions as determinants of the health-disease process in the territory. Accordingly, the plurality of environmental problems calls for the adoption of measures that overcome biomedical and welfare practices, leading to the adoption of transdisciplinary actions imbued with environmental attitudes and collective movements of sensitivity in the ecological-sanitary dimension (3) .
Another challenge relates to the ability of nurses to assist people with morbidities related to environmental and occupational exposure to hazardous substances, through the implementation of early intervention actions in nursing, in these health problems, as well as skills to collaborate with communities with forms coping in disasters, floods, and overflows (1,4) . There is no published knowledge about nursing practices in these problematic contexts (1) .
Nowadays, there is a growing movement of nurse autonomy, with the expansion and consolidation of care and management actions in PHC services, which include emancipatory health promotion practices (2) . However, it is revealed as a challenge of this type of practice, the application of methods of community intervention by nurses, which contribute to the improvement of environmental quality and equity in Collective Health (4) .
Emancipatory practices in health are those that enable people to reflect on the origin of health problems and to equip them to access and fight for their health rights. Such practices encourage values of solidarity and rescue the human condition as a multidimensional and singular condition, in antagonism to the condition of the individual exclusively as a biological being. Examples of emancipatory practices performed by the nurse within the PHC are: home visits, team meetings, and meetings for health education (2) .
Still, the production of knowledge on Environmental Health emancipatory care practicesby the nurse is scarce. Romão et al. 's study (5) pointed out that the participating nurses carried out specific actions of environmental education with the population and the Community Health Agents, in physical spaces of the family health unit, residents association, and domicile.They were restricted to providing information on the environmental risk factors identified in the territories. Another study (6) evidenced the implementation of educational practices carried out by the nurse, who promoted reflections in adolescents in the school setting, on socio-environmental issues in their community.
Accordingly, environmental education practices are limited to the exchange of information and distant from the purpose of training citizens who seek changes in environmental perceptions and attitudes,from a shared production of ethical values and critical knowledge of the political, social, economic, ecological, and sanitary dimensions.
The expansion of environmental education actions by nurses at all levels of education and health care has been consolidated in recent decades.As a result, it has become an important working tool in the management of socio-environmental problems and their impacts on public health (4) . Nevertheless, environmental education still presents a challenge for nurses.
Based on a critical, transformative, and emancipatory perspective, the development of environmental education practices requires the preparation of nurses' knowledge about the involvement of different social actors (health professionals, residents, political agents, etc.) in different stages of this process. These steps include performing diagnostic actions on local environmental conditions and factors, their interrelation with health-risk situations, considering the perception of individuals and group about problems'priority that affect health; implementation of participatory action, whose methodological proposal is appropriate to the social context of the participants; participatory evaluation of the results, through strategies that must be in line with the interest of those involved in the process (1) . The critical dimension concerns the awakening of the subject's consciousness to questions of his own perception and attitude towards life and the environment. Furthermore, critical educational praxis has as its purpose the denial and overcoming of preconceived truths; knowledge of the environmental situation, in order to transcend the preservationist vision, from the historical context of social, economic, and political relations on the environment; and constitution of human skills to synthesize knowledge and actions organized by the social groups involved in praxis (7) .
The transformative dimension of educational praxis refers to the idea of changes in attitudes, as subjective human conditions, and of objective situations of environmental deterioration. In relation to the emancipatory praxis, educational action should offer broad access to information and encourage active participation and empowerment of individuals and groups in the problematization of the environmental reality and its influence on the health situation. These must be indispensable requirements for the construction and use of sustainable solutions and alternatives (3,7) .
In this sense, Paulo Freire's critical pedagogy has been recognized as the theoretical-methodological reference that best supports the development of environmental education practices. The nurse has appropriated the theoretical and methodological knowledge of this pedagogical proposal, to use it as the guiding axis of its educational action in health (7) .
However, the applicability of Paulo Freire's pedagogical assumptions in Environmental Health educational practices has emerged as a challenging possibility for nurses. The pedagogical relationship based on the valorization of a democratic and horizontal dialogue between learners and educators, for knowledge construction, in which authentic thinking and the plurality of knowledge of both and of the protagonism of the participants must be respected, must be linked to the critical dimensions, transforming and emancipating this Environmental Health educational praxis (4,7) .

EMANCIPATORY CARE PRACTICE POSSIBILITIES IN EN-VIRONMENTAL HEALTH BY THE NURSE
Planning and execution initiatives of care practices in Environmental Health, with quality by nurses, should contemplate ecosystem actions in their daily work. Thus, opportunities for comprehensive care based on the precepts of interactivity, balance and sustainability between humans and their multiple biological, social, psychological, and spiritual dimensions with the environment would be created (2) .
The scope of an ecosystem health care by nurses is possible through the practice of environmental health-risk management practices that are included in the level of health promotion actions. These practices are consistent with the implementation of diagnostic actions and local surveillance of the state of environmental health, investigation and follow-up on the epidemiological profile of the assisted population'shealth situation (1) .
Nurses must distance themselves from naturalistic conceptions that have been guiding practices in Environmental Health. They must know different tools of territorial analysis and possibilities of socio-environmental participatory diagnosis, which are closer to the curricular aspects of their training, based more on social theories than on laboratory and quantitative analyzes (1,4) .
Another important contribution possibility of nurses is through their participation in health and environmental decision-making (municipal, state, and Brazilian boards and conferences). In these collegiate instances, it is evident the importance of the nurse's engagement as a social actor and possible representative of civil society and the health professionals segment on the formulation of public policies, with a view to social justice (1) .
In this sense, nurses have shown lack of knowledge and little engagement about global health problems from the perspective of sustainability (8) . It is worth noting that nursing has been internationally recognized by the International Council of Nurses and by the Sigma Theta Tau International Nursing Honor Society (STTI) as an important category for the achievement of sustainable development goals (9) .
In modern Western societies, the use of sustainable development is indispensable in the health sector. This sector is linked to the social, scientific, and political concern of ensuring equitable and equal access of individuals and communities to the resources and possibilities of exercising rights for the promotion of healthy environments (8)(9) . Sustainable development advocates the search of current populations for conditions to maintain their needs, without making it impossible for future generations to meet their needs. It is therefore urgent to develop a sense of global interdependence and universal responsibility (9) .
It is necessary to explore and incorporate sustainability in all its environmental, socio-cultural, economic, political, and organizational dimensions in the areas of teaching, research, and nursing care (8) . The understanding of ecological care as a complex phenomenon and commitment to citizenship, ethics and environmental sustainability is essential for the practice of extended, emancipatory, and systemic health care by nurses (10) .
In order to do so, the training context of nurses should provide different spaces and settings for the production of knowledge, skills, movements and attitudes in relation to the different forms and needs of this professional in Environmental Health (10) .
The methodology of the problematization, in accordance with Paulo Freire's proposal, has embraced dynamic and affective strategies with good results in the process of teaching and environmental awareness (1,7) . This strategy, as an alternative methodology, has broadened the possibilities of students' empowerment in the exercise of environmental ethics. Therefore, it is a path that aims to offer opportunities for changes in attitude and to assume co-responsibility for complex local and global environmental issues (1) .
In addition, in the nurses' training processes, interdisciplinary environmental education should be considered, with a view to opening spaces that allow reflection and critical capacity of the people to construct identities and values with the environment and modern society (4) . It is therefore reiterated the importance of constructing formal and non-formal spaces and instigators for debates and reflections on the health and environment interface, constituting a fundamental attitude for the search for a more inclusive vision on the theme (6) . Recent studies (1,4) developed with nursing students from a Brazilian public university, revealed the possibility of applying two research techniques rarely used in nursing scientific production, the photovoice and the World Café, which also served as teaching-learning strategies based on real problems.
In this way, health and education institutions have fundamental roles as promoters of this discussion. They offer not only an academic and social contribution in this respect, but also provide spaces, mechanisms and resources for students and workers to rethink their work, based on their experiences and individual reflections on themes involving co-responsibility, ethics, and socio-environmental sustainability, as well as its repercussion on human health and quality of life (10) .

Contributions to Nursing
The emancipatory and critical perspective has brought about amplification of the analyzeson challenges and possibilities of care practices in Environmental Health. The nurse, showing that they should not be restricted to the raise of environmental problems that are affecting human health and quality of life, can develop them. These practices should promote strategies of care among people and communities, aiming to broaden their critical capacities of perception, engagement, and attitude in the search for the resolvability of such problems and health-risk situations in their real contexts.
Therefore, there are significant demands of Environmental Health emancipatory care practices by the nurse, which need to be systematized by the health and training institutions.
It is hoped that the knowledge of this reflection can subsidize changes not only in training settings and in qualification of the nurse's knowledge and practices in Environmental Health, but also of health institutions and in territories.These include the need to adjust political, social and professional structures,contributing to enable the professional to understand, incorporate and implement Environmental Health emancipatory care practices in health actions'agenda.

FINAL CONSIDERTIONS
A healthy environment is not only an element of quality of life but also an inalienable right to health. Therefore, it is up to nurses to perform a comprehensive and ecosystem health care. They should encompass not only the biological, psychosocial, spiritual aspects of the individual, but the intervention on the environmental conditions of life and work of communities and collectivities.
There are indications that nurses are gradually distancing themselves from naturalistic conceptions about the environment. Environmental changes can be affected by political, economic, cultural, social, and infrastructure activities, as well as by the population's health risks.
Furthermore, they advance the perceptions of these professionals about the relevance of the practices of care in Environmental Health, built from the emancipatory and critical perspective. Nonetheless, there is a need for such practices to be systematized and legitimized by health institutions and for training institutions to be places where this movement should be triggered.
Environmental Health emancipatory care practices by nurses enables the community and members of its health team to be trained to understand the ways of guaranteeing the environmental rights that constitute health rights.
Nurses, as educating agents, should offer practices of empowerment and shared socio-environmental responsibility, with a view to recovering an ecological well-being. Possibly, this will allow the consolidation of active human attitudes for the transformation and improvement of the environmental and human life quality.