Comprehensiveness of care-permanence in nephrology: nurses’ conceptions* Integralidade do cuidado-permanência na nefrologia: concepções de enfermeiros Integralidad del cuidado-permanencia en la nefrología: concepciones de enfermeros

* Extracted from the thesis: “Cuidado permanência uma construção conceitual e sociopoética por enfermeiros na nefrologia”, Escola de Enfermagem Anna Nery, Universidade Federal do Rio de Janeiro, 2019. 1 Universidade Federal do Rio de Janeiro, Escola de Enfermagem Anna Nery, Rio de Janeiro, RJ, Brazil. 2 Universidad Autónoma del Estado del México, Facultad de Enfermería y Obstetricia, Toluca, Mexico. ABSTRACT Objective: To discuss how care-permanence comprehensiveness is for patients undergoing treatment in nephrology. Method: A qualitative, exploratory and descriptive study anchored in Sociopoetics, conducted in the first semester of 2018, in Rio de Janeiro, Brazil, with nurses from nephrology services. The data were produced after applying the creative technique with drawings and collages and taking recorded statements about the signifieds and signfiers of care-permanence. The analysis was performed based on the principles of Sociopoetics from the philosophical conceptions of the research groups. Results: Fifteen (15) nurses with experience in nephrology services participated in this study. Four conceptual axes were shared referring to: comprehensive care; complex care; continuous care; and inclusive care, which considers the patient’s family, team, society and their context, in addition to the patient themselves. Conclusion: A philosophical reflection on care of the human being implies considering the physical, emotional, and individual dimensions, but also its micro and macromolecular revolutions of existence as a social being. The nature of knowledge from the ludic production enabled reflection and awareness for all the time and at all times about the comprehensiveness of care by nurses in nephrology.


INTRODUCTION
This study has the comprehensiveness of nursing care in the Nephrology service as its object. Greater attention is given to the fundamental issues for comprehensive care, as well as their signifieds and signfiers from reflecting on the concept of care-permanence in order to address this issue.
The concept of comprehensiveness is a doctrinal principle of the Unified Health System (SUS -Sistema Único de Saúde) and confers criticism to disassociated care practices, highlighting the need to create regional networks articulated with a broader view of the individual and their needs. This concept is based on health promotion, disease prevention and health recovery actions, that is, on the holistic perception of the patient and considering all their historical, social, political, family and environmental contexts. Thus, comprehensiveness ensures protagonism of new healthcare practices, such as care-permanence (1)(2) .
Chronic Kidney Disease (CKD) is characterized as a public health problem, whose prevalence is alarmingly increasing worldwide, and represents a difficulty in completing the physical, mental and social well-being states in addition to a need for healthcare, reflecting the rapid and temporary loss of kidney function (3) .
In hospital settings such as in nephrology, inserting the concept of comprehensiveness into practice is still a challenge for many health professionals, and the earlier the understanding of its importance, the more favorable the health control interventions may be. This challenge in the United States is reflected in the diagnostic estimate of 30 million people with Chronic Kidney Disease (4) . In Brazil, there is no accurate estimate of the number of people diagnosed with CKD (5) .
Linked to these challenges there is also the need to sensitize nurses to look at issues related to subjectivity, intimate space and the individual's singular marks, beliefs and values, which are constantly present during care. When considered in actions, they are able to make care permanent by the professional's own attitudes, through respectful reception, positive communication and expanded listening, although often not recognized during their practice (6)(7) .
The concept of care-permanence emerged as follows: "Care-permanence is an articulated and complementary relationship between scientific knowledge which is present in nursing care, and valuing the essence of the other, recognizing them as being complex in its entirety" (6) .
Considering the complexity of care and constantly evolving knowledge (8) , it is understood that a concept is not definitive, and therefore it needs to be constantly refined, especially in the management field in implementing essential instruments which require more than scientific knowledge. Such care requires ethical commitment and training to improve and awaken competences and skills focused on the human and technical dimensions, in addition to knowing how to do, thereby enhancing relational and interactive processes (9)(10) .
Reformulating a previously used concept in other contexts about care-permanence enables to recognize both its applicability and updating its usage and broadening its discussion, as well as involving knowing how to be and how to recognize care needs, care demands, being with and for the other. Thus, care comprehensiveness is discussed and emerges as a fundamental condition because it is a skill that requires professional discipline and attitudes, such as knowing how to listen, perceive, understand, identify needs, express empathy, and then plan articulated, systematized and humanized care actions (11) .
In considering what is contextualized, the following guiding question was defined for this study: How can the concept of care-permanence be applicable to nursing care in the nephrology service? Objective: To discuss how the comprehensiveness of care-permanence is provided to a patient undergoing treatment in nephrology.

Study deSign
This is a descriptive, exploratory study with a qualitative approach anchored in the Sociopoetic method, based on five principles which value the dimensions of self, person, subject and citizen in nursing care, since the method enables participants to immerse themselves completely into the study with body, mind, and emotion. The principles of this method are constituted by: the research group; the importance of the categories and concepts it produces; the spiritual and human sense in knowledge construction; the body as a source of knowledge; and creativity in knowledge production (12)(13) .

Scenario and population
The study was conducted in the first semester of 2018 in a public higher education institution located in the city of Rio de Janeiro, southeastern Brazil. Fifteen (15) nurses with experience in Nephrology participated.

Selection criteria
Inclusion criteria were: being over 18 years old, being a nurse with more than 1 year of experience in the field of Nephrology, as it is believed that their contributions would be greater from this profile. Two participants who did not participate in all proposed stages (individual and collective) for data production were excluded from the study.

data collection
In the data collection and organization stage, the invitation to participate in the study was initially made available to eligible participants through a folder for online registration by virtual and printed dissemination in health institutions, with information about the registration and the research proposal. The meetings were scheduled after registration, considering the preferred indicated date by the majority.
Four meetings took place on different days in order to serve the largest number of interested participants, and each meeting formed a research group (RG), totaling four groups and four concepts. A concept of care-permanence emerged from each group, and the combination of all these concepts reformulates a new concept according to the initially presented concept (6) . Thus, the concepts formed from the collective productions originated what Sociopoetics (12) calls confect (concept + affect), since it considered the signifieds and signfiers attributed by each research group.
Activities were carried out in the morning and in the afternoon. The individual production took place in the morning, and the collective in the afternoon. The environment was prepared and the nurses were welcomed by the facilitator (researcher), as recommended by the method. A nominal presentation activity was started in the affective cafe and then the informed consent form was read, accepted and signed by each participant. As a way of welcoming and affiliating the individuals into the group, this step helped their participation during a relaxation technique to the sound of instrumental music.
By providing material for the individual production of drawings, collages and the generating theme: "What does care-permanence mean in the nephrology service?", it was possible to draw and write the individual experiences in care. The enunciation of the material produced on the signifieds and signfiers of care-permanence was shared for approximately 2 hours. At each meeting in the afternoon the participants were invited to a new collective drawing and written production about confect (concept + affect) related to care-permanence.

data analySiS and proceSSing
All statements were recorded on a digital device in MP3 format, resulting in 180 minutes of audio. The transcription, reading and rereading of the statements enabled us to grasp the significant units of thought and the philosophical concept produced by the participants. For the pre-analysis of these we used the conceptual framework of care-permanence as a starting point (6) .
Guided by its five fundamental principles according to the theoretical framework of Sociopoetics (12) , the research group was responsible for all produced and analyzed knowledge, pointing out new units of signifieds and signfiers in both the individual phase and in the collective phase. Confect as a philosophical concept was produced from constructing empirical knowledge from the ludic activity and a new reformulating proposal of the care-permanence concept, presenting the unprecedented and innovative result of this research.
Evidence of repetition of the word "comprehensiveness" in constructing the care-permanence concept in nephrology led to the group category: "Comprehensiveness in the concept attributed by nurses to care-permanence in the context of Nephrology."

RESULTS
Most of the 15 study participants were female (n = 14; 93.33%). Regarding length of experience in nephrology, 14 participants (n = 14; 93.33%) reported having 1 to 10 years of professional experience. One (n = 1; 6.6%) participant had over 30 years of experience devoted exclusively to the field.
Regarding the performance scenario, eight (n = 8; 53.33%) nurses reported acting in hemodialysis (HD); four (n = 4; 26.66%) in the nephroclinic; and three (n = 3; 20%) nurses in peritoneal dialysis (PD). There was no interest in participating in this study from nurses of the conservative treatment and kidney transplant scenarios.
Four concepts of care-permanence were produced and analyzed by the participants when considering the collective productions generated in the meetings, as they shared: Complex care, because it is linked to the demands of comprehensiveness, energy, interpersonal relationships, treatment continuity, bonding and is marked by communication between the health team, person and family (RG1).
It is reflected in respect for taking care of oneself and others with scientific knowledge allied to practice, aiming to achieve quality of life in a comprehensive way (RG2).
It concentrates: technology, family, team, patient, quality of life, knowledge, interaction, self-care, reception, and health education which complement each other (RG3).
The continuity of comprehensive care, in a transversal and transcultural way, taking into account the existing diversity (RG4).
The meaning of care-permanence permeates the idea of comprehensive care, according to the following individual statements: (...) It is clear that the human being is complex, the disease is complex, care is complex. So they are distinct complexities, but at the same time they favor articulation and should favor comprehensiveness (CR1).
To achieve comprehensiveness, it's no use cutting out the kidney and forgetting the person, right? (CR2).
Comprehensiveness is an opportunity to pave the way (CR3).
Comprehensiveness favors professional growth and automatically helps to achieve success and respect, because the chronic kidney patient suffers prejudice (CR4).
A complex question which runs through me by comprehensiveness, because there is no point in looking at the other fragmented (CR5).
When we look at it as a whole, we value comprehensiveness (CR6).
Communication presents itself in this way; for treatment continuity, for maintaining hope, for attaining comprehensiveness, energy exchange, and for interpersonal relationships to succeed (CR7).
There is no point in thinking about care-permanence without considering the whole, without considering the question of comprehensiveness (CR8).

It is complex and is linked to demands of comprehensiveness (CR9).
It is a set of actions that guide the care of the person, and which overlaps with the care of their clinical condition. It is more than comprehensive, humanized, sensitive and relational care, from everyone, family, staff, patient. Everyone grows when they think and rethink actions, behaviors and attitudes (CR10).
It is the search for comprehensiveness (...) it's to look at the patient as a whole (CR11).

DISCUSSION
The implemented method enabled stimulating discussions and in-depth reflections on the proposed object. The statements were highlighted by the repetition of comprehensiveness as a fundamental condition for care-permanence of nurses in nephrology. The result of this study represents what is effectively experienced by nephrologist nurses in their daily care practices and presents a construction of an updated and reformulated concept of care-permanence applicable to this context.
A study limitation was in recruiting the participants with the challenge of overcoming unavailability and incompatibility of schedule to participate in the research due to their work routines. Only 50% of the expected sample attended from the 30 nurses who expressed interest in participating and enrolled.
The predefined concept of care-permanence refers to "an articulated and complementary relationship between scientific knowledge present in nursing care and valuing the essence of the other as a complex being in their comprehensiveness" (6) .
The concept proposed in this study after triangulating the concepts formed by the research groups refers to comprehensive, complex, continuous and inclusive care, being applied by nurses based on scientific knowledge and valuing the other while complex being in its essence and comprehensiveness, with communication aid for interpersonal relationships, and considering the nurse-person-family-team in this process.
In this sense, care-permanence is care which not only includes the patient, but the family, the team and the nurse. The nurse as a member of this team appears highlighted as the main agent of care, because the results of this study defend care-permanence as a specific object of the nurse, and even though recognizing the importance of the multidisciplinary team, it highlights the fundamental role of the nurse.
In this experience, all groups worked on the care-permanence concept based on the proposed guiding question, even though there was no presentation to the research group of the predefined concept (6) . All were able to bring in themselves elements which are generally intertwined with it (6) . The nature of knowledge from the ludic production enabled reflection and awareness (12)(13) in all concept construction stages about care comprehensiveness by nurses in nephrology.
Nurses complementarily and very pertinently added new elements, which means new units of signifieds and signfiers to the care-permanence concept (6) , which enabled understanding it, applying it to examples in practical experiences and contextualizing them effectively in their daily life. Although the word "nursing care" did not appear in the concepts produced by the research groups, the reflection on care-permanence led to an agreement by all for the representation of nursing care in its specificity and particularity.
The four conceptual axes shared by participants form the meaning of care-permanence in nephrology. Comprehensive care considers the patient in its essence, participating in their treatment autonomously; complex care values the human being in their different dimensions entirely; continuous care recognizes the chronicity of kidney disease and its need for uninterrupted treatment, but with care beyond the disease, targeting the person, which goes beyond the limits of the nurse-patient relationship; and inclusive care is not only directed to the patient, but also considers their family, team, society and their contexts at the individual and collective levels.
In this experience, it could be seen that the demands of renal patients are not few and not simple, and understanding these demands by nurses requires reflection and commitment to care actions, so that they are resolute. In this process, care comprehensiveness objectively and clearly appears in the reformulation of the care-permanence concept (6) . Although the clinical condition of kidney disease patients is an essential element in managing therapeutic approaches, the evaluation performed by nurses in the nephrology field must recognize the need for comprehensive care of the patient's real needs in order to be effective, and for understanding the impact of the disease and treatment on their life in their general context, considering the uniqueness of each person (7,(14)(15) .
RG1 worked with the care-permanence concept mainly with regard to inclusive, complex and comprehensive care, highlighting the relationship involving the patient, family and health team. RG3 also highlights the importance of interaction and articulated care, which not only relates to and involves the patient, but also their family and health team. In addition to being inclusive, this care is relational and interactional, supported by communication and a harmonious relationship between those involved (10) .
The family was a recurring point in the discourses of RG1 and RG2, which emphasized the importance of inclusive and contextual care, also considering the care of oneself and the other, as confrontations of patients with CKD and their family often occur, including affecting the professional team that deals with this process (16) . In relation to care, nurses should consider their knowledge, skills and attitudes so as to favor promoting comprehensive and humanized care. Recognizing the ways of caring in interpersonal relationships is essential to nursing care, reinforcing that it should be extended to the family, the team and the context in which the patient is inserted.
As members of the multiprofessional health team, nurses need to recognize their role and relevance in performing systematic evaluations, implementing actions which guide the renal patient in need of care and directing them to promote positive feelings, encouraging self-care and autonomy, and including family members in this care. Explanations and information delivered to the patient and family regarding CKD, treatment options and potential complications (16)(17) are essential in this process.
In this dialogue, nurses need to take responsibility with and for the patient in coping with CKD, strengthening knowledge for preventing complications of the disease and instructing them on the most appropriate treatment in articulation with the family and staff, encouraging their commitment and participation from the beginning of treatment, regardless of the type chosen or made available. Nurses have the important role of communicating, guiding and instructing patients and families in the caring process (18) .
RG1 also highlighted care-permanence as treatment, citing it several times referring to hemodialysis as a tough treatment that can be rough, chronic (RG1), demarcated by care at the health institution in the late search for information to clarify questions, fears and uncertainties related to CKD. This group understood that the renal patient is undergoing long-term treatment, but (as highlighted by RG4) such care requires continuity, revealing the need for follow-up by the multiprofessional team in order to help them experience the complexity of the disease beyond the consultation offered to them in the institutional environment (17) .
RG2 pointed to the need to focus on the quality of life of renal patients and professionals. RG4 highlighted the idea of continuity, of moment, of time. Nurses demonstrated a temporality demarcation in care, which is characterized as long and continuous, and not of a time with beginning, middle and end. Therefore, the caregiver and health educator roles stand out, as they responsibly synthesize and encourage self-care in exercising their ethical and professional commitment through developing health promotion activities and knowledge exchange, which may reduce CKD incidence, aiming at well-being and improving the patient's quality of life in the partnership between professionals and the family (19) .
It is important to emphasize that the idea of continuity pointed out by the RG4 also refers to care which sees and considers the other as a whole, and in this sense needs to occur transversally and cross-culturally, without discrimination of any nature, comprehensively considering the existing diversity, so that this care is effectively comprehensive (20) . In this sense, the nurses shared that it is important to take care of the person, to understand them beyond their illness, as a complex Being in their essence and entirety. This means the need to develop new ways of understanding and acting in health in order to contribute to overcoming mechanistic, fragmented and chronic practices. Thus, care will favor the person as a Human Being, since caring for a person in complex conditions as CKD requires an approach that surpasses technical-scientific knowledge (8) .
The complexity of this care is related to the inability to clarify this process in a simple way. The complexity paradigm considers human beings in a condition of totality and not only as agents reduced to the functioning of their parts; thus, healthcare is a way to generate support for the autonomy of the individual from the interpersonal relationships that they establish with other human beings, with the social environment and the environment in which they live. As such, it is possible to consider the human being in their biopsychosocial totality (8,21) .
The complexity framework is related to comprehensiveness, multidisciplinarity, attention to support networks and knowledge articulation, thus generating repercussions in nursing care management, because complex thinking as a paradigm "sees the comprehensiveness of being, the relationships and interactions that exist between health organizations through care networks and the need for interactions between health professionals themselves" (21) .
It is important to have an articulated and complementary relationship "between the different professions, since knowledge construction and best care practices" (21) require national and international interdisciplinary and multidisciplinary support networks in order to humanize and fully meet the needs of the person in a dialogical perspective (22)(23) . However, the confrontations imposed on nurses in the context of the nephrology service do not refer to the patient itself, but to complex interpersonal relationships, which may affect all therapy, even compromising the quality of the care provided (24) . Communication, empathy, listening and reception consist of fundamental relational instruments for care, and are technologies that enable nurses to interact, conduct and produce care, thereby making it possible to meet the needs of the person, their family, the team, the nurse themselves who provides care and of the context in which they care (10) .
It is noteworthy that when taking care of the patient from the perspective of comprehensiveness, disease prevention and health promotion are extremely relevant to the quality of life, therefore it is important that the nurse be aware of comprehensive care to the person with kidney disease and not only guide but autonomously involve patients under their care (25) .
RG2 also emphasized that the care-permanence in nephrology has marked points and needs to be light and attentive as it includes attributions and competences such as knowledge and respect, and should be disseminated through a practice based on competences and attitudes grounded on knowledge, thinking and know-how, which demand specific knowledge about Nursing and require joining practice with theory (26) .
Linked to the thinking of RG2, RG3 corroborated essential and complementary elements without which care--permanence would not be possible, such as: technology, family-team-patient relationship, promotion of quality of life, knowledge, interaction, self-care, reception and health education. The development of technologies focused on the needs of those involved in care has established appropriate and innovative conditions favoring interaction and knowledge which goes beyond singular knowledge (10,(27)(28) .
The product of group discussions and individual reports associate the idea of care-permanence with health promotion, and consequently its impact on the patient's quality of life. Thus, health promotion is understood as an instrument for comprehensive care, an object of complex knowledge that addresses the needs of actions and health services (27) , as well as being an action that facilitates recognizing experiences which advance regarding the formation of the integrating idea as a guiding axis of knowledge and doing in health from the action of nurses.
Although the CKD development process is complex and permeated by difficulties, as exposed by professionals who work daily in this practice, the application of care-permanence by nurses represents coping with the disease and such challenges not only opens possibilities for care to the patient, but also to the family, the context and the collectivity, including care for the caregiver and the health team; since even though this represents the nursing care due to its specificity and applicability, it is not possible to take care alone, and nurses themselves recognize this. Therefore, the nurse and the entire health team must be technically, scientifically and affectionately prepared to provide effective care in nephrology, which should be started as early as possible for the preventive purpose and based on identifying underlying pathologies which may compromise the renal system and care continuity (29) . As raised in this study, health promotion and quality of life issues also require attention. Thus, nurses need to be able to offer comprehensive, continuous and inclusive care to this patient in a context that is individual, but also collective, and therefore complex, as conceptualized in this study as care-permanence.

CONCLUSION
The philosophical reflection on the care of human beings implies considering the physical, emotional, and individual dimensions, but also its micro and macromolecular revolutions of existing as a social being in a complex context.
The nature of this knowledge based on ludic productions favored reflection and awareness for all the time and at all times, highlighting comprehensiveness as a fundamental condition for the care and permanence of nurses in nephrology, stimulated their creative and sensitive power, revealing the hidden structure in knowledge production from care comprehensiveness, with elements that sometimes behave in a mechanistic, fragmented and chronic manner; however, the care-permanence process requires more than technical-scientific knowledge.
Sociopoetics led the production and analysis of the care--permanence concept applicable to the context of nursing in nephrology from reflecting, interacting and favoring a dialogical space through sharing experiences arising from this professional practice and communication and creative expression, together with professionals in the field. Thus, the implemented method enabled reformulating the care-permanence concept based on new signifieds and signfiers which emerged from the researcher group production. Similarly, the various authors used in the theoretical basis of this study made it possible to broaden the discussion and rationale of the presented ideas.
Therefore, care-permanence is nursing care which includes the being in their essence and comprehensiveness, considering all their complexity, the context in which care is developed and the need to strengthen interpersonal relationships between those who provide care and those who receive it, i.e. the person-family-nurse-team. Caring for the renal patient in their entirety in facing the complexity of the disease and of the human being represents a challenge.