Strategic directions for strengthening nursing and midwifery: potentialities and connections in the complex perspective*

Objective: to understand from the complex perspective the connections established between the Strategic Directions for Strengthening Nursing and Midwifery, delimited by the World Health Organization; to discuss the implications of these strategies for the investment of human resources in nursing and midwifery, with a view to strengthening the technical health capacity to face global health demands. Method: a documentary research, carried out from official WHO documents, from September to October 2019. A categorical analysis technique was performed, and the interpretation of the data was achieved based on the theoretical framework of Complexity. Results: three interdependent categories were defined, namely: challenges for the training of human resources in nursing and midwifery in order to meet the needs for global health; challenges for the development of the work of nursing and midwifery professionals in different contexts of practice; challenges for governments, leaders and health services to strengthen human resources in nursing and midwifery. Conclusion: the strategic directions corroborate the complex perspective because they value multidimensionality in the challenges for the professional practice of nurses and obstetricians. However, these challenges are also related to contextual, political, and leadership factors.


Introduction
The development of the nations is in line with the complex and dynamic health demands of their peoples, which establish implications in different social, economic, and political contexts for guaranteeing human dignity based on people's quality of life (1)(2)(3) .
In this context, it is necessary to consider the importance of human health resources so as to implement and strengthen strategic actions that guarantee efficient health and care practices to people in the face of current and coming challenges for local and global health, estimated from the epidemiology of aging population, chronic health conditions, emerging and neglected diseases, mental health, and social inequities, among others (4)(5) .
Thus, nursing and midwifery must be understood as professions that, within the scope of human resources for health, assume and practice valuable contributions to ensure access to health services and practices for people and their families in different care contexts (6)(7) . However, it is essential to understand it beyond the profession itself and its reach, significantly, different leaders, which can result in unfolding actions performed by nursing and midwifery, so that they can reach the understanding that investing in these professionals is equivalent to investing in people's quality of life, as well as efficient management of resources to reduce expenses with the fight against diseases (8)(9) .
Furthermore, by guaranteeing decent conditions for the maintenance of the economically active population, based on the health and care actions performed by nursing and midwifery, it is possible to conceive the interdependence relationship between these professionals and the economic development of nations. Therefore, in this relationship, there is the principle of the recursive circuit of complexity, "in which products and effects are themselves producers and causes of what produces them" (10) .
On the other hand, it must be considered that the development of the nursing and midwifery work process with a view to universal access to health is conditioned to the political context for the exercise of the autonomy of these professionals, as well as the development of skills to better intervene (5,11) . Despite this reality, the connections between macro-and micro-politics, which are positioned in multidimensional perspectives, are fundamental to guarantee strategies for strengthening human resources of nurses and obstetricians, with regard to the commitment of these professionals to consolidated training, as well as of the health institutions to implement dignified conditions so that they act with the necessary autonomy to reach their full potential. Therefore, the World Health Organization (WHO) launches the set of Strategic Directions for Strengthening Nursing and Midwifery Services (5,(12)(13) and recently, in partnership with the International Nurses Council, the global program for the valorization of Nursing and Midwifery, Nursing Now (14) , with a focus on leadership for care practices that advance new and distinct health scenarios, among other purposes.
On the other hand, it is advocated that these strategies should be perceived in their complexities, that is, interconnected in their contextual, multidimensional and dynamic perspectives. It follows from this logic the ability of these strategies to be conceived as guiding axes for the connections between macro-and micropolitics that involve investment and development for the human resources of health, with a view to expanding conditions of understanding by the formulators of public policies on the importance of nursing and midwifery to the world. Therefore, it is envisaged that civil society, politicians, and health employers appreciate the understanding that investment in these professionals is essential to respond to current and future epidemiological challenges (5) .
In this sense, the question is the following: How  (10,15) .

Complex
Thinking aims at understanding phenomena from the interactions among the parts that constitute them, in a dynamic, procedural, and nonlinear perspective. For that, it uses principles that allow understanding the complexity inserted in the dynamics of operation of the analyzed phenomenon, such as the recursive organizational principle, which considers that a phenomenon is at the same time a product and producer of itself (10,15) . In this sense, the strengthening of Silva IR, Mendes IAC, Ventura CAA.
nursing and midwifery is now understood from internal and external mechanisms to the work process of these professionals.
In the complex perspective, the principles complement each other to better explain the phenomenon in its living dynamics of operation. This way, for example, another principle can be added,

Results
The grouping of the results is presented by    Related factors: it is necessary to encourage active and systematic collaboration among nursing and midwifery organizations, in addition to community-based organizations, professional groups, and the government. Therefore, it aims at the following: implementation and monitoring of these strategic directions, and articulation and strengthening of effective networks and partnerships to improve nursing and midwifery services.

Action: Ensuring an educated, competent and motivated nursing and midwifery workforce within effective and responsive health systems at all levels and in different settings
Related factors: educating, recruiting, implementing, and maintaining the adequate number of nursing and midwifery workers with the necessary competences, strengthened with resources favorable to the performance of work, governed by professional regulations. To this end, it establishes the following as a strategy: to align investments and to coordinate plans for the development of nursing and midwifery in the management of the workforce.

Action: Working together to maximize the capacities and potentials of nurses and midwives through intra-and inter-professional collaborative partnerships, education and continuing professional development
Related factors: to optimize the impact of nursing and midwifery on the health systems, at all levels of health care, by means of inter-and intra-professional collaboration and partnership. For that, it is necessary to outline, monitor, and evaluate roles/ responsibilities of the nursing and midwifery workforce to promote education and collaborative practice.

Discussion
For Complex Thinking, strategy means a mechanism to better deal with the objective reality, because reality itself is permeated by uncertainties, risks, and illusions that may not be controlled in its entirety by the action mechanisms defined by man (15) . However, it is up to the strategies to predict better conditions to deal with the dynamic phenomena of reality (16) .
Therefore, in the health context in which nursing and midwifery play important roles (5) , the strategies for strengthening them must contemplate the possibilities to intervene based on current and future challenges.
For this reason, the strategic directions, especially their most recent version (5) , are supported by a contextual perspective in a global logic, based on evidence that calls for the strengthening of these professionals to exercise their competences.
The following documents emerge from this reality: The WHO 2013 directions to transform and expand the education and training of the health professionals, namely: the World Midwifery Study Report (17)  This principle is the unitas-multiplex, which asks to consider that the whole can be more or less than the sum of its parts (15) . This is because the quality of the interactions matters more than their existence because, in a context unfavorable for the development of the parts, the negative interactions of the work process can limit, reduce, and disfavor the potential for

Conclusion
The strategic directions for strengthening nursing and midwifery corroborate the perspective of complexity, while they value the multidimensionality inserted in the challenges for the professional practice of nurses and midwives.
In this logic, they reinforce the need for connections based on partnerships; the contextual implications for successfully implementing action-interaction strategies; and the interdisciplinary perspective, without, however, devaluing the need for professional autonomy.