Autonomy in acupuncture practice by nurses in southern Brazil (1997-2020)^a

ABSTRACT

Objective  to identify nurses’ autonomy in acupuncture practice in southern Brazil from 1997 to 2020.

Method  a qualitative, historical-social study, applying the thematic oral history technique under arguments of sociology of professions defended by Eliot Freidson. A semi-structured script was used for the interview of 18 nurses and one nurse acupuncturist selected in the three states of the federation by snowball technique. Data were collected and analyzed from April 2021 to December 2022.

Results  from the thematic content analysis emerged four categories, called: absence of autonomy; pursuit of autonomy; professional autonomy; and autonomy in light of Credentialism.

Final considerations and implications for practice  specialist nurses’ autonomy in professional practice is strengthened by specialized knowledge. Validity of the specialty contributes to the regulation of aspects involving nursing as a profession, in addition to boosting the possibility of occupying workspaces and promoting a comprehensive and collaborative approach to healthcare as well as professional training.

Keywords:
Acupuncture; Professional Autonomy; Nursing; Specialization; Health Profession

RESUMO

Objetivo  identificar a autonomia das enfermeiras na prática da acupuntura na região Sul do Brasil no período de 1997 a 2020.

Método  estudo de natureza qualitativa, histórico-social, aplicando a técnica da história oral temática sob argumentos da sociologia das profissões defendida por Eliot Freidson. Foi utilizado roteiro semiestruturado para entrevista de 18 enfermeiras e um enfermeiro acupunturista, selecionados nos três estados da federação pela técnica de snowball. Os dados foram coletados e analisados de abril de 2021 a dezembro de 2022.

Resultados  da análise de conteúdo temática, emergiram quatro categorias, denominadas: ausência da autonomia; busca pela autonomia; autonomia profissional; e autonomia à luz do credencialismo.

Considerações finais e implicações para a prática  a autonomia das enfermeiras especialistas na prática profissional é fortalecida pelo conhecimento especializado. A validação da especialidade contribui na regulação dos aspectos que envolvem a enfermagem como uma profissão, além de impulsionar a possibilidade de ocupação dos espaços de trabalho e promover uma abordagem abrangente e colaborativa no cuidado da saúde, assim como na formação profissional.

Palavras-chave:
Acupuntura; Autonomia Profissional; Enfermagem; Especialização; Profissão de Saúde

RESUMEN

Objetivo  identificar la autonomía de los enfermeros en la práctica de la acupuntura en la región Sur de Brasil en el período de 1997 a 2020.

Método  este estudio cualitativo histórico-social aplicó la técnica de historia oral temática basada en argumentos de la sociología de las profesiones de Eliot Freidson. Se utilizó una guía de entrevista semiestructurada para entrevistar a 18 enfermeras y un enfermero acupunturista, seleccionadas de los tres estados de la federación, mediante la técnica de bola de nieve.

Resultados  del análisis de contenido temático surgieron cuatro categorías, denominadas: la ausencia de autonomía; la búsqueda de autonomía; la autonomía profesional; y la autonomía a la luz del credencialismo.

Consideraciones finales e implicaciones para la práctica  la autonomía de las enfermeras especialistas en el ejercicio profesional se ve fortalecida por el conocimiento especializado. La validación de la especialidad contribuye a la regulación de aspectos relacionados con la enfermería como profesión, además de impulsar la posibilidad de ocupar espacios de trabajo y promover un enfoque integral y colaborativo de la atención sanitaria, así como la formación profesional.

Palabras clave:
Acupuntura; Autonomía Profesional; Enfermería; Especialización; Profesión Sanitaria

INTRODUCTION

Autonomy is a value that implies individuals’ freedom and involves decision-making about daily life choices and relationships with society. It is also the ability to govern oneself by one’s own means, representing the right of an individual to make decisions freely, or even the moral or intellectual independence of one’s right and/or conviction to execute them.¹ From this perspective, it refers to self-sufficiency and is related to the fact that a person can solve problems on their own, knowing how to manage the different aspects of a given situation. This thought converges when it states that autonomy is the foundation of all morality in human actions.² It consists of the presentation of reason to itself and of a moral law valid for the will of all rational beings.¹,² This occurs in various areas of human life, such as professional autonomy, which is a quality that confers power on nursing, which achieves its status when it performs its work under the aegis of society and State control.³

Furthermore, to achieve and maintain professional autonomy, there are two levels of authority: one based on expertise and the other based on socioeconomic factors and powers.³,⁴ A profession is characterized by elements such as a monopoly of specialized knowledge, in which practitioners have authority and control over decisions related to their work, professional regulation, which involves ethical and conduct standards, and the authority to impose these standards and regulate professional practice.⁵

Professional autonomy refers to a professional’s ability to make independent decisions regarding their work, without external interference or control, guided by knowledge and expertise in a given topic.⁶ To achieve this, it depends on standardization and organization of occupations within the State, as well as regulatory bodies that legislate on the knowledge and skills specific to the group to which one belongs. Understanding autonomy can vary depending on individual preferences, the nature of the work, and the environment in which one operates. It can bring benefits such as greater job satisfaction, intrinsic motivation, increased creativity, and a sense of responsibility. Furthermore, autonomy also implies greater responsibility, requiring self-regulation skills to ensure the efficient completion of daily tasks.

Illustrating this theme, a study is highlighted that investigated how professional associations contributed to Brazilian nursing professionalization, showing that they promoted knowledge, expertise, autonomy and self-regulation, reinforcing nursing as an academic and consultative profession capable of controlling the essence of its work, consolidating itself as a legitimate profession in Brazil.⁷ Another study⁵ establishes an important distinction between technical autonomy, which is the decisive criterion for differentiating an occupation from a profession, and socioeconomic autonomy. While the former is at the core of medical authority, the latter is more peripheral. A problematic issue in Freidson’s analysis is the conviction that professional (technical) autonomy is not undermined by any environmental constraints, when we know that powerful agents (the State, society, and the clientele itself) interfere and can alter the extent of professional autonomy.⁸

Professional autonomy is seen as a fundamental characteristic of established professions, allowing professionals to exercise a high degree of control over their practices and decision-making. Its preservation is crucial to the quality of care provided to individuals and to public trust in professions.⁹ To this end, according to Eliot Freidson, three factors characterize a profession - technical autonomy, knowledge/expertise and credentialism -,³ and are fundamental to the exercise of autonomy.

Acupuncture practice by nurses as an independent and specialized activity has become increasingly common in several countries as a complementary or optional treatment for various pathologies. It is a Traditional Chinese Medicine technique that involves the application of needles to specific points of the body to stimulate the central and peripheral nervous systems. This care technique promotes the body’s energy balance and treats numerous diseases. This practice has been applied to pain relief, in chronic pathology treatment and as a complement to obesity, in the area of women’s health, as a complement to sleep and gestational lower back pain, in helping postpartum women during breastfeeding, and as a reducer of stress levels for health workers.¹⁰,¹¹

It is considered that this technique offers an additional possibility of viable autonomous professional activity for nurses who wish to dedicate themselves to it.¹² In Brazil, acupuncturist nurse training is still a developing field. Acupuncture is not yet part of the official curriculum of undergraduate nursing programs, and acupuncturist nurses are trained through lato sensu graduate programs, with a workload of approximately 1,200 hours of theoretical and practical work, and have been regulated by the Federal Council of Nursing (In Portuguese, Conselho Federal de Enfermagem - COFEn) since 1997.¹³

Despite the knowledge gap observed in this field, it can be stated that acupuncture is the most widely used integrative and complementary practice in the West and is widely incorporated into public health systems. An example of this is a study that analyzed the approaches of 21 professionals trained in acupuncture who work in primary care services in Campinas, São Paulo, Brazil. It was identified that, despite the challenges, there is a desire among professionals to introduce and practice the knowledge of Traditional Chinese Medicine to contribute to the health of the population assisted in primary care.¹⁴ Another study carried out in the state of Santa Catarina highlights the analysis of nurses’ performance, who use the fundamental principles of health promotion, disease prevention and a comprehensive approach to individuals via acupuncture.¹⁵ The training process for these nurses follows the national standard, characterized by the availability of lato sensu graduate courses dedicated to this specialty.¹⁵

The need to address this topic aims to explore the strengthening of autonomy in the specialty in question. It also aims to enrich research related to the trajectory of acupuncture in the context of Brazilian and international nursing.

This study aimed to identify nurses’ autonomy in acupuncture practice by these professionals in southern Brazil from 1997 to 2020. The initial historical cut refers to the recognition of acupuncture as a multiprofessional practice by Resolution COFEn 197, 1997. The final cut accounts for two years after the last update of the Brazilian National Policy for Integrative and Complementary Practices (In Portuguese, Política Nacional de Práticas Integrativas e Complementares - PNPICs), which occurred in 2018.

METHOD

This is a sociohistorical study with a qualitative approach. Sociohistorical research has the potential to provide a deeper and more contextualized understanding of social and cultural phenomena, allowing them to be assessed in all their complexity.¹⁶ It is important to emphasize that sociohistorical research requires extensive analysis and interpretation of oral and documentary sources, which can be a time-consuming and complex process.¹⁷

The COnsolidated criteria for REporting Qualitative research guide, Brazilian Portuguese version, was applied.¹⁸ We chose to use thematic oral history as a methodological strategy, which allows interviews to be directed to a specific focus over time, aiming to understand the phenomenon under study in its contextual totality.¹⁹ The approach to the oral sources of the study occurred through contacts provided by the coordinator of the graduate course in acupuncture at the first author’s training school, who conducted the interviews. Initial contact was made via email, and after positive responses, messages were sent via WhatsApp^® and email with the formal invitation and the research project.

Hence, inclusion criteria for participants were applied. Professionals who specialized between 1997 and 2020 and who had worked in the field for at least three years were included. This length of experience was determined based on the understanding that a certain period of continuous professional practice is necessary for participants to have a clear understanding of the study subject and be able to provide relevant information about it. There was no need to establish exclusion criteria. Subsequently, invitations to participate in the study were sent along with the Informed Consent Form. Interviews were conducted at a location and date chosen by participants. The first interview was conducted on April 9, 2021, with one of the nurses from Paraná. The snowball technique was used to select the remaining participants.²⁰

Data collection was conducted using a semi-structured interview guide consisting of 15 questions related to autonomy, credentialing, and expertise. Four interviews were conducted via video call via Google Meet^®, 13 via WhatsApp^® audio, and one in-person interview at the interviewee’s home. The interviews took place from April 2021 to April 2022, with an average duration of 60 minutes each. All interviews were recorded, transcribed, and validated by participants, who signed an Interview Assignment Form. Seventeen nurses and one nurse specializing in acupuncture participated in this study, with 12 holding a specialization, one holding a master’s degree, and five holding a doctoral degree. All were acupuncture specialists with varying degrees of experience ranging from five to 26 years. Of the 18 interviewees, six were from Santa Catarina (SC), six from Rio Grande do Sul (RS), and six from Paraná (PR). There were no withdrawals from the study. The number of participants was determined based on theoretical data saturation, which occurred at the 14^th interview. The researchers then decided to interview four more participants,²¹ particularly because more than one method of contacting the interviewees was used.²¹ For data analysis, the content analysis method was adopted.²² The content of participants’ statements was organized in a table in Google Docs (Google Chrome^®), read in depth, and then coded, classified, and grouped. This resulted in categories that brought together the analysis results, which was carried out in light of Eliot Freidson’s theoretical framework.

Regarding the ethical issues of autonomy and individuality required in work with human beings, we chose to identify participants by acupuncture point names (P9, RI7, ST41, ID3, BL67, BP2, LI11, and so on), guaranteeing their anonymity and confidentiality of information. The study was approved by the Universidade Federal de Santa Catarina (UFSC) Research Ethics Committee, under Opinion 014140/2021 and Certificate of Presentation for Ethical Consideration 43345821.2.0000.0121.

RESULTS

The presentation of results of this study was composed of four categories: absence of autonomy; pursuit of autonomy; professional autonomy; and autonomy in light of credentialism.

Absence of autonomy

Nursing professional training spaces remain fragile when it comes to teaching and appropriating knowledge of PNPICs. It is observed that there is a required independence, but submerged in the still biologicist model. Characteristics of this statement are in the words of participants in this study:

The nurses I work with are quite surprised by my way of working. I think it’s that dogma we learn in college that health is just that: dependence on medication, dependence on surgery, dependence on doctors—it’s truly brainwashing, leaving people fearful and insecure (B67).

She said, “I have to send my daughter to you for care”. She sent her daughter. The next thing I knew, I was treating the whole family, and at the same time, I was banned from providing acupuncture at the University Hospital (UH) because I was a nurse. It was Dr. XXX at the time, who was the coordinator, who banned me because he said I couldn’t because acupuncture was a medical specialty. Then Professor XXX, who was the director of nursing at the time, said, “None of that... there will be nurses providing acupuncture, yes”, but it took a long time for that to be resolved. (P9)

Emphasis is placed on extensive care, in which initial treatment with one family member influences other family members, demonstrating the ability to provide comprehensive and complete care to patients. These highlighted points reflect that autonomy is not something granted by specialty, but rather by the need to fight for and conquer professional space.

Pursuit of autonomy

The pursuit of independence and self-determination often involves a desire for freedom and decision-making ability, and for independent management of care and assistance. The statements below indicate this pursuit of autonomy:

I was looking for an alternative path to healthcare. I worked in the emergency room at Hospital de Clínicas; I entered the healthcare system and was looking for an integrative therapy where I could be independent, where I wouldn’t get stressed anymore. Around 1993, I took a massage course, and then I realized it wasn’t quite right for me. So, I searched for a while like that until I found acupuncture (P5).

I worked for ten years in a federal public hospital in Porto Alegre, and I was a little tired of the type of treatment offered to patients, so I thought about doing something different. Working with some complementary practice and also thinking about entrepreneurship, becoming self-employed… moving away from that medical-centric mindset to a more alternative medicine. So, I decided to specialize in acupuncture. I had already graduated 16 years ago, so I had already worked extensively in the field. I didn’t know much about acupuncture, and it was more about moving away from that medical-centric mindset of treating patients within hospitals (VB43).

Before graduating, and after a few months as a clinical nurse, I realized it wasn’t what I wanted. I saw many older, frustrated colleagues. I was in my early 20s, and so I always sought to make money through my profession. I studied nursing because I got a scholarship, and being a nurse was never my dream. So, I really valued this financial gain. The profession gave me credibility. I also take Reiki courses. Adding other therapies was great, very positive, and, of course, it’s always very difficult to invest in your career. There’s a whole system that works against entrepreneurs. But with determination, we know where we want to go. I chose to see difficulties as learning experiences, not as problems (E41).

I became interested when I felt a sense of melancholy working conventionally in a hospital, observing the routine. Full of protocols and without much time to dedicate to the patient, I sought advice from a doctor friend of mine. I wanted to work with energy. I’d already sensed people’s energy, sensed environments. I wanted to understand this better and learn how to use it in healthcare. So, it was in 2014 that I became interested, and then this doctor friend advised me to study Chinese medicine (B67).

So, halfway through the course, I started looking for other options. And then, looking for ways to think about how I could have more autonomy in nursing, I saw an ad in the newspaper for an acupuncture course at CIEPH (Centro Integrado de Estudos e Pesquisas do Homem) (P9).

The search for an alternative, optional path in the field of care, with greater autonomy in nursing practice, fosters interest in an integrative therapeutic approach that allows for the exercise of professional autonomy. It is a way of working with complementary practices and entrepreneurship, leaving aside the traditional medical-centric approach in favor of a more independent approach to health and nursing care. By incorporating therapies such as Reiki and participating in personal development courses, it is possible to obtain positive benefits, breaking with a system that does not value independent entrepreneurship.

Professional autonomy

Ensuring professional autonomy is essential for professionals to maintain a high level of knowledge, skills, professional ethics, and the support of federal and state boards. This professional standardization, guaranteed by the credentials of regulatory bodies, favors and drives the acquisition of professional opportunities. Professionals can also organize into professional associations to promote their interests and ensure their voices are heard in important decisions related to their work.

I have my own workplace. I can set my own hours, in short, have a certain amount of freedom (ID8).

One challenge was becoming an entrepreneur… because we’re not trained by academia to be entrepreneurs. We live within a mindset that requires having a formal contract, working within the walls of a hospital or healthcare unit, but they don’t prepare nurses for entrepreneurship. My sister and I are launching a book about self-care. We present various integrative practices, which were a big part of these ten years of practical care and care. I also specialized in cupping therapy and aesthetic acupuncture. I already had a degree in massage therapy when I entered nursing. When I went to China, I returned with all the equipment I needed in my office (P9).

I set up a practice in my home to meet the demand I couldn’t meet at university. I started doing home visits. I contacted doulas in the obstetrics world; if you have doula friends, you have everything. So, they would end up recommending her when she was accompanying their patients. And patients needed an induction and wanted a more natural method. I never needed to promote my work, you know? Patients would come to me, and there were difficulties, yes. When I started working with pregnant women, I was very apprehensive, even though I knew, researched, and didn’t use the prohibited points (C7).

In nursing profession, entrepreneurship is challenging, as academic training traditionally prioritizes work in institutions, hospitals and health units.

Today, we have other options. Nursing, like other professionals, benefits from the wide range of options available, allowing you to make a better choice for your course, and from promoting your work through social media and video. In the past, we had to buy materials. Today, we buy through Mercado Livre; you can choose the cheapest option (P5).

I see a lot of progress. In the beginning, it was just me here in the municipality. Here in the municipal health network, it’s me and three other nurses who completed acupuncture training at UFSC to meet the demand. I want more nurses to come, because when I retire, I want them to continue the work. It’s a very expensive treatment in the private sector; here, it costs an average of R$140 to R$150 per acupuncture session. I treat all types of people: those in need and those who can afford private treatment. And of the three nurses who studied acupuncture, one works with wounds using acupuncture and laser therapy, the other does private acupuncture outside of work hours. I don’t do private acupuncture, which, with my schedule here at the SUS, already takes up all my time (C9).

Today, I work at the Centro de Atenção Psicossocial Infanto-Juvenil (CAPSI). I provide acupuncture for parents, children, and adolescents. I schedule my own consultations. We don’t have specific health programs for newborns and similar conditions that require protocols, as nurses are involved in primary care, so I don’t see myself in primary care. Today, my colleagues themselves invite me to provide acupuncture with Traditional Chinese Medicine-based care (IG11).

The desire to explore integrative therapeutic approaches led to the creation of a private practice, offering services such as acupuncture, cupping, and massage therapy, as well as partnerships with established doulas, allowing them to refer patients interested in natural methods during pregnancy. Overcoming initial obstacles such as fears and taboos, acupuncturist nurses are able to promote their work through social media, expanding their reach.

Autonomy in light of credentialism

In the context of credentialism, obtaining academic and professional credentials is seen as a way to acquire specialized knowledge and skills, which, in turn, allow an individual to exercise their autonomy in a more empowered and conscious manner. Similarly, in the context of expertise, autonomy can be seen as the ability to make decisions and act based on specialized knowledge and skills.

The greatest benefit is being able to truly practice what nursing is all about; this humanized, integrative care, which is what I learned in my nursing program: to look at the patient as a whole. I gained more tools to do this with acupuncture because it allowed me to work on something that was very subjective. So, I believe the values it brings—fraternity, compassion—that Traditional Chinese Medicine strongly resonates with nursing, so I think this is another potential. I was very fortunate to be able to combine all this knowledge. When you see the effects on patients of acupuncture, auriculotherapy, cupping, moxa. I did a volunteer project at the UFSC hospital. I served the healthcare professionals who worked within the university hospital (P9).

Doctors, psychologists, and nurses refer me through the system. Today, we have 372 patients on the waiting list, and the system prioritizes patients. So, I see the priorities and then the waiting list (C9).

What’s difficult is finding a nurse every year who wants to pursue a master’s degree, a doctoral degree in acupuncture, and other acupuncturist nurses who can join forces within the university, but I can only be grateful; I don’t see any difficulty (R7).

People have a paradigm of doctors. That the doctor will cure, that the doctor will resolve the problem, but I don’t let myself be shaken. I stay calm. I understand that this is a limitation of the person themselves. And little by little, I reassure them, demonstrating my knowledge and experience. Some people continue with the treatment and leave some prejudices aside, others don’t, and others don’t change at all (B67).

It is still challenging to find nurses interested in deepening their knowledge through master’s and/or doctoral programs in acupuncture, and to have acupuncturist nurses on university faculty. Although there is still a paradigm that doctors are responsible for curing and resolving health problems, acupuncturist nurses are there to demonstrate their knowledge and expertise, gradually overcoming prejudices and informing people throughout the treatment process.

DISCUSSION

The specialty of acupuncture as a practice of autonomy in nursing practice is the focus of this study, emphasizing its independence from conventional health practices institutionalized by other fields of knowledge. The experiences and perceptions regarding autonomy in this practice are similar in terms of the struggles to secure professional space and, at the same time, the confrontation with traditional therapies.²¹

Professional autonomy is particularly important in the fields of healthcare, education, and law, where professionals are responsible for making decisions that affect the lives and well-being of others. In nursing practice, it is characterized by professionals’ ability to make independent decisions based on knowledge and best practices to provide quality care, promote health, and defend patients’ interests. This autonomy is based on knowledge, skills, and abilities acquired through professional training and clinical experience, which directs acupuncturist nurses in this study to pursue a care practice that is innovative, empowering, and characteristically more autonomous.

Autonomy is the ability of professionals to control their specialized knowledge, the work process and professional regulation, allowing them to make independent decisions in their professional practice.³ Traditional Chinese Medicine, specifically in acupuncture practice, enables this freedom of healthcare. This brings an understanding in line with Freidson’s thought, which is organized based on the conceptual scope of autonomy, under the aegis of professional competence, grounded in self-confidence and health promotion through better care plans, decision-making, and shared multidisciplinary interactions.¹⁸

Specific knowledge of a field like acupuncture and the skills developed through nursing practice enhance and enhance the quality of care provided. Traditional Chinese Medicine emphasizes care with professional-to-professional and professional-to-person-to-family-to-community participation and sharing. Nurses who apply autonomy in their practice are able to critically assess available information and apply updated knowledge for the benefit of patients. This values interdisciplinarity and teamwork. This enables effective communication with other healthcare professionals and collaboration to provide integrated, quality care—known as interdisciplinary collaboration. Nursing autonomy includes the ability to educate patients, provide self-care guidance, and promote disease prevention and health maintenance. Nurses are advocates for patients’ rights, ensuring their needs are met and they receive quality care.²²

Pursuit of professional autonomy is a significant aspiration among acupuncturist nurses; at the same time, securing better salaries is a constant and understandable concern for healthcare professionals. This pursuit is associated with the recognition of professional value, where nurses strive for salaries that adequately reflect the critical role required to perform their work in promoting health and caring for patients. Better working conditions are often associated with adequate working hours, well-equipped workspaces, employee benefits, and a safe work environment.²³

These discussions foster autonomy in the hospital context, where the systematization of nursing care, professional experience, issues of job satisfaction and appreciation, and peer relationships enhance autonomy. Restrictive factors include gender issues, identity and hierarchical roles, weak technical and scientific knowledge, and physical, cognitive, and emotional fatigue.²⁴,²⁵

Autonomy in nursing refers to the ability of nursing professionals to exercise independence, make decisions, and act autonomously within their area of expertise. Professional autonomy refers to professionals’ ability to exercise control over the content and process of their work.³ It is also characterized by the monopoly of specialized knowledge, in which professionals possess proprietary knowledge that is essential to the practice of their profession. This specialized knowledge grants professionals authority and control over decisions related to their work. This includes making decisions about how to perform tasks, which techniques or approaches to use, and how to organize the necessary time and resources. This autonomy allows professionals to adapt their work to individual patient needs and handle complex situations flexibly. Professional regulation, in which autonomy is supported by a system of professional self-regulation, involves the definition of ethical standards and professional conduct, as well as the authority to enforce these standards and regulate access to the profession.³,¹²,¹⁵

However, it is important to emphasize that the professional autonomy described is not absolute. It is shaped by contextual factors, such as power relations, organizational structures, and health policies. Furthermore, professional autonomy is also subject to external constraints and pressures, such as market demands, government regulations, and economic influences.¹³

An integrative therapeutic approach like acupuncture sets aside the traditional approach, seeking an alternative path to care. Self-determination provides pleasure in the development of work activities, with control over therapeutic actions, in a dynamic between patient, family, and professional, characterizing professional autonomy. Professional autonomy is a distinctive characteristic that empowers the profession, achieving recognition when it performs its activities within the limits established by society and government regulations. This autonomy is especially highlighted in the category of acupuncturist nurse, where professionals emphasize the desire and satisfaction of specializing in this area of nursing, seeking to achieve the autonomy this practice provides.¹⁵,²⁵

Acupuncturist nurses overcome initial obstacles and promote their work through social media, expanding their reach. The greatest benefit of acupuncture in nursing is the ability to act in an integrative and humanized manner, providing comprehensive patient care and addressing subjective issues. Traditional Chinese Medicine complements nursing practice, bringing values of fraternity and compassion. However, it remains challenging to find nurses interested in specializing in acupuncture and to have more acupuncturist nurses working in education.

In the context of professional organization, there is an authority that occurs in the development of actions that encompass specific practices characteristic of nursing procedures. Autonomy arises in professional spaces where there is a division of nursing labor in relation to other professions, according to the specificity of the areas of knowledge defined and developed by them.⁸

In Brazil, there is an ongoing and growing debate about the managerial dimension of nursing work, particularly in relation to the contradictions and ambiguities involving the autonomy, leadership and decision-making of nurses in health services.²⁶ Autonomy manifests itself among professionals of the same category, established through knowledge, self-regulation, work organization and guidance and supervision relationships within care and educational practices among members of the same category.

The relativization of autonomy is characterized in nursing by the limits that each member of the team faces when developing their activities, expressing their knowledge, skills and attitudes within the same specificity.⁸ Understanding that nursing performs its actions with and for society, professional autonomy in relation to society is understood as the relationship between professionals and the users of the services they provide, based on their own competence and experience. There must be freedom in providing care, in decision-making, in sharing guidance, and in discussions with members of society who use these specialized services.²⁴,²⁷

The autonomy of regulated professions is considered essential for professionalization, established through self-regulation by professional representative bodies, such as professional associations, colleges, and/or councils. It is noted that the creation and development of professional associations and councils are a benchmark for the recognition of a profession. Thus, this appropriate credential confers the status of a state-recognized profession on the occupation, guaranteeing its relevance and usefulness to society.⁸,²⁸

The challenges of including content related to alternative care practices are not exclusive to nursing. In undergraduate medical programs, this content is covered superficially or even optionally, according to a study conducted on this topic in medical education in Brazil. Public policies aimed at the Brazilian Health System are expected to encourage greater investment in acupuncture education during undergraduate programs, aiming to integrate it more deeply into medical curricula.²⁹ As in Brazil, integrative and complementary practices are not yet part of undergraduate nursing curriculums. Nurses’ practice in acupuncture is also based on PNPICs, which recommends this practice as a treatment for various health conditions, and on the creation of Family Health Support Centers, enabling nurses to apply this technique safely, effectively, and independently.³⁰

They also seek to strengthen their autonomy, drawing on their specific acupuncture knowledge to provide quality care. While autonomy is not absolute and interprofessional collaboration is valued, interest in integrative approaches, such as acupuncture, drives the search for more independent and humanized practices. Professional associations and councils play an important role in consolidating this autonomy and in the recognition of the profession.

FINAL CONSIDERATIONS AND IMPLICATIONS FOR PRACTICE

The narratives of the participants in this study point to different forms of professional practice. Sometimes, they are limited by others’ limited knowledge of acupuncture as a treatment, and other times, they are limited by medical instructions. However, by incorporating acupuncture as an additional and autonomous skill, they found an opportunity to develop a differentiated and individualized approach to patient care. The expertise derived from professional acupuncture practice promotes greater autonomy in client care, allowing them to use this complementary therapy to relieve pain, treat symptoms, and promote patient recovery.

Developing autonomy in professional practice not only revitalizes the role of nurses in this field but also reinforces the development of this category’s professional identity. It also drives innovation in nursing practice, integrating science and art, and promoting a more humane approach. This humanized approach strengthens the relationship between professional and patient, promoting more empathetic and effective communication. The evolution of nursing, from a lack of autonomy to the acquisition of this competence in acupuncture, enables a more innovative and patient-centered practice.

The professional regulation of this practice has driven the evolution of workplaces, promoting a comprehensive and collaborative approach to healthcare. It also provides tools for considering the patient as a whole and addressing subjective issues. It fosters values of fraternity and compassion, which align with the science and art of nursing care. Traditional Chinese Medicine significantly complements nursing practice.

It is concluded that autonomy in professional conduct is based on the human understanding of the laws and principles of society, not being an absolute concept, but a freedom sought by professional groups to exercise their profession, have control over their work and be independent in relation to other areas.

As limitations of this study, we understand that the regional scope of the participants coming from the three states of the southern region, as well as the pandemic period, may have made it more difficult to contact them.

ACKNOWLEDGMENTS

To the Brazilian National Council for Scientific and Technological Development (In Portuguese, Conselho Nacional do Desenvolvimento Científico e Tecnológico - CNPq), for granting a scholarship during the development of the doctoral thesis.

DATA AVAILABILITY RESEARCH

The contents underlying the research text are included in the article.

• a
  Excerpt from the doctoral thesis “A prática da acupuntura por enfermeiras na região sul do Brasil no período de 1997 a 2020”, presented to the Graduate Program in Nursing, Universidade Federal de Santa Catarina, in 2023.
• FINANCIAL SUPPORT
  Conselho Nacional do Desenvolvimento Científico e Tecnológico - CNPq awarded the doctoral scholarship to the first author and the productivity scholarship to the second author.

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Edited by

• ASSOCIATED EDITOR
  Rafael Silva https://orcid.org/0000-0002-5211-9586

• SCIENTIFIC EDITOR
  Marcelle Miranda da Silva https://orcid.org/0000-0003-4872-7252

Publication Dates

• Publication in this collection
  26 Sept 2025
• Date of issue
  2025

History

• Received
  31 Jan 2025
• Accepted
  15 July 2025