Care of the self and power relations: female nurses taking care of other women

ABSTRACT

Objective:

to analyze the care of self of female nurses and the power relations established by them in the care of other women.

Method:

integrative review of literature published between 2005 and 2015. There were 25 publications in the sample.

Results:

qualitative state of the art with reference domain of a liberating perspective, based on humanization, autonomy and empowerment as a risk reduction strategy in the practice of care to women. The findings suggest solidified power relations among female nurses and women, focused on professional domain concentrated on nurse education under the patriarchal and society's normalization discourse. Some studies consider the importance of understanding power in a capillary way, operating on the bodies of individuals.

Conclusion:

there is little discussion about the care of self of nurses and the effects on their professional practice, indicating gaps in knowledge in this field.

Descriptors:
Women's health; Power; Nurses; Women; Personal Autonomy

RESUMO

Objetivo:

analisar o cuidado de si de enfermeiras e as relações de poder estabelecidas por elas no cuidado de outras mulheres.

Método:

revisão integrativa da literatura publicada entre os anos de 2005 e 2015. Compuseram a amostra 25 publicações.

Resultados:

estado da arte majoritariamente qualitativo com domínio de referenciais de uma perspectiva libertadora, pautada na humanização, autonomia e empoderamento como estratégia de redução de riscos na prática do cuidado à mulher. Os achados sugerem relações de poder solidificadas entre enfermeiras-mulheres, centradas no domínio profissional com forte concentração na formação da enfermeira sob o discurso patriarcal e de normalização da sociedade. Alguns estudos ponderam a importância da compreensão do poder na forma capilar, operando nos corpos dos indivíduos.

Conclusão:

há pouca discussão sobre o cuidado de si de enfermeiras e dos efeitos na sua prática profissional, indicando lacunas no conhecimento neste campo.

Descritores:
Saúde da Mulher; Poder; Enfermeiras e Enfermeiros; Mulheres; Autonomia Pessoal

RESUMEN

Objetivo:

analizar el cuidado de sí de las enfermeras y las relaciones de poder establecidas por ellas mismas con relación al cuidado de otras mujeres.

Método:

revisión integradora de literatura publicada entre los años 2005 y 2015. La muestra estaba compuesta por 25 publicaciones.

Resultados:

estado del arte mayoritariamente cualitativo con dominio de referenciales desde una perspectiva libertadora, pautada en la humanización, autonomía y empoderamiento como estrategia de reducción de riesgos en la práctica del cuidado de la mujer. Los hallazgos sugieren relaciones de poder solidificadas entre enfermeras-mujeres, centradas en el dominio profesional y fuertemente concentradas en la formación de la enfermera bajo un discurso patriarcal y de normalización de la sociedad. Algunos estudios resaltan la importancia de la comprensión del poder en la forma capilar, actuando en los cuerpos de los individuos.

Conclusión:

existe poca discusión sobre el cuidado de sí de las enfermeras y de los efectos sobre la práctica profesional, lo que implica lagunas en dicho campo del conocimiento.

Descriptores:
Salud de la Mujer; Poder; Enfermeras y Enfermeros; Mujeres; Autonomía Personal

INTRODUCTION

Regarding gender inequalities, women live in a context permeated by ruptures and permanence, whether in the professional, familiar field, and mostly in the field of social relations. For instance, we especially mention the autonomy provided by the possibility of prescribed and safe contraception, breaking with the biological and social determinism of motherhood. We also cite the financial autonomy of female occupations in the labor market. However, many rules are prescribed to woman: she must raise the children, take care of the domestic environment, do not earn more money than their husband; therefore, she cannot be the breadwinner and must have an elegant and skinny body, be driven by emotion - to the detriment of reason - and submissive to her husband, boss, or parent⁽¹⁾.

This scenario is related to the fact that, in the process of struggle and recognition, women sought a space external to the domestic environment, one which they could identify with. The nursing profession was one of them. At the same time, they did not abandon the responsibilities for which they were raised, especially maternity and domestic care.

As well as the social reality of women is marked by significant advances and challenges, the current diagnosis of women's health in Brazil, despite the intense investment in the field, is translated into a reality distinct from what it craves. In this sense, the Brazilian Ministry of Health (MS), through the strategic planning for the 2011-2015 period, establishes goals for "Reducing maternal mortality of black women in five percentage points per year, to decrease the total difference between these and white women"⁽²⁾. It is emphasized that the challenges are enhanced by the real conditions of inequalities experienced by women, whether their gender, race, class, color/ethnicity.

Moreover, in the scope of woman assistance, there still manifestations indicating institutional violence, high rate of cesarean sections, and other expendable interventions. There are also unequal relationships between health professionals and users, based on the control and manipulation of female conducts. Thus, the MS highlights that the search for progress consists in implementing a model of attention to women's health through a health promotion perspective - encouraging female autonomy and protagonism -, humanization, and evidence-based practices, fighting excessive and unnecessary medicalization and interventions⁽²⁾.

Such movement can be discussed in the light of the Foucauldian statement and of postmodern thinkers, according to which the subjects do not actually exist, but are an effect of discursive practices, immersed in a truth game, moved by power and knowledge relations. We highlight the role of health professionals discourses in the individual's education:

For Foucault, 'subjects' are nothing more than an effect of linguistic and discursive practices that build them as such [...] The 'subject', rather than originating and sovereign, is derived from and dependent. The 'subject' that we know as the basis and foundation of action is, in fact, a product of history⁽³⁾.

In this current of thought, Michel Foucault, in the third stage of his work (1980s), elaborates the 'care of the self' concept. He assumes the other two axes previously studied by him: "being-knowing" and "being-power", operating simultaneously in the production of the modern subject. The axis of the care of the self consists of a way to find open spaces, and is interested in the way men self-govern themselves, with emphasis on the ethical aspect⁽⁴⁾. This process is called subjectification, a practice that escapes the powers and knowledge in force⁽⁵⁾.

Thus, we observe, in the reality of health services and practices of health professionals - with focus on nursing - the predominance of normalizing and disciplinarian actions for women's behavior. It is assumed that this problem comes, mostly, from the care of the self of female nurses in decisions about their own body and life and, consequently, from the power relations that they establish with other women they take care of.

This study is justified by the need to understand concepts, theories, and methods in the literature, under the perspective of social research and the Foucault's poststructuralist reference, which considers the subject as a product of linguistic and discursive practices. This understanding may contribute to the construction of new care practices for women.

Under this point of view, as women are formed by discourses, health professionals are also subjects of these utterances. We highlight the relevance of the nursing profession in the care the woman, being one of the 13 health care professions that have governmental recognition and accounting for 64.7% of the health workforce in Brazil. In addition, the class is mostly feminine⁽⁶⁾.

OBJECTIVE

This study aims to analyze the care of self of female nurses and the power relations established by them in the care of other women.

METHOD

Theoretical-methodological reference

This study is based on the poststructuralist perspective and in the theoretical-methodological reference of Michel Foucault. In the field of poststructuralist thought, we have Foucault's contributions to understand the constitution of subjects, power relations, and the production of subjectivity.

Type of study

This is a qualitative study in the form of an integrative review, selected as a research method for its scope and possibility of simultaneous inclusion of theoretical and empirical research conducted by several methodologies. The integrative review provides general conclusions about the research problem, identifying gaps of knowledge in the phenomenon studied. It also reveals central issues of the area in focus, identifying conceptual or theoretical landmarks and showing the state of the art of scientific literature on a given topic^(7-8).

Methodological procedures

We carried out an integrative review of literature through the development of a research protocol, following six steps: establishment of research question; sampling or search in the literature; categorization of studies; assessment of studies included in the review; interpretation of results; and synthesis of knowledge^(7-8). The review was guided by the following question: how does the care of self of female nurses and the power relations established by them are evidenced in the care of other women?

Data source

For the selection of articles, we accessed online databases PUBMED/Medline, covering the international literature, and Biblioteca Virtual de Saúde [Virtual Health Library] (BVS) focusing on Latin American and Caribbean literature. In addition, to cover the area of Sociology, we included Portal Capes focused on the database named 'Sociological Abstracts'. We also included PsycINFO database to comprise Psychology, a related area. The inclusion of Cochrane database was not necessary, since the studies found with the search strategy adopted in this research were only clinical trials that certainly would be included in the PUBMED search.

Data collection and organization

Assisted by a librarian, search strategies were elaborated for each database, in accordance with the technical language appropriate to each one of them. Homogeneously, the inclusion criteria set for all the databases were: to be in Portuguese, English, or Spanish; to have been published in the last 10 years, in order to include recent literature; to be an article, dissertation, or thesis fully published; and to contain the terms Woman (women), Power (Psychology), and female nurse(s) as Health Sciences Descriptors (DeCS), titles, or isolated terms in abstracts. In addition to these, we included the DeCs 'Personal Autonomy' with the OR option in the 'Power' subset. The terms were set after thorough analysis of the options and definitions established by the BVS in relation to the object of study. The survey was conducted in July and August 2015, totaling 457 publications found.

Data analysis

Initially, we excluded publications that did not refer to the theme established as the object of this study. To do so, we conducted a preliminary eligibility test to refine the publications identified that were totally analyzed after this stage. This step was performed by researchers, with clarity of purpose of this study and through reading and analysis of the title and abstract of all publications. At the end of this step, a total of 53 selected references, mostly indexed in PUBMED/Medline, respectively followed by BVS; PsyINFO, and Portal Capes.

The publications selected were totally analyzed and categorized by themes. Yet at this stage, we excluded those which did not contribute to answer the question that guided the review. We also assessed the questions related to the methodology of the studies to apprehend the quality of the sources, considering that an integrative review "[...] requires a standard of excellence regarding the methodological rigor in such a way that its product can bring significant contributions to science and clinical practice."⁽⁸⁾. Whittemore and Knaft⁽⁹⁾ highlight the complexity of this action in integrative reviews, proposing different criteria for analysis of theoretical and empirical sources. Analysis of authenticity, quality of the methodology, informational values and representativeness are indicated⁽⁹⁾. For this integrative review, the analysis of the quality of publications was based on such criteria, influenced by the experience of researchers, considering in a theoretical and critical analysis the research topic, the conceptual basis, and the references adopted in texts as well as the justification of the study and the implications for the theoretical field investigated.

Following the analysis of the empirical publications and of review publications, we applied a checklist developed by the Critical Appraisal Skills Programme (CASP)⁽¹⁰⁾, which aids the critical analysis of the studies regarding accuracy, credibility, and relevance. This instrument proved to be applicable and consistent to evaluate the quality of the text and has been reported on methodology of integrative reviews of other authors. The studies that have reached a score of seven or more - maximum of 10 points - were included in the sample. Thus, at this stage of the review, 28 references were excluded; the selected ones were analyzed and synthesized in a descriptive way, enabling us to observe, count, describe, and classify the data to gather the knowledge produced on the topic explored in the review. The detailed description of the search and selection of the publications can be found in Figure 1.

Figure 1
Search and selection scheme of publications

RESULTS

Characteristics of publications

The 25 publications that composed the final sample are listed in Box 1, characterized regarding authorship, year of publication/database, language, type, nature of the study, and theme.

Box 1
Selected articles that composed the sample

Authorship	Year/ Database	Language	Type	Nature	Theme
Goldberg LS(11)	2005 PsycNet	English	Article	Qualitative	Relationship between perinatal nurses and women in labor.
Stewart M(12)	2005 Pubmed	English	Article	Qualitative	Experience of nurse-midwives and women regarding vaginal exam in labor.
Hayter M(13)	2006 Pubmed PsycNet	English	Article	Qualitative	Nursing consultation on reproductive counseling
Quitete JB(14)	2007 BDENF	Portuguese	Thesis	Qualitative	Role of the nurse in the care of women
Fletcher K(15)	2007 Pubmed PsycNet	English	Article	Literature review	Public images of nursing professionals.
Simmonds AH(16)	2008 Pubmed PsycNet	English	Article	Theoretical	Perinatal nurse-patient relationship.
Quitete JB, Vargens OMC(17)	2009 LILACS	Portuguese	Article	Qualitative	Care and empowerment of women provided by nurses.
Albuquerque RA, Jorge MSB(18)	2010 LILACS	Portuguese	Article	Qualitative	Construction of women’s autonomy in the relation with the professional of the Family Health Strategy.
Lopes DFM, Merighi MAB, Garanhani, ML(19)	2010 LILACS	Portuguese	Article	Theoretical reflection	Historical corporeity of female nurses
Barbosa R, Labronici LM, Sarquis LMM, Mantovani MF(20)	2011 LILACS	Portuguese	Article	Quantitative	Psychological violence in the nurse’s professional practice
Dantas CN, Enders BC, Salvador PTCO(21)	2011 LILACS	Portuguese	Article	Qualitative	Nurse’s experience when carrying out nurse consultation.
Nash WA(22)	2011 Pubmed PsycNet	English	Article	Quantitative	Nurses’ self-efficacy in promoting the use of condoms.
Van Herk KA, Smith D, Andrew C(23)	2011 Pubmed PsycNet	English	Article	Theoretical	Paradigm in Nursing.
Pereira ALF, Bento AD(24)	2011 LILACS	Portuguese	Article	Qualitative	Women’s autonomy in natural childbirth and the obstetric nursing care.
Barros CS; et.al(25)	2012 LILACS	Portuguese	Article	Qualitative	Breastfeeding experience of mother-child area nurses
Henriques CMG, Catarino HCBP, Franco JJS(26)	2012 LILACS	Portuguese	Article	Quantitative	Nurse’s empowerment level
Anderson CJ, Kilpatrick C(27)	2012 Pubmed	English	Article	Integrative review	Birth plans and satisfaction regarding childbirth
Gregório VRP, Padilha MICS(28)	2012 Pubmed	Portuguese	Article	Qualitative	Woman care practices provided by nurses of a maternity
Alex M, Whitty-Rogers J(29)	2012 Pubmed	English	Article	Theoretical	Pejorative use of language by health care professionals regarding the care provided to women.
Vieira A, Alves M, Monteiro PRR, Garcia FC(30)	2013 Pubmed LILACS	Portuguese/ English	Article	Quantitative	Organizational identification and experiences of pleasure and pain of women in nursing teams.
Durand MK, Heidemann, ITSB(31)	2013 Pubmed LILACS	Portuguese	Article	Qualitative	Promotion of autonomy in the nursing consultation.
Aguiar JM, d’Oliveira AFPL, Schraiber LB(32)	2013 Pubmed LILACS	Portuguese	Article	Qualitative	Institutional violence from the health professionals’ point of view.
DeSouza R(33)	2013 Pubmed	English	Article	Qualitative	Nurses’ discourse in the care of migrant women.
Gomes ML, Moura MAV, Souza IEO(34)	2013 LILACS	Portuguese	Article	Qualitative	Meanings assigned by nurses to changes in their obstetric practice.
Lessa HF et. al(35)	2014 BDENF	Portuguese/ English	Article	Qualitative	Social relations and planned home childbirth.

• Source: Elaborated by the researchers (own authorship)

We observe that the chronological distribution of studies took place especially after 2011. Regarding the language of the articles, those published were mostly in Portuguese and/or English. Regarding the methodology of the studies included, 60% refer to qualitative research, 16% to quantitative research, 8% to literature reviews, and also 16% to theoretical articles. The data collection technique of higher predominance in this sample is the interview. Most selected publications refer to articles published in scientific journals, except for a master's thesis⁽¹⁴⁾. Despite the existence of an article by the same author of this thesis and with similar themes, both were included for contributing in a complementary way to answer the question that guided the review.

Notwithstanding the search methodological option on the database Sociological Abstracts through Portal Capes, and IBECS basis, indexed in the BVS, none of the studies of the final sample come from these databases.

Regarding the participants of empirical research, research with generalist nurses outstand, followed by studies with midwives (obstetric nurses) and women of childbearing age (recent mothers and pregnant women, especially). According to the profile of the participants, we highlight that, regarding the theme of the studies, only 20% of publications are not specifically aimed at women in their life reproductive cycle.

Quantitatively, we highlight studies focused on childbirth. Moreover, recurring themes were: nurse/woman relationship; care or health education practices in relation with autonomy and empowerment; procedures that focus mainly on the female body; discourse of health professionals and, finally, two studies that discuss health paradigms.

In Table 1 we can observe that none of the included studies defined power relations directly as an object of study, since this subject is not explicit in the themes and objectives of such research. However, all the selected references contribute to the understanding of the subject of the review. The results are discussed in the following two themes: Power relations, autonomy and empowerment: taking care of women; and Female nurses' care of the self: escape to the powers or another standardization?

DISCUSSION

Power relations, autonomy and empowerment: taking care of women

Relations between nurses and women presented in this category are distributed, in the scenarios and actions, in different directions and are guided by several references and paradigms. It is worth noting the predominance of studies guided by the understanding that social relations, established in health care, should be guided by the principles of humanization, completeness and guarantee of human rights and therefore must promote autonomy and empowerment of individuals - in this case, women.

Publications are especially located in the field of health promotion, instrumentalized by Health Education. This publication trend of the last 10 years follows the movement of critical and participatory concepts of health education in contrast to traditional concepts. This field acquires relevance with stimuli to the development of pedagogical practices of participatory and emancipatory character aimed at the confrontation of individual and collective situations that interfere with the quality of life, through awareness, conscientization, and mobilization⁽³⁶⁾.

Empowerment is defined in the studies as additional power or power appropriation to oneself. This is a field in which nurses must act in such a way that the woman they are taking care of empowers herself, in a relationship that must be based on autonomy, regarded as the share of power, knowledge and experiences that, to be promoted, assumes the democratization of relationships between professionals and patients, overcoming power asymmetries^(18,24,26): "For the exercise of autonomy, women have acquired the power of individuals able to choose and decide the care practices along with the nurses"⁽²⁴⁾.

Autonomy allows conscious choices of women, seeking improvements in the childbirth experience and its results for the woman, the child, and the family: a quality, humanized assistance that guarantees citizenship and human rights, focusing on sexual and reproductive rights^(14,24): "Humanizing and qualifying health care is learning to share knowledge and to recognize rights"⁽²⁴⁾. At the same time, it is expected that women's autonomy and empowerment allow transitions in the care practice, contributing to the transformation of the biomedical, technocratic model and promoting changes in the reality of body medicalization⁽¹⁴⁾. Thus, domestic violence against women is highlighted as a clear situation of need for empowerment of the female gender⁽³¹⁾.

In addition, to contribute to the empowerment of women is necessary empowered professionals⁽¹⁸⁾. The empowerment of female nurses emerges as a possibility to envision professional autonomy and to generate autonomy of women they take care of, being measured in terms of: effective management and interdisciplinary relations, sustained and autonomous practice, professional communication and consent, recognition on the health team and training/education⁽²⁶⁾.

In the analyzed texts, the empowerment of women is still seen as a strategy aimed at the reduction of risks and the adoption of healthy behaviors such as empowering women to use condoms and reduce the risk of HIV infection^(22,27). Moreover, nurses teach women to examine their own body, promoting a discourse of "body at risk" and the risk of not being vigilant, becoming ill, and getting pregnant⁽¹³⁾. In this sense, women are responsible for their choices and, at certain times, blamed.

The concepts of empowerment and autonomy can be questioned with the foucauldian referential. In this sense, the subject is not a substance, but a product of history, a form, and that form is not always identical to itself. With this understanding, it is not possible for individuals "to acquire" the power to transform and emancipate themselves from exposure to risk practices. In each circumstance, subjects establish forms of different relationships between themselves as the product of power relations, relations of forces, strategic games among freedoms and subjects. That means that power exists in a set of social practices historically constituted that operate by strategic devices that influence everyone and from which no one can escape, since there is not even an area of social life that is free from its mechanisms^(5,37).

Discourses are guided by a vision of an ideal standard of women: she must have a job, get married, get a home, raise children and take care of them, besides being autonomous, having control over herself and her life. These parameters are adopted as behaviors that will allow good health, through the compliance with the professionals' advice, "making the right choices". In this context, women who decide for different behaviors are accused and discriminated⁽³³⁾.

Moreover, educational practices, such as stimulating breast self-examination, are pointed as strategies that lead women to incorporate the health discourse. It means developing an understanding of their body on the perspective of the dominant medical science with the responsibility to carry out a careful examination, through the observation of their own body to identify possible signs of the disease⁽¹³⁾.

Some tools with potential to empower and promote autonomy of women were mentioned by the studies. Information as a strategic instrument of subjects' empowerment⁽¹⁴⁾, as well as relationships based on dialogue, listening, reflection, attention to verbal and non-verbal communication, respect and trust are very important issues^(11,31). The nursing consultation is presented as a space where the nurse should use these tools to promote women's empowerment and autonomy^(21,31).

A study shows the potential of the Childbirth Plan for improving communication between women, medical and nursing team, in a reality in which there is a conflict between beliefs regarding birth, what is safe, and effective care. The Childbirth Plan is envisioned as a possibility of reducing the medicalization of bodies, avoiding invasive procedures, and enhancing women's autonomy. The article points out, yet, strategies for nurses to advocate for women's choices and support their autonomys: reviewing this plan with the patients on admission in health services; keep it as a central plan of the care; help women without a Childbirth Plan to create it (informed women), in addition to providing verbal and physical support⁽²⁷⁾.

In particular attention to childbirth, the home and the Birthing Centers of Normal Childbirth - as places with less medical influence and somehow distant from hospital institutions - arise as environments that facilitate women's autonomy and empowerment. In home childbirth, the woman is in an environment that is part of her own life, which minimizes the domain of professionals on her body⁽³⁵⁾. Also, Birthing Centers of Normal Childbirth constitute a stimulus to childbirth physiology, a space of subjectivity and intersubjectivity that aims at women's protagonism regarding their citizenship, rights, and autonomy. The care in this scenario allows freedom of choice through dialogue, education and informational activities, use of the childbirth plan, and support/encouragement during the childbirth process^(24,34).

On the other hand, some studies start address power relations as solidified relations that benefit the health professional and the systems they represent, to the detriment of the user of health^{(13-14,16,18,29,32-33)}. It is mentioned that health professionals disregard the singularities of subjects assisted by them. Practices are standardized and addressed to predictable and passive subjects, based on technical relations and in disregard of common knowledge⁽¹⁸⁾. In addition, professionals recognize the everyday existence of discriminatory and disrespectful practices in the assistance to pregnant women, women giving birth, and those who have recently given birth⁽³²⁾. Specifically female nurses, in the relation of care of other women, play the role of subject when they submit women to the scientific rationality model in which they are involved⁽¹⁴⁾.

The vaginal exam - procedure used worldwide to evaluate the childbirth process - is seen in a field of social control, acting on the body and representing a power relation; in this context, a domain relation. Woman's body is seen as problematic, sick, and transgressive, as well as the dirty and polluted genitalia, that needs to be examined and cleaned⁽¹²⁾.

In the vaginal examination context, the tact of professionals, especially in the vaginal examination, consists of an external manifestation of power and authority, in which he who has the power to touch the "relatively powerless". Midwives ritualize this procedure and, although they aim some attention at getting the consent before performing the examination, they do not precisely explain or request a directed consent. They sanitize their terminology in a process of words' abbreviation and euphemisms; retain the information, for instance, about the exam details, and do not report the required frequency⁽¹²⁾.

Under Foucault's perspective, power does not only repress, but, especially, produces realities. In this perspective, it is not conceived as an essence of unique identity, nor it is a right that some have over others^(5,37). A power relation is articulated in two elements that are essential for it: that the other (the one on whom power is exercised) is fully recognized and maintained until the end as the subject of action; and that it opens, before the power relation, an entire field of responses, reactions, effects, possible inventions, resistance, and escape routes. Otherwise, states of domination coexist and are different from power relations. In these, relations, instead of being mobile and enabling the various partners a strategy that change them, they are blocked and crystallized by instruments that can be political or military^(37-38). Hence, the institutional violence against women, reality of many maternities - and under the reference of Hannah Arendt and Michel Foucault - is treated as a state of "non-power"⁽³²⁾.

We especially emphasize the childbirth scenario that, in terms of relationships between women and female nurses, has the great challenge of sharing and trading perspectives. Doctors, nurses, women, and families decisions are influenced by local policies and philosophies⁽¹⁶⁾. Thus, not only the subject of care are involved in power relations, but the health professional is also subjected to laws, policies, and disciplines⁽¹⁸⁾.

At this point, we have the boundary between professionals' responsibility and the enforcement of knowledge over the other⁽¹⁸⁾. Thus, acts of institutional violence are not seen as violent actions, but exercise of power in a context considered arduous under justifications such as: professional nature, scandalous/non-collaborative patients, and alienating routine. This scenario is consistent with the tenuous limit between violence and the exercise of professional authority, in which health professionals assume a position of technical-scientific authority and there is a trivialization of violence disguised of good practice⁽³²⁾.

We observe the advancement of some studies in relation to the foucauldian reference, when pondering the importance of discourses in the understanding of power as capillary, acting in microtechnologies of discipline systems operating daily in the bodies of individuals⁽¹³⁾. We highlight the importance of language as a political tool of power and change in nursing, with the potential to shape culture, history, and human experiences. We also mention the potential that discourse has to conform behaviors and enforce decisions. For example, when the nurse says "failed to breastfeed", she introject in women a feeling of impotence and guilt⁽²⁹⁾. Thus, the linguistic practices of nurses and midwives are seen from the point of view of disciplinarization and the way they construct ideal standards for female consumption^(13,33).

It is worth highlighting the predominance of studies found and analyzed that adopt the midwife (the obstetric nurse) and the scenario of childbirth as objects of study. Childbirth is a singular moment in a woman's life, in which there is great intensity of relationships, involving decisions such as the kind of childbirth and pain relief measures. Since pregnant women are mostly healthy individuals and do not need health treatments, they are able to make choices regarding birth, but they are also dependent on relationships that support them during childbirth. They also assume a position of weakness by the constant relationship with the child that is about to be born, which makes choices difficult⁽¹⁶⁾.

Midwives are considered able to create relationships that promote women's empowerment and autonomy, by the intensity and closeness of the relationship they establish, and by creating opportunities for women to impose their choices^(11,16). However, there is the challenge of seeking a balance between their own conceptions, impositions of the profession, and the institution to which they are linked with the need to allow the choice autonomy of women and advocate for their rights⁽¹⁶⁾.

The midwife coexists with the duality between emancipating from their oppression and at the same time feeling afraid for assuming a behavior of power:

"[...] when assuming control of themselves, their lives, their bodies, therefore empowered, the nurses will be fundamental paradigmatic transformation agents in the course of the consolidation of humanization through the power shared with women they assist"⁽¹⁷⁾.

Female nurses' care of self: escaping the powers or just another standardization?

Some publications contribute to understand the care of the self provided by nurses, although not explicitly dealing with philosophy under the poststructuralist perspective. Specifically under the foucauldian reference, the exercise of care of the self practices assumes a context of freedom, in which, by the subjectification modes, constitute, define, organize, instrumentalize strategies in relation to the other: "to whom authorizes and what"^(37-39). The technologies of the I are a privileged subjectification field and of this being-with-the-self domain; they consist of a certain number of operations made by individuals regarding their body and soul, thoughts, conduct or any way of transforming oneself, in search of a certain state of happiness, immortality^(37-39).

Some factors involving the care of the self of nurses were mentioned in the studies^{(14-15,17,19-20,22,24,28,30,34}): historical constitution of nursing; need for self-reflection; nurse's social position as a woman and health professional, and resistance movements of nurses. The historical constitution of nurses assumes that corporeity, i.e., the body in the world, is formed by historical influence⁽¹⁹⁾. For Foucault, history is entirely related to the formation of subjects: "[...] because it characterizes where we went from, what surrounds us, what we are about to break through to find new relations that express ourselves"⁽⁴⁰⁾.

An article points out the potentiality of the self-reflection practice of nursing for providing changes in actions and consequently in the reality of devaluation of the professional class⁽¹⁴⁾. It is also valued the importance of females nurses' care of the self through the way nurses see and recognize themselves in the world, what they consider capable of being, and how to use these capabilities, in order to question their own power and thus allow the empowerment of women they assist⁽¹⁷⁾.

Regarding the relationship between nurse and women who they assist, Foucault contributes to the understanding that there is no malevolence in the practice in which someone, in a given game of truth, possessing specific knowledge, tells you what needs to be done, "[...] teaches you, conveys knowledge, communicates techniques"⁽³⁷⁾. The problem is in investigating how these meetings will be possible, when power cannot cease to be exercised and is not bad in itself, preventing domination effects. Foucault called it "new ethic": playing with the minimum of domination⁽³⁷⁾.

Some texts emphasize the social position occupied by the female nurse, in a profession mostly feminine and permeated by gender inequalities based on patriarchalism. Such facts are expressed in crystallized power relations, in situations of submission to other professionals (especially physicians) and standardized behaviors and conducts. This context is associated with the experience of displeasure, pain, and low institutional identification, in addition to negatively impact on the quality of the assistance^{(15,20, 25,30)}. The social position of the nurse is also related to the high risk of suffering psychological assaults, arising mostly from gender inequality⁽²⁰⁾.

Besides being stigmatized as a woman, the female nurse, who owns the knowledge, faces internal and external demands regarding her attitude with her own body. The act of breastfeeding, for example, is an imposition to nurses, when they assume not only the condition of someone who has recently given birth, but also of someone who "knows" that breastfeeding is fundamental⁽²⁵⁾.

Under the patriarchy logic, oppression is a reality for women; for the nurses, it is the norm in which they are raised as women and developed as nurses⁽¹⁵⁾. Thus, history shows that the training to which nurses were subjected aimed not only to the development of skills, but to make them useful for the institution, through the manipulation of their elements, gestures, and behaviors⁽²⁸⁾.

In the sense of control over the bodies of nurses, a strategy that supports the prescription and imposition of conducts for them regarding their own body and life is the discourse of vicarious experience.

In Foucault, the practices of the self are not something that individuals create, but refer to schemes that individuals find, which are proposed to them, suggested, imposed by their culture, society or social group. The subjectification processes are aimed at the creation of modes of existence, what Nietzsche called the "invention of new possibilities of life" with origins in Ancient Greece. Therefore, we highlight the importance of the practices of the self of female nurses formerly in the care of other women: "One should not pass the care of others in front of the care of themselves; the care of themselves comes ethically firstly, to the extent the relationship with yourself is ontologically primary"⁽³⁷⁾.

We also point out the lack of knowledge and the difficulty of nurses in thinking and talking about themselves as women taking care of other women: "[...] 'Who is this woman? Am I talking about myself? Don't I know who I am?' [...]"⁽¹⁴⁾. Female nurses do not recognize themselves as subjects of their lives, which also contributes for them not to recognize this protagonism in women they take care of. Therefore, they play the role of subjects unconsciously, and submit users to a secondary role⁽¹⁴⁾.

But nurses are also on the move, seeking to study, work, and have financial independence aiming at growth and emancipation. They are in search to be subjects of their lives and bodies in the everyday life, overcoming the limits of power relations, seeking distinction, creating escape routes and resistance^(14,34).

Historically, nurses exercised and suffered the action of power, especially the movement of struggle and resistance to the institutionalized power-knowing. Escape strategies of nurses aiming at improving the quality of care toward women are highlighted, being based on critical discourse of scientific nature⁽²⁸⁾. In this sense, the experience, on the part of nursing, of a transitional period, on the way to another paradigm that questions the various forms of privilege and oppression, is aspired and indicated^(23,34).

They live at the borders - balance between what is ancient and still remains and what should be abandoned; confrontation between the biomedical knowledge acquired and the experiences of everyday life; and this confrontation to colonizer knowledge initiates an emancipation process. The rupture is like a time of death that brings the new to light "because I no longer believed in that, I would have to skip that line. Going back was not an option [...]"⁽³⁴⁾. In this exploration of subjectivities, emancipatory practices are formulated considering the female user and sharing with her in a relationship of freedom for both. All emancipating process constitutes self-knowledge; it is not discovered, but created⁽³⁴⁾.

FINAL CONSIDERATIONS

Knowledge can be produced under the perspective of different paradigms in relation to nursing care, a characteristic that integrative review allows portraying, since the methodology for selection of studies enables the inclusion of several approaches and methods.

Overall, the studies presented had a state of the art of the knowledge produced mostly in a qualitative form, by several methodologies and complementary theories, but focused especially on theoretical references of a liberating perspective, i.e., from active, autonomous, and emancipated subjects. This can be contrasted with the post-critical foucaldian perspective, in which the subject is a product of history.

The analysis of power relations presented focuses on the search for equal relations between professional-user, based on humanization, completeness, citizenship, and human rights guarantee for constructing an emancipatory perspective of the subject. In addition, studies indicate a field of crystallized relations and of domination in contrast to the foucauldian perspective of capillary power and subjective production.

Although the presented studies analyze the care of the self of female nurses, they do not refer directly to the foucauldian perspective and not directed to the understanding of the impact of these relations on the lives and bodies nurses. Studies are directed to the discussion of the impacts of the care of the self in the nursing practice and professional autonomy.

In the relation with the other (other women), outstands the consideration of Foucault in which you can play with minimal domination, having the professional an important role related to their knowledge. Although few, outstand studies that contribute to the understanding of the discourses on the power in its capillary form, daily operating in the bodies of individuals.

Thus, through the evidence presented, and bearing in mind the social context of women's health, the care of the self presents itself as a foucauldian concept-tool with potential for the theoretical and practical field under study. We emphasize the thematic implications of power relations for nursing care to women, a care constructed by subjects on the condition of women and health professionals.

We identified as the main limitation of this study the lack of the "care of the self" descriptor, which demanded the choice of other terms that approached the desired construct. In none of the studies analyzed the care of the self of female nurses is taken as an object of study, what is a gap in knowledge and thus demanding, for its relevance, investments.

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Publication Dates

• Publication in this collection
  Nov-Dec 2016

History

• Received
  18 July 2016
• Accepted
  15 Aug 2016