Print version ISSN 0080-6234
Rev. esc. enferm. USP vol.46 no.2 São Paulo Apr. 2012
Percepción del enfermero sobre promoción de la salud en la Unidad de Terapia Intensiva
Adriana Sousa Carvalho de AguiarI; Monaliza Ribeiro MarianoII; Lívia Silva AlmeidaIII; Maria Vera Lúcia Moreira Leitão CardosoIV; Lorita Marlena Freitag PagliucaV; Cristiana Brasil de Almeida RebouçasVI
IRegistered Nurse. Master's Student of the Post-graduation in Nursing Program of the Federal University of Ceará. FUNCAP Scholarship. Fortaleza, CE, Brazil. firstname.lastname@example.org
IIRegistered Nurse. Master's Student of the Post-graduation in Nursing Program of the Federal University of Ceará. FUNCAP Scholarship. Fortaleza, CE, Brazil. email@example.com
IIIRegistered Nurse. Master's Student of the Post-graduation in Nursing Program of the Federal University of Ceará. Fortaleza, CE, Brazil. firstname.lastname@example.org
IVRegistered Nurse. PhD in Nursing. Post-doctorate in Vancouver/Canada. Associate Professor of the Post-graduation in Nursing Program of the Federal University of Ceará. Fortaleza, CE, Brazil. email@example.com
VRegistered Nurse. PhD in Nursing. Full professor of the Post-graduation in Nursing Program of the Federal University of Ceará. CNPq Productivity Scholarship. Fortaleza, CE, Brazil. firstname.lastname@example.org
VIRegistered Nurse. PhD in Nursing. Post-doctorate in Nursing. Collaborating professor of the Post-graduation in Nursing Program of the Federal University of Ceará. CNPq Scholarship. Fortaleza, CE, Brazil. email@example.com
The objective of this study was to report the nurses' perceptions regarding health promotion, describe health promotion activities, and identify difficulties in performing health promotion activities in the Intensive Care Unit (ICU). This descriptive, exploratory study was performed with 31 nurses from two adult ICUs and one neonatal ICU of a reference hospital in Fortaleza, Ceará, Brazil, between July and August 2009, using a questionnaire. Data were analyzed and categorized using Bardin's content analysis. The following categories and subcategories emerged: the concept of health promotion: biomedical and holistic view of health promotion; health promotion activities; communication and emotional support for patients/family; health promotion in the ICU; health promotion focusing on health education; and the difficulties in developing health promotion activities.
Descriptors: Health promotion; Intensive Care Units; Nursing care
Se objetivó relatar la percepción de enfermeros sobre promoción de la salud, describir acciones de promoción de salud e identificar dificultades en la realización de actividades de promoción de salud en Unidad de Terapia Intensiva (UTI). Estudio descriptivo, exploratorio, cualitativo, realizado con 31 enfermeros de dos UTIs de adultos y una UTI neonatal de hospital de referencia en Fortaleza-CE-Brasil, entre julio y agosto 2009, mediante cuestionario. Datos analizados y categorizados a partir de análisis de contenido de Bardin. Emergieron las siguientes categorías y subcategorías: Concepto de la promoción de la salud: visión biomédica x visión holística de promoción de la salud; Acciones de promoción de la salud; Comunicación y apoyo emocional al paciente/familia; Promoción de la salud en la UTI; Promoción de la salud con enfoque en la educación sanitaria; y Dificultades para el desarrollo de acciones de promoción de la salud.
Descriptores: Promoción de la salud; Unidades de Terapia Intensiva; Atención de enfermería
In recent years, health promotion has been one of the most discussed subjects in the different spaces of knowledge production and health practices. The theme has permeated diverse scenarios in the national and international context, supporting an expanded concept of health. The ideas regarding health promotion were introduced in Brazil in the mid 1980s, with the Health Reform debate. Furthermore, it also influenced some movements such as the VIII National Health Conference; the 1988 Constitution; and the creation of the Brazilian National Health System (SUS). Currently, it still contributes to the (re)structuring of the Family Health Strategy, the bases of which represent the ideal for health promotion(1). The idea of promotion involves the strengthening of the individual and collective capacity to deal with the multiplicity of health determinants. Therefore, health promotion goes beyond the absence of disease and must be understood as a cross-sectional, multidisciplinary and interdisciplinary strategy. Given this concept, it can not be limited to issues related to the prevention, treatment and cure of diseases(2). It covers all actions directed towards the care itself, independent of the environment where this care is performed. However, it is common to associate the strategies of health promotion with the context of public health, since in this level of care such activities appear more evident, especially considering that the main focus is the family or the individual inserted into the environment where they live. In hospital settings, where the nursing care is more directed towards the curative or preventive aspects of the disease, often the actions of health promotion become limited or undervalued. Involved in this theme, is a paucity of research on how health promotion could be incorporated successfully into the role of nursing and how nurses perceive their role(3).
Concerning the Intensive Care Unit (ICU), studies in this field have shown that, due to its specificity and great technological diversity, the nursing care in these units has in its scope particularities that differentiate it from the other units(4). This unit is staffed by qualified people and offers continuous care with the use of sophisticated devices capable of maintaining the survival of the patient, requiring a high level knowledge from the professional as well as flexibility and rigorous attention in the care provided. The issues inherent in the context of the ICU can contribute towards health promotion actions in the care of the patient treated in this unit becoming undervalued, disconnected from the professional practice or even actions implicit in the act of caring sometimes being overlooked. Based on this, the guiding questions of the study were: do the nurses comprehend health promotion in its broadest sense? Do they develop health promotion actions or not? How do they relate to the act of caring? Are such actions restricted to the treatment of diseases? Thus, the study seeks to contribute to the reflection and the formation of a professional practice directed towards health promotion in its broadest sense.
The aims of the study were to report the perceptions of nurses regarding the meaning of health promotion; to describe the health promotion actions performed by nurses in the care of patients treated in the intensive care unit; and to identify the difficulties highlighted by nurses in the performance of health promotion activities in the intensive care unit.
This is a descriptive, exploratory, qualitative study conducted with nurses from two adult ICUs and one neonatal ICU of a public reference hospital in Fortaleza. A total of 47 nurses work in the three units mentioned, distributed between the day and nightshifts. The number of subjects was defined by the saturation of the data, according to the relevance of the content of the discourses pertinent to the design of the object of this study. Nurses were excluded from the study who were on sick leave or vacation during the data collection. The data collection was performed between July and August 2009 and a semi-structured questionnaire was used, which was completed by the nurses of the previously mentioned units and subsequently collected by the researchers. This instrument consisted of two parts: the first scored aspects related to the characterization of the professionals and the second investigated the discourse of the nurse regarding the definition of health promotion, activities related to this practice and difficulties encountered in its implementation.
After compiling the completed instruments, the information was analyzed following the content analysis method(5). The data were grouped into categories and subcategories according to the theme of health promotion. To preserve the anonymity of the participants, the discourses were identified by the letter A, then the number corresponding to the sequence of interviews. As required, the project was approved by the Ethics Committee of the institution under Protocol No. 020702/09 and the Terms of Free Prior Informed Consent was signed by the study participants, with all the rights conferred to them conforming to the ethical aspects of research with humans.
RESULTS AND DISCUSSION
A total of 31 nurses participated in the study, of which 17 worked in the adult ICU and 14 in the neonatal ICU. The majority were female, with a mean age of 32 years and a mean of eight years work in the nursing profession. Regarding the majority of qualifications, 16 of them had the title of specialist, three possessed master's degrees and the other 12 graduate degrees. From the content analysis method and according to the information obtained through the completion of the questionnaires by the nurses, three categories were delineated, which are presented and discussed below with their respective subcategories: 1. The concept of health promotion: the biomedical view vs. the holistic view of health promotion; 2. Health promotion actions in the intensive care unit; 3. Difficulties in the development of health promotion actions.
The concept of health promotion: the biomedical view vs. holistic view of health promotion
In this category it was sought to evaluate the perceptions of the nurses regarding the concept of health promotion and its relationship with the hospital environment, particularly with the ICU. From the analysis of the discourses concepts emerged related to the biomedical and holistic view of health promotion. Therefore, in the concepts of health promotion reported by nurses, perceptions were observed ranging from a reduced view to an expanded view of health promotion. It was noticed among the discourses, that the nurses understand health promotion as the establishment of preventive and curative measures, focused on the disease process. However, it is known that health promotion is broader and transcends the strictly biological focus.
It is the act of protecting the patient from any disease and/or complication (A13).
It is the prevention of disease; to perform procedures in order to maintain or promote health (A9).
(...) healthy practices are focused on prevention and/or rehabilitation (A16).
Actions performed that make the person not become sick (A20).
The reports show the ignorance regarding the true meaning of the health promotion theme, with confusion between the concepts of promotion and prevention. Therefore, it is worth mentioning that there is a radical and, at the same time, slight difference between prevention and health promotion. Radical because it implies profound changes in the way of articulating and using knowledge in the formulation and operationalization of the health practices and slight because the practices of promotion, as well as prevention, make use of scientific knowledge. Preventive actions are defined as interventions aimed at preventing the emergence of specific diseases and reducing their incidence and prevalence in the populations. The health model is merely medical and only addresses the risk groups of the population(2).
The discourse presented by the nurses reflects the context of the ICU, where the care practices concentrate more attention on the situations that require the use of equipment or focus on the disease and its cure. The applicability of health promotion appears to be limited, with the following of rules and routines predominating. This excludes the possibilities of care in order to promote health in various situations where, for example, the cure is not presented as the only alternative to be achieved(6-7).
The modern concepts of health promotion are directed toward a more comprehensive dimension of health that considers the biological, psychological, social, cultural, and environmental variables. This refers to the measures aimed not only at the determined disease, but able to provide health and well-being. Consequently, this dimension requires interdisciplinary work. Therefore, to include new knowledge means comprehending that the hegemonic knowledge in the clinic is indispensable for healthcare, but harmful when used in isolation from other knowledge(8).
Still concerning the concept of health promotion, the discourse presented by the other nurses revealed that the majority of them expressed a broader concept of the term health promotion, i.e. a holistic view. Etymologically, the word holism or holistic comes from the Greek holos, meaning whole, complete. The influence of the holistic view in the health practices refers to the development of a view of the human being within a biopsychosocial context, as a unique being who carries a life history impregnated with cultural values(9). Therefore, in the understanding of the nurses participating in the research, health promotion is tied to the quality of life of the individuals, to their well-being and the measures that provide health, in its physical, mental, social and emotional aspects. The subject is visualized in an integral way, within a social and family context, and the importance of interdisciplinary work emphasized, so that health problems are comprehended from the point of view of different areas of knowledge, in which biological, psychosocial, cultural and environmental variables should be considered. This can be seen in the following discourses:
It is any action that promotes the physical and mental well-being of the patient, professional and family (A15).
(...) a set of interdisciplinary strategies that address the health problems of the individual, whether in the biological, psychological or environmental dimensions (A29).
It is all actions that aim to meet the needs of the human being in all its states (mental, spiritual and physical) (A1).
These actions are performed by the health professionals and governors to maintain the physical, social and psychological integrity of the human being (A5).
Measures that guide the client to have a better quality of life (A19).
It was noted in the reports of the nurses that, although health promotion is a recurring theme in the quotidian, it presents itself as a complex and multifaceted concept. The limitations inherent in the conceptual definition of health promotion stem from the difficulty of defining health, especially in the face of the different dimensions present in the concept: social, psychological, economic, spiritual, as well as the more traditional biomedical dimension. The fact that particularly emerges is that health is, above all, an individual experience. The way people perceive their health and the means to care for it are as diverse as the different forms of meaning and life experience(10). For the World Health Organization, the term health promotion is related to the holistic in a more political denotation. Thus, the words reveal the broad amplitude, contemplating diverse actions that involve all aspects aimed at improving the health status of the individuals. Health promotion therefore includes multiple aspects and does not constitute an activity in itself(8,11).
Health promotion actions in the intensive care unit
This category aggregates the practices of health promotion that the nurse demonstrates in the care to the patient hospitalized in the intensive care unit. Among the nurses participating in this study, 27 reported that they perform some health promotion strategy, while four respondents said they did not perform any strategies or rarely performed them. It is believed that the responses of the nurses, with regard to the performance or not of health promotion actions, were influenced both by their concept regarding the idea as well as by their view related to their professional practice.
Based on the analysis of the discourses of the nurses regarding the performance of health promotion activities in the context of the intensive care unit, varying concepts emerged. These were focused on the procedures, care and control of infection, but also on the user and their families, and the working environment. Thus, the following subcategories emerged: 2.1. Attention directed toward infection control, treatment and rehabilitation; 2.2. Communication and emotional support to the patient/family; 2.3. Health promotion in the environment of the ICU; 2.4. Health promotion focused on health education.
Attention directed toward infection control, treatment and rehabilitation
In the perception of the nurses, the effectiveness of health promotion actions in ICU patient care is directed predominantly toward the execution of care procedures with appropriate techniques for the treatment of the disease and the control of infection, illustrated by the following the discourses:
(...) administration of medication and performance of procedures with aseptic techniques (A22).
Administration of the diets by catheter; encouragement of the oral diet in the conscious patients; performing position changes in patients with impaired mobility (...) (A17).
(...) not leaving the patient without a diet or with a poor diet, keeping the patient well hydrated (A21).
Performing procedures in the direct care to the hospitalized newborn: tracheal aspiration, sample collection (...) (A5).
Handwashing, careful hygiene, use of PPE (A13).
(...) guidance to the patients and companions regarding disease prevention measures (A4).
In relation to the care performed in an intensive care unit and the type of clientele attended, hospitalizations in these centers are preceded by present and potential organic complications, which endanger the life of the patient. This fact has contributed to the nursing care in these units being guided by the biomedical model. Also care based on the physical aspects of disease, such as control and maintenance of vital functions, predominates(12). Therefore, as observed in the statements of the nurses, one of the concepts regarding the performance of health promotion activities in the hospital setting refers to the performance of procedures, to disease prevention, treatment and to the cure of diseases. This statement is corroborated, because the formation of healthcare professionals and of nurses is particularly focused on biological aspects and is centered on the prevention, treatment and curative actions(6).
As can be seen in the discourses presented, the concern with the performance of procedures and techniques that lead to the prevention of disease or to the adequate implementation of therapies is confused with the true meaning of health promotion in the hospital. Although the attitudes evident in the discourses of the nurses are important and coherent, the view of care as a practice for health promotion must be broadened. From the concept of various authors, the role of nurses in the ICU goes beyond the performance of therapeutic procedures and of care for physical signs and symptoms presented by the client. It should also identify problems and assist the individual in their plenitude, in order to meet the demonstrated needs, evaluating the care provided and guaranteeing the efficacy of their recovery. It also includes making possible the development of the autonomy of users to enable them to participate in their own care and to assume a healthy lifestyle, even when in the hospital environment, preparing for discharge(6,8).
Communication and emotional support to the patient/family
Although the actions cited by the nurses focus greatly on the therapeutic model and the cure of disease, practices that advocate health promotion in a broad sense also emerged from the discourses, recovering the humanization.
(...) to talk to and reassure the conscious patient. I try to maintain these attitudes as far as possible (A21).
(...) giving emotional support to the patients, talking with them, despite the majority being sedated and anesthetized (A23).
(...) communication with the conscious patients, so they are not disorientated (A17).
To guide the patients when conscious, improving their self-esteem, stimulating their exit from the ICU with comforting and friendly words (A18).
Talking with patients that are awake and interacting with the family members (A15).
To provide guidance to the family members and conscious patients about their health status, clinical condition, healthy lifestyle practices (...) (A24).
Direct assistance to the hospitalized newborns, guidance for the family, support for the mother (...) (A5).
As seen from these discourses, communication with the patient in the intensive care unit was exposed by the nurses as an instrument for health promotion for the care process. Several studies consider communication as an important tool for the promotion and humanization of health (7-8,13-15). In the healthcare practices in the hospital context, communication enhances the interaction between professionals, patients and their family members. Thus, it makes the healthcare actions more humanized, reducing the doubts and anxieties that exist in the hospitalization process. However, the act of communicating is a challenge for most nursing professionals, especially those who care for patients in critical situations, such as in intensive care units.
The nursing team in an ICU, involved in the daily and complex routine and in the provision of a high complexity technological service, often begins to present less interest in the personal relationships. They forget to play, talk and listen to the patient in front of them there(11). According to that evidenced by the discourse of the nurses, the majority reported communication with patients who are conscious. Although, in this environment patients predominate with impaired capacities for verbal expression, due, for example, to endotracheal intubation and tracheostomy, it is still possible to establish the transmission of messages through nonverbal communication. Few nurses, however, mentioned the use of communication with sedated and anesthetized patients. Authors report that the comatose patient becomes isolated in the environment of hospitalization by the inability to communicate, which also constitutes a great challenge for the nursing team to perform the care(15). Another aspect present in the statements of the nurses was the bond with the family. The family has been shown to be responsible for many positive aspects related to the recovery of their family member hospitalized in an ICU, fulfilling many of their needs and contributing with significant information in respect of the patient, which favors decision-making regarding the performance of procedures(7,15).
Health promotion in the ICU environment
As shown by the statements, the concern regarding the impact of the intensive care unit environment on the well-being of the bedridden patient was observed in the discourses of the nurses as an attitude of health promotion. In their discourses they stressed the importance of adopting measures that minimize the stressors and benefit the clients.
(...) I seek to minimize the sources of stress for the patient, as far as possible (...) such as to reduce the noise, to try to provide conditions for sleep and quiet rest (A21).
I practice peace, education and respect in the workplace (...) (A23).
(...) to provide a safe and peaceful environment (A24).
(...) I try to do everything for the well-being of the patient; food, clothing, an adequate resting place, etc. (A25).
Articles published with an emphasis on clients hospitalized in the ICU present statements that highlight noise (of people and equipment) to be the most important factor to be controlled in an ICU. Given the technical specifications of construction, the ICU has a limited physical area, which allows the person hospitalized there to see or perceive everything around them. Besides the presence of equipment, the uninterrupted dynamics of team work, constant and monotonous noise and alarms, permanent artificial lighting and ventilation, lack of windows for viewing the external environment, etc., contribute to alter the emotions of the people treated there. Thus, the physical environment can trigger psychological disturbances, disorientation in time and space, and increased sleep deprivation because of the constant noise(11,16).
Given this situation, all the aspects that could be improved in order to minimize the stressors should be valorized, making the environment of the ICU less exhaustive and tense. One of these involves, for example, the implementation of forms of relaxation that promote the harmonization of the environment through music, the reduction of noise pollution, the reduction of illumination at certain times and the maintenance of a pleasant temperature. Strategies that facilitate contact, interaction and dynamics within the context of the ICU provide integral health promotion, not only for the patients but also for the professionals.
Health promotion focused on health education
Some nurses mentioned in their discourses the use of health education as a tool for health promotion actions.
(...) health education guidance for mothers of hospitalized newborns regarding breastfeeding, immunization (...) (A14).
(...) to provide guidance to the patient's family about the discharge, procedures performed (...) (A8).
When there are conscious patients, advising them about the surgical procedures, for example (A16).
(...) guidance to the mothers about caring for the newborns; guidance regarding breastfeeding (...) (A11).
(...) to advise mothers about the care that must be performed to prevent infections in the babies (...) (A4).
All health promotion activities, including health education, need to be characterized by empowerment, that is, actions that lead the individual to their autonomy and empowerment. Many educational practices developed by nurses focus on disease prevention, without, however, incorporating the comprehension of the determinant factors of health problems or the needs and knowledge of the population they work with(17-18).
According to that observed in the statements, the reference to health education was made mostly by the nurses working in the neonatal intensive care unit. From the concept of these professionals, health education has an important dimension as a strategy for health promotion, because it opens up space for the professional relationship with the mother, involving her in the treatment and encouraging her to take care of her baby. The educational process developed by the nurses in the neonatal unit is essential, and the mothers need to obtain knowledge with regard to care for the child, because the sharing of experiences is reflected in mutual aid favoring assimilation of and apprehension of knowledge(19). Also, as seen in the discourses, few nurses working in the adult intensive care units cited health education as a health promotion activity due to the limiting factors related to the context of the ICU, especially those related to the clinical condition of the patient. Others, when they referred to some kind of health education within the ICU, returned to explanations regarding techniques or procedures. As shown in studies, the restriction of visiting hours, the small amount of contact with family members, the closed environment and the aggravating factors of health that lead the patients to be hospitalized in the ICU were identified by the nurses as negative points for health education in this sector(20).
Difficulties in the development of health promotion actions
In this category, some difficulties were mentioned by the nurses regarding the performance of health promotion strategies. Corresponding to the discourses of the nurses, seven did not encounter any impediments in the development of health promotion actions in the workplace where they operate, i.e. in the context of the intensive care unit. However, the majority of the nurses recognized some type of difficulty or obstacle that limits the performance of health promotion activities in the environment of the intensive care unit. Among the difficulties most often cited were: work overload, lack of material, the lack of commitment of the professionals, and the fact that many ICU patients are sedated, which hampers communication. Another aspect highlighted by the nurses was the lack of sensitivity of the professionals and the resistance to changes.
(...) there are difficulties, for example, to provide quality care (humanized) due to the large number of tasks (A25).
Noise from devices; too many people in a small space. Excessive handling of the patients; lack of some type of therapy for the conscious patients that are in the ICU (A23).
Lack of time; shortage of materials; lack of commitment of some professionals (A7).
(...) the majority of patients are critically ill, sedated, anesthetized, with it not being easy to establish communication (A26).
(...) the resistance to changes; old ingrained habits (...) (A6).
To sensitize the professionals to exercise their functions with emotional involvement, so that they do not become just mechanical workers, but have a holistic view (A1).
(...) insufficient number of professionals for the demand (...) (A5).
The culture of the people is not promotion but curative (A20).
The study highlighted as negative aspects which make the interpersonal relationship of the nurse with the patient in the ICU difficult: behavior mediated by affective insensitivity, the technicist care, and anxiety of the professionals in the daily routine with critically ill patients. The high demand, the procedures and flexibility the in care may also contribute to impersonality in the relationship. Furthermore, the concern with the administrative aspects of the care consumes a significant part of the nursing work hours, leading to distancing from their goals(15).
A factor also mentioned by the nurses in their discourses refers to the work overload. As studies show, in the majority of cases, the shifts took place in an atmosphere of agitation, and this requires attention and rigorous care for all the team members(4,20). Another aspect mentioned refers to the lack of material resources. Faced with the shortage of material and human resources, the professionals end up doing the best they can. Sometimes it is necessary to improvise. This initiative does not always bring benefits to the patient, and may even culminate in damage to the quality of the care(21).
It was noted in the discourses presented that among the difficulties emphatically addressed by the nurses working in the adult ICUs the following were mentioned: the majority of patients are sedated and, consequently, have an altered level of consciousness. Thus, communication is difficult. Studies indicate that the mechanization of the technical procedures, the lack of dialogue and the absence of empathy often happen because the coma patient is unconscious. Authors emphasize that the impairment of some cerebral and sensory functions does not necessarily imply the inexistence of perceptual expressions. Studies have shown that coma patients present physiological changes when they hear a song or a familiar voice. These findings support the possibility of communication between the patient and the environment(13,15).
The knowledge of the nurses regarding the concept of health promotion portrayed different approaches, varying from a biomedical view of health promotion, focused on curative measures and the disease process, to a broader concept, with the purpose of promoting well-being, which transcends the strictly biological focus. Although the responses related to the concept of health promotion indicated its broader perspective, the strategies presented by the nurses were predominantly directed toward the realization of care procedures, for the treatment of disease and infection control. According to that observed, the majority of the professionals were unaware of the true meaning of the health promotion theme and often confused the concepts of promotion and prevention.
Generally, the particular characteristics related to the context of the ICU, for example, the ongoing emergency situations, the severity of the patients and the accelerated dynamics of the service, contribute to automated behavior, in which dialogue and critical thinking have no space. However, some nurses mentioned health promotion activities focused on the broad aspects of care, addressing the user and their families, as well as the work environment. Thus, in their discourses health promotion activities were present, directed toward health education, communication and the nurse-patient-family relationship. The concern of the nurses with the impact of the ICU environment on the well-being of the hospitalized patient as a health promotion attitude was also highlighted.
Among the difficulties cited by the nurses that limit the development of health promotion actions in the context of the ICU were: the work overload, the lack of sensitivity of the professionals, the resistance to change, and the clinical status (altered level of consciousness due to sedation) of the majority of the patients that impaired communication. It should be noted that some issues require further discussion. There is still a long way to go to achieve the development of health promotion in the hospital context, particularly in the context of the ICU, mainly because the healthcare practices established in the care for the client are hegemonically centered on the physical aspects of the disease.
Despite the unique characteristics that permeate the context of the ICU and it being a sector in which specific and complex care is performed, it is highlighted that it is not enough to dominate the knowledge regarding the high complexity technology existing in these units. It is necessary to pay particular attention to the client in their totality. For this, the professionals must be active, applying their knowledge and skills, exercising their political and social capacity, beyond the technical. Therefore, for the healthcare services to promote health, multidisciplinary work is necessary, as well as the professionals comprehending and expanding their view of health promotion, including themselves as critical authors and participants in the process of construction and reformulation of this system.
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from the discipline "Bases Teóricas da Promoção da Saúde"
of the Post-graduation in Nursing Course of the Federal University of Ceará,
* Extracted from the discipline "Bases Teóricas da Promoção da Saúde" of the Post-graduation in Nursing Course of the Federal University of Ceará, 2010.