The (in)visibility of caring and of the profession of nursing in the relations space

Abstracts

OBJETIVO: Compreender como os profissionais de enfermagem atuantes em unidade de internação cirúrgica de um Hospital Universitário significam a visibilidade do cuidado ao outro e da profissão em seu espaço de relações. MÉTODOS: Estudo qualitativo e interpretativo. Os dados foram coletados mediante oficinas com a participação de dez profissionais de enfermagem e as falas foram submetidas à análise de conteúdo interpretados à luz do pensamento complexo. RESULTADOS: Categorias encontradas: o cuidado do outro invisível e visível na dimensão laboral; o cuidado do outro invisível e visível na dimensão familiar; a invisibilidade da enfermagem em sua categoria profissional. As relações, interações e associações humanas nos espaços organizacionais do cuidado e da prática da profissão em suas interconexões e trocas são visíveis e invisíveis. CONCLUSÃO: A visibilidade do cuidado ao outro e da profissão processa-se nas interações e trocas mobilizadas na convivência com os seres de relação nas suas múltiplas dimensões e complexidade organizacional.

Equipe de enfermagem; Cuidados de enfermagem; Papel do profissional de enfermagem; Administração dos cuidados ao paciente

ORIGINAL ARTICLE

The (in)visibility of caring and of the profession of nursing in the relations space^*

La (in)visibilidad del cuidado y de la profesión de enfermería en el espacio de relaciones

Maria Aparecida Baggio^I; Alacoque Lorenzini Erdmann^II

^INursing post graduation student (Ph.D.) at the Nursing Post graduation program, Universidade Federal de Santa Catarina - UFSC - Florianópolis (SC), Brazil. CNPq fellowship holder

^IIPhD in Nursing. Full Professor at the Nursing Department, Universidade Federal de Santa Catarina - UFSC - Florianópolis (SC), Brazil. Researcher 1 A at CNPq

Corresponding Author

ABSTRACT

OBJECTIVE: To understand how the nursing professionals, in a unity of surgical admission of a University Hospital, give meaning to the visibility of caring for others and to the profession of nursing, in their relations space.

METHODS: Is a qualitative and interpretative study. The data were collected by means of workshops with the participation of ten professionals of nursing; and the statements were subjected to the content analysis interpreted under the theoretical frame of the complex thought.

RESULTS: Were found the following categories: the invisible and visible care of others in the working dimension; the invisible and visible care of others in the familiar dimension; and, the nursing invisibility in his professional category. The relations, interactions and human associations, in the organizational spaces, where the care and the professional practice are performed, remain visible and invisible in his interconnections and exchanges.

CONCLUSION: The visibility of caring for others and of the nursing profession is processed in the interactions and exchanges that happen with the beings of relation in his multiple dimensions and in the organizational complexity.

Keywords: Nursing team; Nursing care; Role of the nursing professional; Administration of patient care

RESUMEN

OBJETIVO: Comprender cómo los profesionales de enfermería, que actúan en una unidad de internación quirúrgica de un Hospital Universitario, le dan significado a la visibilidad del cuidar de otro y a la profesión de enfermería en su espacio de relaciones.

MÉTODOS: Se trata de un estudio cualitativo e interpretativo. Los datos fueron recolectados mediante talleres con la participación de diez profesionales de enfermería; las declaraciones fueron sometidas al análisis de contenido e interpretadas bajo el marco teórico del pensamiento complejo.

RESULTADOS: Fueron encontradas las siguientes categorías: el cuidado del otro es invisible y visible en la dimensión laboral; el cuidado del otro es invisible y visible en la dimensión familiar; y, la invisibilidad de la enfermería en su categoría profesional. Las relaciones, interacciones y asociaciones humanas en los espacios organizacionales del cuidado y de la práctica de la profesión en sus interconexiones e intercambios, son visibles e invisibles.

CONCLUSIÓN: La visibilidad del cuidar de otro y de la profesión de enfermería se procesa en las interacciones e intercambios que suceden en las relaciones con los seres en sus múltiples dimensiones y complejidad organizacional.

Descriptores: Equipo de enfermería; Cuidados de enfermería; Papel del profesional de enfermería; Administración de los cuidados al paciente

INTRODUCTION

The process nursing care involves the dimensions of knowledge/knowing and the praxis that are present in the nursing routine. Nursing praxis, just as other professions, is permeated by adverse conditions but also by achievements because the knowledge that subsidizes the profession is constantly constructed, deconstructed and reconstructed, enabling the development and opening up new paths which include the practice of citizenship of professionals in the development of their competences and the personal and professional self-realization; conditioning the constant attempt to meet the individual and collective human needs; contributing to professionals' acknowledgement/valuation for a praxis that is liberating, supportive and emancipatory, integrating those providing and those receiving care, linking knowledge and procedures in which care makes the convergence between science, ethics, art and esthetic⁽¹⁾.

The work of nurses, based on scientific knowledge, is valued and acknowledged when there is respect between health professionals and reliability in the team; when the clientele's needs are met and their problems are solved by the social organization, and when there is social and financial return coming from the rational and effective action of professionals. Thus, the term "little acknowledged" encompasses the relationship of the profession in the environment it is inserted, involving the team, the population and the health institution, whose acknowledgement comes from social representations and the value given to concrete (wage, institutional facilities, consumers' good) and symbolic issues (prestige, acknowledgement and admiration)⁽²⁾.

Currently, care in the nursing profession is based on the scientific knowledge, which leads to its acknowledgement, different from the time of Florence Nightingale, until mid-twentieth century, when it was seen as submissive to medicine⁽³⁾. Nursing will evolve in comprehension, importance and depth, gaining space and acknowledgment both regionally and internationally, supported by the engagement of nursing professionals and researchers in studies and research to search for knowledge/procedures that are scientifically based and that foster the visibility of the profession and of nursing professionals⁽⁴⁾.

Nonetheless, in their work and in the hospital organizational dynamic, nursing professionals can have their work process and their appreciation affected, leading to anguish and suffering. The first is related to the countless tasks of their routine since they are seen as polyvalent due to the lack of limitation of their work field, the second is related to inadequate remuneration, excessive demand and lack of encouragement for capacity building⁽⁵⁾.

As nursing care faces several and complex conditions of physical and psychological exhaustion in its routine, it is essential to understand and interact with the people involved to promote well being in a contextualized and individualized way, not only in the relationship with clients but also with peers⁽⁶⁾. Thus, these attitudes can reflect in the acknowledgement and appreciation among peers and other people, expanding and giving visibility to the profession, to human beings, and to professionals and to the care provided by them. Based on the above, we ask: How do nursing professionals give meaning to the visibility of care for the others and of the profession in their spaces of relations?

The present study, taken from a Master dissertation, had the goal to understand how nursing professionals working in a surgical unit in a University Hospital, give meaning to the visibility of care to other people and of the profession in their relation space.

METHODS

Qualitative, interpretative study, carried out in a surgical unit of a University Hospital in the South of the country, with 26 beds, eight nurses and 24 nursing assistants, used in the preoperative period of gastrointestinal, chest and emergency surgeries such as herniorraphy and appendicectomy. Ten female nursing professionals took part voluntarily in the study, after the objectives and the methodology proposed were explained by giving their written consent. The Research Ethics Committee with Human Beings at the Universidade Federal de Santa Catarina approved the research project, No 266/07. The ethical aspects involving human beings were respected according to Resolution No 196/96 of the National Health Council in all the research stages⁽⁷⁾.

Five workshops were carried out at three different times, developed through an educational/reflective/interpretative process, with themes previously selected, proposing the reflection on the meanings of care for oneself, care for others and of "us" for "me -the nursing professional", using the complex thinking^(8-9) as the guiding axis. About seven professionals took part in the workshops.

Data record was carried out through digital voice recording and field notes. To protect their identity, participants have been identified with the letter "P", followed by the ordinal number to their participation in the statements (e.g.: P.1; P.2; P.3...).

Data underwent thematic content analysis⁽¹⁰⁾, following three different times: data collected were read, then several readings of the same material were carried out to check the information in depth and to look for the meanings in the statements of individuals, highlighting the keywords or sentences with the meaning of the contents presented in the text to form units of meaning; later these units of meaning were classified and added, and the categories that guided the specifications of the themes were defined and interpreted (thematic units).

RESULTS

The analysis allowed for the identification of three categories that represent the (in) visibility of care to the other and of the nursing profession in the spaces of nursing professional relations presented next.

The care to the other visible and invisible in the work dimension

The invisible care refers to the silent, spontaneous, voluntary, care that is not explicit which is evident or visible and it is not perceived by others. This is felt when nursing professionals see themselves as invisible professionals and human beings and "devalued in the perception of the other" being. However, to provide care you don't have to know the other person, a friendship that makes them closer is not necessary. They just need to have a capacity for empathy and sense of human solidarity, conditions that refer to multiple human cares rather than just one:

There is care for the other without a direct friendship. If I see a banana peel on the floor, and I don't take it, I don't have care, but if I take it, I am thinking about other people who are not my friends [...] (P.9).

Care actions and attitudes, when they are routine, are not perceived; however, the absence of it is seen as lack of care. Thus, care that was invisible becomes visible as lack of care, when it is not received, demonstrating complex, disturbing, contradictory, apparently divergent movements in the human relations that conceive care and lack of care; these are ambiguous conditions that feed the process of human life.

In the dynamic reflective interaction of meanings and experiences, the professionals pointed out visible care that used to be invisible in the work routine:

As I told you about the banana peel, if it is on the floor, they will ask: "Who left this here?" But, if someone removed it, nobody will notice! (P.9).

In the laboratory, there are tubes that stay on the top of the refrigerator, everybody puts it there and if no one takes them, the people from the afternoon shift, remove them with no obligation. But if they are not removed, someone will notice. We care for the other without them knowing it (P.5).

The organizations of the work environment, the part of leaving the material to the next shift, to leave the place clean for those that will arrive (P.2).

Reflexivity articulates the multidimensionality of care, making the dialog between one individual and all people possible, integrating the uncertainties and contradictions of the complex thinking, in a complementarily and antagonistic way, allowing participants to review their experiences and behaviors in the settings of the work routine of visible and invisible care.

We complain about something when it wrong, but when care is taken all the time, nobody notices [...] a broader, more silent care that no one sees. Invisible care that is for the other, but the other does not know that it is done for them and, because of that, sometimes it is not expressed. But when someone fails to do it, when care for the other is not taken, we miss it (P.9).

The reflection on the situations experienced made it easier to understand care actions that were part of the participants' world, either as workers of a health service organization, or within their families. To think and reflect critically on the context in which they live and the relations they establish made participants perceive themselves as "devaluated in the perception of others", as care agents. However, this feeling of worthlessness makes them think about themselves but also makes them think about the other.

Care for the other invisible and visible in the family dimension

Family organization of the nursing professionals is also formed by invisible or little visible care relations, that were already mentioned, however, it is not very visible in the participants' perception.

Mothers' care to children is invisible. Mothers complain about invisible care, complain that they do and their children do not value or see (P.9).

[...] all the dedication to the house, the children, the husband [...] (P.7).

Doing the laundry for example, if you don't do it, they will complain that there are no clean clothes, if you don't cook they will complain that there is no food. It is not an obligation but we have to do it as it is involuntary (P.5).

The routine of nursing professionals in the present study is marked by household chores such as cooking, cleaning the house, doing the laundry, and taking care of children, even though there have been significant changes in gender equality from the mid-twentieth century onwards in the private life^(11-13). Therefore, the care relations, gender and nursing in their different scopes, are constantly being built and developed, and it is little visible and valued by society, including the children of these women that do not value the care received, but complain about the lack of care, as if it was the mother's duty to do so.

These female care professionals are always shaping their work, both in the public and private life, as human beings and professionals. They are becoming aware of the spaces and paths that were already shaped and achieved in the gender and professional path, and they are facing the conflicts, questions and incompleteness that form the contradictory and complementary actions that are necessary to understand phenomena that have not been understood so far.

Nursing invisibility in their professional category

The biomedical model is prevalent in the common sense, and nursing is little or not acknowledged by society for its work, understood as complementary and submissive to physicians. The dissatisfaction exposed in the common places to nursing, prevents the spread of discussions on the practice and consequently acknowledgement of the profession and of the professionals by the society and by the other members of the health team, leading to frustration and feelings of lack of appreciation in workers.

For professionals, the feeling of appreciation comes from feeling useful for the care provided to others - clients, preserved by the historical characteristics of care and, thus valued and socially acknowledged⁽¹⁴⁾. It is evident, therefore, the contradictory and ambiguous sense of value that makes understanding complex especially the little knowledge about the other and about us.

When the reflection is expanded, professionals discuss invisibility in the categories of nursing assistant, nursing technicians and nurses by clients, because they consider all of them nurses and just a few people know that there are several different levels in the profession and they also have an inadequate understanding or lack of it regarding the spheres of the profession, its status and competences of its knowledge/procedures. This condition is frequently observed in the media, news programs and other media and it is confirmed by the present study.

[...] when we say we are nurses they say: "Oh, don't you want to study to become a doctor? Don't you want to study more?" (P.7).

Ah, but are you a technician? But are you more than a nurse? (P.1).

For communication professionals, "the nursing profession is totally anonymous and invisible in the media regarding their attribution and actions", with lack of knowledge on the nursing action and the professional categories⁽¹⁵⁾. Because of the anonymity of the profession and its invisibility in the media, nursing is responsible for informing its potentialities, attributions and categories.

In addition to the difficulty to distinguish between the different nursing classes, the clients find it hard to distinguish nursing professionals from other professionals (dieticians, psychotherapists, physicians, social workers and pharmacists), from university students and technical students from the health area, because they all wear the white coat as a uniform.

Yes, they confuse a lot! (P.8).

[...] they (clients) find it hard to identify all professionals in the hospital. Students, professionals [...]. They can't tell the difference if you are a physician, social worker, if you are a dietician (P.7).

[...] for them, everybody is a nurse [...] you are in the hospital, you are wearing white, everybody is a nurse, there is no technician, assistant, nothing at all [...] (P.1).

Verbal introduction of the nursing professional and/or the use of the badge for identification, since other health professionals also use the white coat in the institution, would be a way to differentiate nurses from other professionals, ensuring their personal and professional identity to clients. Thus, they can be recognized and therefore they are visible. However, some participants do not believe these measures would solve the invisibility of nursing professionals.

Eve if it is written (on the badge) nursing technician or nurse, they won't know the difference (P.2).

Sometimes, they have been in the hospital for a month and they don't know very well who the physician taking care of them is. [...]. In the morning the doctorate comes to assess the patient, then the R1 (resident physician1), the R2 (resident physician2) of the team. So, sometimes, they are aggressive to us (nursing): "Oh, you are the physician, when am I going to be discharged?" (P.7).

As illustrated by the following statement, clients do not have to know the difference between professionals, because this distinction should be made by professionals themselves.

They (clients) don't have to know, we have to know the difference (P.9).

In addition to not having a written identification - non- verbal - through the use of a badge with name and profession or having them embroidered on the coat, the verbal communication is lacking as referred by this participant:

I say "good afternoon! How are you?" I don't tell them my name [...] we usually don't tell. We say: "I am a technician and I'll take care of you." (P.1).

On her statement, P.1 mentions her level of habilitation, which is a technician, but technician in what/of what? What is her name? How can you complain about visibility if the protagonist of care - the nursing professional - does not acknowledge the opportunity to interact with the client as a special moment to become visible to the other?

It is important to provide clients, either through the use of the badge or through verbal or non-verbal communication, the personal/professional identification of those providing care, because clients cannot perceive individuals or professions they don't know. The use of the badge is not common among some professionals, as justified by P.9: The badge, we are not used to reading this information... However, professionals that gives their personal and professional information show satisfaction and appreciation by the other.

[...] we think, no one reads, but people read the name of the person (embroidered on the white coat). I see that they call: "Jane Doe!" It draws attention! (P.4).

Whenever you are called by your name, you feel appreciated (P.8).

Professional identity is built from what the other identifies as the product of the relation, "through their values (social and subjectively attributed), quality and quantity characters (form and content of their attributes) and achievements (what they are for and what they do)"⁽¹⁶⁾.To make the nursing routine known, will enable other people to identify the role played by them and the product of their work, contributing to the construction, identification, as well as to break the image of nursing that does not match the reality of the meanings and value judgments made.

DISCUSSION

Nursing professionals, in the multi-dimension of care for oneself and for the others, should consider the affection expressions, the care and respect actions, processing their capacity for empathy and the manifestation of supportive attitudes that approach and facilitate the interaction between beings. These actions should be adopted so that professionals are not stuck in their condition of being, so that they don't lose the consciousness about their ability to build their own path, keeping in mind that the essence of the profession and of the professional is in care⁽⁶⁾.

Professionals in the present study experience and share the small visibility and devaluation of their work, both in the private (me - as a human being) and in the public level (me - as a professional). Their work in the nursing area, as a unique specialty, associated with the routine tasks, as women and mothers make them feel consumed and devalued⁽⁵⁾.

Being a female or male leads to different perceptions regarding men and women, that were built based on their experiences and personal life due to the historical and cultural conditions, at a certain place and time. Gender differences are built, in addition to the sexual identification at the time of birth, in the relationship of human beings with the culture, and with the society which is especially represented by the family, school, religion and work⁽¹¹⁾. These differences guide the human behavior in the inter-relation with other beings.

Female professionals' invisibility in the family is related to the internal place they have, when they are responsible for or are made responsible for the household chores and children care. This care involves the private, the family, where these women are usually responsible for taking care of their children, their husbands and relatives with a few exceptions⁽¹¹⁾.

The interpersonal process of communication fosters subject visibility when it is positive. To that end, the objective that nursing professionals want to communicate should be reached. If the goal is to become visible for the others, personally or professionally, it is assumed that professionals are aware of the verbal and non-verbal behaviors in interactions, communicating in a clear and objective fashion the message they want to convey; that they feel encouraged to communicate, recognizing nursing as an interpersonal, symbolic and complex process⁽¹⁷⁾. Because of its complexity, nursing communicates, teaches, learns, and interacts, favoring exchanges that allow for the beginning of a dialog, essential conditions for understanding, and reflection, giving the opportunity to make them visible while interacting with other people⁽⁸⁾.

Based on the results, some concerns are raised to be reflected upon: Is the invisibility of nursing professionals, according to their category of class, education and skills a reflex of the lack of appreciation of professionals themselves? Is the badge really not seen by the others - clients or even by other - professionals that are in the institution? Is the badge a possibility to become visible? How to increase visibility of nursing professionals in the health area and socially? How to change this reality? How to provide clients the correct identification of professionals providing them care? How to become visible to others, the client and their family members?

Professionals are responsible for building the nursing identity, fostering appreciation of actions geared to promote knowledge, acknowledgement and visibility by others, by the clients and their family when they develop their sociopolitical skill in care places.

To raise critical awareness of professionals regarding the routine construction of the procedures, knowledge and being, nursing professionals should earn the prestige they deserve by being careful with the care profession. "In addition to teaching and research, a political organization of the profession is important, because when it is stronger, an important social representativeness will be achieved", giving professionals the visibility they long for. To that end, there should be a change in the attitudes of professionals that form the profession and that want to become known and acknowledged as beings that know/do by society in a way that the profession and professionals are dignified⁽¹⁸⁾.

Human relations, interactions and associations occur in places of care and profession practice with interconnections and exchanges that are visible and invisible. There are many opportunities to go beyond, and according to the view of organizational complexity, the relations in the places of nursing work can become more visible.

CONCLUSION

The study presents care for other people as invisible and visible in the work and family dimensions and the invisibility of nursing in its professional category. Professionals see themselves as human beings and professionals in the public and private level that are invisible and devalued according to the perception of other human beings. However, care visibility to the other and to the profession occurs in the interactions and exchanges that occur in the life with other beings and in their multiple dimensions and organizational complexity.

The different nursing categories are not recognized and differentiated by clients and all professionals are considered nurses, that is, they are invisible in the several spheres of the profession. The feeling of appreciation comes from feeling useful while providing care to other people - to clients, preserved by the historical characteristics of care, demonstrating the contradictory and ambiguous sense of value in its complexity.

We understand that professionals are responsible for creating the identity, image, representation, appreciation, knowledge/acknowledgement and visibility of their profession. So that nursing becomes more visible to society and to clients, in comprehension and representativeness to the others, professionals should educate, and spread knowledge about their actions, even though a lot has already been accomplished and achieved.

Understanding the complexity that involves the profession is still a major challenge for reflection, question and concerns. Thus, in the relations established with others, we, nursing professionals have to recognize this complexity and have to be forced to strengthen, every day, our ability and capacity to recognize the (in) visibilities of the profession that are, at the same time contradictory and complementary, facing them dialogically because of the inability to have absolute certainties.

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*

Artigo extraído da Dissertação de Mestrado intitulada: "O significado das relações múltiplas do cuidado de si, do outro e "do nós" sob a perspectiva da complexidade" apresentada ao Programa de Pós-Graduação em Enfermagem da Universidade Federal de Santa Catarina - UFSC- Florianópolis (SC), Brasil.

Publication Dates

• Publication in this collection
  13 Jan 2011
• Date of issue
  2010

History

• Received
  04 Nov 2009
• Accepted
  06 Aug 2010