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Human living process and nursing from the vulnerability perspective

Abstracts

OBJECTIVE: This is an integrative review study aimed at analyzing the articles addressing this subject, health vulnerability and nursing, published in national and international journals. METHODS: The survey was conducted on the following database: MEDLINE, CINAHL and SciELO, covering the period 2004 to 2008, using the descriptors Vulnerability, Health vulnerability, vulnerable populations associated with the descriptor Nursing, being selected 28 articles for analysis. RESULTS: The characterization study allowed a brief history describing the concept of vulnerability and extracting their contributions to nursing practice. CONCLUSION: From the several approaches and perspectives of the concept of vulnerability it is important that nurses take ownership of this concept to contribute to the renewal of the care practices giving greater completeness and fairness to the actions in the health care.

Vulnerability; Health vulnerability; Vulnerable populations; Nursing


OBJETIVO: Trata-se de um estudo de revisão integrativa objetivando analisar os artigos que abordam o tema vulnerabilidade em saúde e enfermagem, divulgados em periódicos nacionais e internacionais. MÉTODOS: A pesquisa foi realizada nas bases de dados MEDLINE, CINAHL e SciELO, abrangendo o período de 2004 a 2008, utilizando os descritores Vulnerabilidade, Vulnerabilidade em saúde, Populações vulneráveis associados ao descritor Enfermagem, sendo selecionados 24 artigos para análise. RESULTADOS: A caracterização dos estudos permitiu descrever um breve histórico do conceito de vulnerabilidade e extrair suas contribuições para a prática de enfermagem. CONCLUSÃO: A partir das diversas abordagens e perspectivas do conceito de vulnerabilidade, considera-se importante que a enfermagem aproprie-se desse conceito para contribuir com a renovação das práticas de cuidado, podendo conferir maior integralidade e equidade às ações de saúde.

Vulnerabilidade; Vulnerabilidade em saúde; Populações vulneráveis; Enfermagem


OBJETIVOS: Se trata de un estudio de revisión integradora com el objetivo de analisar los artigos que abordan el tema, vulnerabilidad en la salud y enfermería publicados en revistas nacionales y internacionales. MÉTODOS: La encuesta fue realizada en MEDLINE, CINAHL e SciELO, abarcando el período de 2004 a 2008, utilizando los descriptores Vulnerabilidad, Vulnerabilidad en salud, Poblaciones vulnerables asociados con el descriptor Enfermería, siendo seleccionados 28 artículos para análisis. RESULTADOS: La caracterización de los estudios permitió una breve historia que describe el concepto de vulnerabilidad extrayendo sus contribuciones a la práctica de enfermería. CONCLUSIÓN: De las diversas abordajes y perspectivas del concepto de vulnerabilidad, es importante que el enfermero adquiere la propiedad de este concepto para contribuir a la renovación de las prácticas de cuidado, pudiendo dar major integralidad y equidad a las acciones de salud.

Vulnerabilidad; Vulnrabilidad en salud; Poblaciones vulnerable; Enfermería


ARTICLE REVISION

Human living process and nursing from the vulnerability perspective

Proceso de la vida humana y de enfermería desde la perspectiva de la vulnerabilidad

Daniela Couto Carvalho BarraI; Gabriela Marcellino de Melo LanzoniII; Isabel Cristina Alves MaliskaIII; Luciara Fabiane SeboldIV; Betina Hörner Schlindwein MeirellesV

IGraduate student (Ph.D.) at the Nursing graduate program, Universidade Federal de Santa Catarina - UFSC - Florianópolis (SC), Brazil. CNPq fellowship holder

IIGraduate student (Ph.D.) at the Nursing graduate program, Universidade Federal de Santa Catarina - UFSC - Florianópolis (SC), Brazil. CAPES fellowship holder

IIIGraduate student (Ph.D.) at the Nursing graduate program, Universidade Federal de Santa Catarina - UFSC - Florianópolis (SC), Brazil

IVGraduate student (Ph.D.) at the Nursing graduate program, Universidade Federal de Santa Catarina - UFSC - Florianópolis (SC), Brazil. CNPq fellowship holder

VPhilosophy PhD Health Philosophy and Nursing. Associate Professor at Universidade Federal de Santa Catarina - UFSC - Florianópolis (SC), Brazil

Corresponding Author Corresponding Author: Luciara Fabiane Sebold R. das Roseiras, 685 São José - SC - Brazil - CEP. 88108-460 E-mail: fabisebold@gmail.com

ABSTRACT

OBJECTIVE: This is an integrative review study aimed at analyzing the articles addressing this subject, health vulnerability and nursing, published in national and international journals.

METHODS: The survey was conducted on the following database: MEDLINE, CINAHL and SciELO, covering the period 2004 to 2008, using the descriptors Vulnerability, Health vulnerability, vulnerable populations associated with the descriptor Nursing, being selected 28 articles for analysis.

RESULTS: The characterization study allowed a brief history describing the concept of vulnerability and extracting their contributions to nursing practice.

CONCLUSION: From the several approaches and perspectives of the concept of vulnerability it is important that nurses take ownership of this concept to contribute to the renewal of the care practices giving greater completeness and fairness to the actions in the health care.

Keywords: Vulnerability; Health vulnerability; Vulnerable populations; Nursing

RESUMEN

OBJETIVOS: Se trata de un estudio de revisión integradora com el objetivo de analisar los artigos que abordan el tema, vulnerabilidad en la salud y enfermería publicados en revistas nacionales y internacionales.

MÉTODOS: La encuesta fue realizada en MEDLINE, CINAHL e SciELO, abarcando el período de 2004 a 2008, utilizando los descriptores Vulnerabilidad, Vulnerabilidad en salud, Poblaciones vulnerables asociados con el descriptor Enfermería, siendo seleccionados 28 artículos para análisis.

RESULTADOS: La caracterización de los estudios permitió una breve historia que describe el concepto de vulnerabilidad extrayendo sus contribuciones a la práctica de enfermería.

CONCLUSIÓN: De las diversas abordajes y perspectivas del concepto de vulnerabilidad, es importante que el enfermero adquiere la propiedad de este concepto para contribuir a la renovación de las prácticas de cuidado, pudiendo dar major integralidad y equidad a las acciones de salud.

Descriptores: Vulnerabilidad; Vulnrabilidad en salud; Poblaciones vulnerable; Enfermería

INTRODUCTION

The search for quality of life is constant for many people in their process of living. The adoption of good health practices, such as a healthy diet and physical exercises make people look for different resources to reach a good standard of health. These practices are expected to be incorporated by individuals themselves to reduce the risks that threaten their health.

The control of health risks, one of the central elements of the process of civilization has represented an effort in the search for protection against the threats to human life. In this perspective, it is observed that risk identification and reduction has been one of the most important goals in public health. Therefore, risk management is directly related to health promotion through the reorientation of intervention strategies towards this objective(1).

To search for health promotion and disease prevention, Nursing has worked intensively with the population, performing its role of health educator in different levels of care. Its professional work aims to guide and encourage better conditions of life and health. In this context, one of the adopted strategies is to assess the risk to which a certain individual or population is exposed to.

Scientific studies that assess risk factors to which human beings are exposed to traditionally approach their central core within the perspective of Epidemiology. Generally, studies based on the assumptions of Epidemiology attempt to identify in individuals certain characteristics that put them under higher or lower risk of exposure, either physical, psychological and/or social, calculating the likelihood and the chances of becoming sick or dying due to some health problem(2).

The concept of risk/risk factors and the studies approaching this theme do not discuss many of the issues related to the health-disease process and to society. Thus, to search the aspects that are present in the process of human living, the term vulnerability started to be used in the field of public health, increasing its biological dimension and incorporating other elements to it(3).

Within this context, there were some concerns regarding this theme, such as: What knowledge has nursing produced on health vulnerability? What are the contributions of the conceptual use of the term for the process of human living, seen in scientific articles?

These questionings encouraged the search for knowledge in nursing publications and justified the present study, because we understand that because of its transforming nature, to apprehend and give visibility to the contributions of the use of the concept of vulnerability improves the dynamic existing in the interactive process of care, to redirect the demands/needs, as well as to improve best practices in nursing and health.

Thus, to show the different conceptual approach to vulnerability in the process of human living and its contributions to the process of nursing care, the objective of the present study was to assess the article that approach the theme of vulnerability in health and nursing, published in national and international journals.

METHODS

This is a thematic integrative review study assessing the update of scientific studies in the period from 2004 to 2008.

In the present study, the following stages of the proposed integrative review of the literature are supported by a work structure defined by a previously prepared protocol adopted to maintain scientific rigor: selection of the research question; definition of the inclusion criteria for the study and sample selection; representation of the selected studies in a table format, considering all the common characteristics; critical analysis of the findings, identifying differences and conflicts; results interpretation; and, clear report of the evidence found. These stages formed the protocol that was followed(4).

The search strategy to identify and select studies was performed through the bibliographic survey of the publication indexed in the following data base: Medical Literature and Retrieval System on Line (MEDLINE), Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Scientific Electronic Library Online (SciELO). The MEDLINE and CINAHL database were accessed through links made available by the University Library of the Universidade Federal de Santa Catarina (BU/UFSC) at the website <http://www.bu.ufsc.br/>. The SciELO database was accessed by the portal of the Virtual Health Library (BVS), available at the website <http://www.bireme.br/php/index.php>.

The study was performed using this database in September and October 2009, and the studies found in more than one database were considered only once. The criteria adopted to select the articles were: all types of articles (original, literature review, reflection, update, experience report, etc.); available articles with abstract and complete texts with free access for analysis; made available in Portuguese, English or Spanish, published from 2004 to 2008 and; articles that had in their titles and/or abstracts the following descriptors: Vulnerability, Health vulnerability, vulnerable populations, associated to Nursing and their respective translations into English and Spanish. The resource used in the study was the option "exact term", during the searches. The exclusion criteria of the articles were studies that did not meet the inclusion criteria mentioned above. Thus, we have selected 24 articles for analysis. The five-year-period for the inclusion of the studies in the integrative review was to assess the most updated concepts regarding vulnerability and nursing.

Each article/abstract of the material obtained was carefully read, highlighting those that responded to the objective proposed by the study. To organize and tabulate data, the researchers prepared a data collection instrument with: title, journal, year of publication, country, type and nature of the study, theoretical reference, and method of analysis, study population, nursing clinical specialty, and focus of the themes. Later, the concepts/contributions approached in each article that interested the researchers have been extracted.

RESULTS

From the CINAHL database eight articles have been assessed, seven articles from MEDLINE and nine articles from SciELO with a total of 24 articles. During the search performed at the CINAHL database, the item "exclude studies from MEDLINE" was selected so that we would not get double studies available in the two databases.

Articles according to country of origin were distributed the following way: 8 (33.33%) from Brazil; 6 (25%) from the United States; 3 (12.5%) from Canada; 2 (8.33%) from Cuba; and one study (4.17%) from Australia, Sweden, Pennsylvania, Germany and Multicenter respectively.

The studies selected were classified according to the following types of publication, according to the journals' definition: 17 (70.83%) original studies; five (20.83%) literature review studies, and one (4.17%) theoretical reflection and experience report article respectively. As for the years of publication of the articles between 2004 and 2008, the data collected presented the following distribution, presented in Picture 1.

The articles have been classified according to type of study and the theoretical reference adopted, and were thus characterized: 20 (83.33%) qualitative studies; 3 (12.5%) quantitative/qualitative studies, and one (4.17%) quantitative study. As for the theoretical reference used in the studies, 75% (18) did not specify and/or did not adopt a theoretical referential; 12.5% (03) were based on Phenomenology, and the following references: Model of Vulnerable Populations/Self-care theory of management of Vulnerable populations, Communicative Action Theory and Moral Consciousness; Theoretical Model of Human Dignity; Symbolic Interactionism; Reference Program in Leprosy Studies, Theory of the Praxic Intervention of Nursing in Collective Health totaled 25.2% (06), with one study for each reference.

The selected studies were characterized according to the population studied, displaying a broad picture of the populations that are considered vulnerable, some examples are: patients with chronic diseases (diabetes and heart diseases); people vulnerable to natural/environmental disasters (hurricanes and tsunamis); overall patients, with or without a health plan, people susceptible to death by firearms; newborns, babies and children; adolescents; people with severe mental diseases; people with leprosy; women in social and economic need, young mothers with infants below one year old, alcoholics and primiparous women, the elderly in general and elderly with dementia, victims of abuse, those susceptible to ulcers and those caring for elderly people and last, nurses (group vulnerable to violence) and nursing scholars.

An overview of the work of nursing professionals during the process of human living can be demonstrated through the characterization of the clinical specialties approached by the selected studies, as specified: Pediatrics, Child-maternal health, women's health, sexual education, chronic diseases and/or heart diseases, nephrology, emergency service; geriatrics/gerontology, mental health and/or Psychiatry, environmental/natural disasters, violence, ethics and/or professional legislation, Nursing education and Philosophy.

Last, the studies were characterized regarding the thematic focus used, showing some perspectives and operationalizations of the concept of vulnerability for nursing care, some examples are: survey of the risk factors/epidemiological studies (potential negative effects of alcoholism; adolescents in greater risk to develop mental diseases, early pregnancy and substance abuse; cardiovascular diseases); self-care organization and management; work process/management; care based on several views (vulnerabilities and patients and nurses needs; errors in medication/patients' safety; people's dignity; care terminology; related to gender - depression, sexual abuse of the partner, tobacco dependence; suffering experiences and survival to natural disasters, different treatment received by patients with severe mental diseases from the penal system, etc.).

The descriptors Vulnerability, Health Vulnerability, Vulnerable Populations, associated with Nursing present studies that highlight the vulnerability potential of some specific populations, allowing to know and understand the differences, how each person, individually and in group, experience and face the health-disease process(5). The unfavorable social, economic, political and cultural conditions of the individuals contribute to their loss of autonomy and the establishment of an asymmetric relationship with the health team and the institution, favoring the establishment of a relation of power between them and thus the restriction of citizenship of these individuals, families or social group(6-7).

DISCUSSION

Currently, the concept of risk reaches almost all dimensions of life. Risk is related with the idea of the adverse, subject to uncertainty(8); and it is seen as a potential threat that may lead to a reaction, that is adverse to the health of people exposed to it, or yet, to the possibility of harm in several dimensions such as: the physical, psychological, moral, intellectual, cultural or spiritual of human beings(9). The assumption is that to avoid risk, one must recognize, accept and, whenever possible, avoid it. Because of that, several behaviors may not be considered in certain risk situations. Thus, risks are considered as socially built processes and are articulated by individual behaviors and by the collective perception of risk(10).

Epidemiological risk is defined as the likelihood to occur a certain health-related event, estimated based on what happened in the recent past. Also, it can be understood as an individual factor, referring to some personal characteristics such as family history, habits, lifestyle, among others. In this context, changes in personal risk behaviors become the focus of the intervention(11).

Thus, the individual risk was used by Epidemiology in the beginning of the 80's, when the fast spread of AIDS worldwide was associated with some sexual practices and with the use of drugs. With the development of studies about the disease and the first study searching for a treatment, the concept of "risk group" started to be criticized because of its objectivist and analytical-discriminative feature(12-13).

There are some conditions of life that are not controlled by people, such as poor diet or education, inadequate distribution of wealth, unfavorable working conditions, poor sanitary conditions, and most of the times, one cannot choose these(14). In addition to this set of conditions, there are also violence aspects, unemployment, social inequalities and gender and power relations, absence of government and public policies in several social spaces, leading to situations of lack of protection, social abandonment, directly reflecting on the health-disease process.

Therefore, based on the setting displayed, the term vulnerability started to be used in public health, going beyond its biological dimension and incorporating other elements to assess some diseases. The term vulnerability characterizes a person or population group that becomes more or less vulnerable due to a set of political, economic, cultural and psychological processes, and the biomedical processes such as genetics, risk factors connected with family history, race etc., that lead to higher or lower susceptibility to the occurrence of different health problems(3).

Vulnerability is different from risk because it does not present a likelihood component; risk tries to express mathematical chances of individuals to get sick when they have specific characteristics, and vulnerability expresses the potential to get sick/unrelated to all and any individuals that live within the same set of conditions(2, 12).

The concept of social vulnerability encounters the reality currently faced by the AIDS epidemic, since there is a greater occurrence of this disease in the marginalized sector of the society (12-13). The concept of vulnerability, applied to the HIV/AIDS infection has been approached through the articulated assessment of three central components: the individual, the social and the programmatic. The individual component includes the quality of information that individuals present on the problem, the ability to understand and incorporate these pieces of information to their daily lives, as well as the interest and the possibilities to put them into practices for protection and prevention. The social component refers to obtaining information that depend not only on individuals but also on the access to the media, to education, resources, the possibility to influence on political decisions and overcoming cultural barriers. The programmatic component includes resources that individuals need so that they are not exposed to risk situations, the public policies for disease prevention and control, the timely application of resources and availability of inputs necessary for protection, the level of commitment of the institutions, and the programs in the different care levels(12,16).

Thus, the assessment of vulnerability components can be used as a reference to interpret any worsening. Based on this approach, the field of work of health programs is enlarged and it is possible to prepare policies that have as a reference point the needs of the population(17).

When the aspects that lead to greater individual, family or group vulnerability are identified, there is an opportunity for nursing interventions that favor changes and a more equal and supportive care, making individuals stronger to practice their rights. Operationalization of the concept of vulnerability contributes to the renewal of nursing practices and can give greater integrality to health actions(5, 7). This is a commitment with care involving the three ethical dimensions: justice, autonomy and kindness(6).

When the vulnerability of individuals and/or population groups are considered, both health professionals and the civil population can become involved through a constructivist educational process for social changes that are based on intersectoral relations and in the communicative action between social subjects. Thus, we believe in the importance of different forms of coping not only for care and for clinical and rehabilitation treatments but also for the introduction of public policies and actions for disease prevention to promote the health of the population in a full and resolving form(18).

Likewise, the vulnerability potential perceived by the nursing team, involved in the process of interactive and continuous care, experiences, in addition to the physical exhaustion, feelings, emotions and experiences that require mechanisms to cope with more stressful situations, which, sometimes affects the well being and the work health of professionals, making them vulnerable to physical and psychological problems such as the burnout syndrome. Thus, these professionals that care for the health of human beings should be able to foster their own health through self-care, to promote their biological and psychological well being to have an image that inspires and conveys the idea of health(19).

The social bases that influence the health status and the nursing profession in its practice, education, policy and research must reflect on their social commitment. When this is renewed, under graduation and graduation nursing programs will increasingly incorporate in their curriculum proposals and contents regarding social justice and equality for health care that deal with the vulnerable population in the best possible way. Epistemological criticism should be explored and deepened to give visibility to the relations that lead to inequalities. Thus, nurses need to take control of the knowledge that is being developed, using it in their clinical practice to cooperate to the validation of the knowledge acquired through theoretical research and to make nursing recognized as a science(6, 20-21).

FINAL REMARKS

Through a brief history of the concept of vulnerability and the analysis of selected articles, we consider that for the present study the several approaches and the contributions of this thematic to nursing care encompasses the discussion and acknowledgement of several issues related with the process of human living, since they incorporate the biological dimension and the political, economical, social, cultural, and psychological processes of individuals and/or vulnerable groups.

We could observe that vulnerable populations belonging to the studies assessed encompass all the stages of the process of human living, that is, from birth to ageing of the individuals. Thus, it is believed that nurses should be able to recognize the different manifestations of vulnerability, and to reflect on the inequalities, either ethical, cultural, gender, political, social or economic in the different stages of the life cycle. Thus, it can contribute to the strengthening of the autonomy and citizenship of these populations, consequently contributing to fostering the improvement of the quality of health services. In this sense, future studies should investigate the appropriation and operationalization of the concept of vulnerability by nursing in the care context to renew their practices, giving greater integrality and equality to health actions.

The nursing team itself is a vulnerable population; its vulnerability is in the professional practice, that is, the work conditions and/or stressful factors such as physical, psychological and emotional exhaustion. In this context, nursing should pay attention to its professional practice, fighting for better work conditions and fostering self-care.

REFERENCES

Received article 09/02/2010 and accepted 02/06/2010

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  • Corresponding Author:
    Luciara Fabiane Sebold
    R. das Roseiras, 685
    São José - SC - Brazil - CEP. 88108-460
    E-mail:
  • Publication Dates

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

    History

    • Received
      09 Feb 2010
    • Accepted
      02 June 2010
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