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Texto & Contexto - Enfermagem

Print version ISSN 0104-0707On-line version ISSN 1980-265X

Texto contexto - enferm. vol.25 no.1 Florianópolis  2016  Epub Apr 01, 2016

http://dx.doi.org/10.1590/0104-07072016004550014 

Original Article

WELCOMING AND NURSING CARE: A PHENOMENOLOGICAL STUDY1

ACOGIDA Y CUIDADOS DE ENFERMERÍA: UN ESTUDIO FENOMENOLÓGICO

Paula Cristina Pereira da Costa2 

Ana Paula Rigon Francischetti Garcia3 

Vanessa Pellegrino Toledo4 

2Ph.D. candidate, Graduate Nursing Program at UNICAMP. Campinas, São Paulo, Brazil. E-mail: paulinhapcosta@hotmail.com

3Ph.D. candidate, Graduate Nursing Program, School of Nursing, UNICAMP. Campinas, São Paulo, Brazil. E-mail: apgarcia@fcm.unicamp.br

4Ph.D. in Nursing. Professor, School of Nursing, UNICAMP. Campinas, São Paulo, Brazil. E-mail: vtoledo@unicamp.br

ABSTRACT

The objective of this study was to identify the acknowledgement of welcoming as a form of nursing care in the experience of primary care nurses. This is a qualitative research, guided by Alfred Schutz' social phenomenology. The participants were nine nurses working in health centers in the city of Campinas-SP, Brazil. The fieldwork took place through interviews in 2013 and data were analyzed according to the steps of social phenomenology researchers. It was identified in the research that the nurses were capable of recognizing the translation of welcoming into qualified listening, humanization, accountability and commitment to the needs of the other. In practice, however, welcoming was not acknowledged as nursing care and was characterized by occasional, fragmented and complaint-oriented visits. For this action to be acknowledged as nursing care, the nurses need to focus on relational care.

Key words: User embracement; Family health strategy; Nursing

RESUMEN

El objetivo fue identificar el reconocimiento de la acogida como forma de atención de enfermería en la experiencia de las enfermeras que trabajan en atención primaria. Investigación cualitativa, orientada por la fenomenológica social de Alfred Schutz. Participaron nueve enfermeras que trabajaban en centros de salud en la ciudad de Campinas-SP, Brasil. El trabajo de campo se llevó a cabo a través de entrevistas en 2013 y se analizaron según los pasos de los investigadores de la fenomenología social. Las enfermeras fueron capaces de reconocer la traducción de la acogida en la escucha calificada, humanización, responsabilidad y compromiso con las necesidades del otro, sin embargo, en la práctica, esta acción no era reconocida como una atención de enfermería y se caracterizaba por visitas ocasionales, fragmentadas y dirigidas a la queja. Para que tal acción sea reconocida como un cuidado de enfermería, las enfermeras tienen que centrarse en la atención relacional.

Palabras-clave: Acogimiento; Estrategia de salud familiar; Enfermería

INTRODUCTION

The essence of the nurse's work is care, a process that involves close contact with users and their health needs.1 Care refers to assisting human beings in their needs, involving acts, behaviors and attitudes, which depend on the context and the relations established between users and professionals.2 In addition, this action comprises attitudes of care for the body, of looking into the user's eyes, of perceiving feelings.3

In this context, an attitude of the nursing professional can mean a lot for who needs care.3 Thus, if the relationship between this professional and the user takes place mechanically, the latter will feel like an object, alienated from his historical and social context, and his needs will not be fully attended to.4-5

To the extent that this professional considers the user as a human being, subject and social actor, he can construct a new trajectory for the health-disease process together with him, leading to the acknowledgement of care as social practice,6 an activity that aims to attend to people's needs. It happens at the heart of the interpersonal relations, as part of the cultural and historical process of the interaction among human beings.7

Understanding nursing as a social practice means surpassing the technical-operative perspective and recognizing it as one of the many practices in society, whose end product is nursing care for the person.7 Nurses are not only capable of understanding the individuals as singular beings, but are recognized by the capacity to welcome the users' needs and expectations.8

Welcoming is a technical care action, that is, a process of qualified listening aimed at care, which implies changes in the relationship between professional and user, facilitating the reorganization of the services and improving the quality of care, with the patient serving as a main axis and active participant.9-11

Welcoming should be a tool for the humanization of health services, with qualified listening, favoring of bonding and of guaranteed access to the population, which presupposes holding the professionals accountable for the care delivered.12 When the listen to the users, the professionals' relationship will improve and a more collaborative partnership will be developed.13

Welcoming and nursing care are constructed during the encounter with the user, characterized by the articulation between dead work (used as a tool or raw material) and live work, that is, work that takes place at the same moment as the production and takes form through the use of light technologies (present in the relations between users and workers).14-15

In that sense, this study considers that welcoming approaches nursing care as both involve the establishment of interpersonal relationships, aiming for comfort, acknowledgement of the user as a subject with objective and subjective conditions within a context of life.

In view of the above, the objective was to identify the acknowledgement of welcoming as a form of nursing care in the experience of primary care nurses.

METHOD

As this research intended to investigate experiences in the nurses' daily world, endowed with subjectivity and experienced in the interpersonal relationships, an underlying theoretical-methodological framework was needed. Therefore, a qualitative research was taken, guided by Alfred Schutz' social phenomenology.

This reference framework is intended to understand the subject's action with the other, in his intersubjective meaning, proposing the analysis of the social relations present in the daily experiences.16

The intentional action aimed at the subject, based on conscious experiences, is called social action, which emerges in the form of spontaneous activities. To accomplish a social action, the subject's own experiences need to follow his actions, including feelings of sympathy, antipathy and all others, and the other person's experiences need to be taken into account.17

The social action of nursing is to take care of people.16 Therefore, welcoming is also understood as a social action, considering the actions/reactions of other individuals and changing in accordance with these events. When considering welcoming as a social action, the nurses who welcome the individual who presents his demand should treat him as a care subject. However, the fruit of this social relationship should be problem solving.

The subject's accomplishment of social actions is expected to provoke a reaction in the other which, similarly, will report like another action. This picture is called social relationship as it relates us with one another.18

When this relationship permits reaching one another's direct experience, that is, it shares the same space and chronological time and both are present, the face-to-face relationship takes place,18-19 required for nursing care to occur.16

In the sociologist Alfred Schutz' perspective, the understanding of the meaning of human action is based on existential reasons.17 The reasons referring to the experience lived, contextualized through the knowledge inventory, are called "reasons why", while those related to the projects, objectives one wants to achieve, are called "reasons for".16,19 The set of reasons for and why constitute the subject's action in the social world.19

Thus, when interviewing the nurses who practice welcoming, their experience can be understood based on what was lived, looking for reasons to justify their actions and to project possibilities that will emerge after the experience of practicing welcoming. The guiding questions for the interview were: what is it like for you to practice welcoming at the health center? How would you like the welcoming to be practiced?

The place of study is not a physical space, but a conceptual context, in which the experiences are lived and the phenomenon happens16 Hence, the place of study in this research was where the phenomenon took place, the daily life world of nurses who practice welcoming at health centers in the city of Campinas-SP, Brazil.

Nursing professionals were included who were active at the health services in the Northern health district of Campinas. Nine nurses participated who were contacted based on network sampling, in which one participant indicates the other.20 The first participant was selected for being an acquaintance of the researcher, but his testimony was not considered in the analysis of the results. It was used to check whether the answers addressed the research concerns, as the only way to analyze whether the questions are understandable to the target population is by applying them through a pretest in a similar sample.20

Initially, the participants were contacted by telephone, when they were informed that they had been indicated to participate in the research, the study objectives were explained and they were invited to participate. After the nurses accepted, the date and place were scheduled for the researcher to visit and interview them.

The field work took place between September and November 2013, based on interviews recorded at the participants' workplace, and was closed off when the researcher's concerns had been answered and the study objective had been achieved.21

The information was analyzed according to the steps of social phenomenology researchers:17,19,22 reading and rereading of each testimony, aiming to identify relevant aspects in the context of the nurses' experience; identification and further grouping of significant aspects in the testimonies in units of meaning; synthesis of the units of meaning to compose the categories.17,22 The discussion of the data was guided by the theoretical framework of Alfred Schutz' social phenomenology and literature on the research theme.

The study was developed in compliance with Resolution 466, from December 12th 2012, on research involving human beings,23 being approved under opinion 206.078. To guarantee the participants' anonymity, they were identified using the first letter of the word nurse, followed by Arabic numerals in the order in which the interviews were held "n1" till "n9".

RESULTS

After discovering the nurses' perception about welcoming as a form of nursing care, categories could be organized and analyzed that incorporate the meanings of accomplishing this action, expressing "reasons why" in the past and present and the "reasons for" related to the expectations.

The "reasons why" of the nurses who performed welcoming are expressed in the category Distance between nursing care and welcoming. The "reasons for" were translated by the category "Idealization as a trajectory for welcoming as nursing care".

Distance between nursing care and welcoming

The study participants did not acknowledge the act of welcoming as care inherent to the work of primary care nurses. In that sense, it is deduced that distance exists between nursing care and welcoming.

The nurses reported how welcoming was performed in practice, representing an action distant from nursing care, which was aimed at integral care delivery to human beings.

Today, the welcoming that exists at the health center where I work is pre-care [...] (n4).

Welcoming is complaint-conduct, everyone knows that [...] (n1).

The findings demonstrate that the welcoming the study participants perform was a screening and is departs from the form in which the patient presents a complaint, based on which a conduct is established.

The nurses expressed that, in practice, the welcoming was punctual, focused on responding to the spontaneous demand, emphasizing that this action was not performed, aiming to qualify the care by listening.

The welcoming at the Campinas health center means that you do have a consult upon spontaneous demand, it is not welcoming in the literal sense of the word [...] (n8).

The nurses' statements demonstrated that welcoming corresponded to a significant part of the hour load, without acknowledging this action as care inherent in primary care nurses' practice. They classified the welcoming as an impediment for them to perform their functions, i.e. nursing care.

[...] more than half of my hour load goes to emergency care, I don't have time to work within my team and play my fundamental role in here [...]. We are in a health center, which should work on prevention, scheduled appointments and emergency care takes up many of the work hours (n1).

Idealization as a trajectory for welcoming and nursing care

The interviewed nurses' expectations referred to welcoming idealized as an action that prioritized the relation with the patient by understanding the needs, the interest in getting closer and willingness to put oneself in the other person's place. Nevertheless, they considered that these expectations could be reached if the team were dimensioned to the size of the population covered, considered as a determinant for the supply of high-quality nursing care.

Welcoming is idealized as an action that permits qualifying the relationship between user and professional, the identification of the presented demands. In the nurses' statements, the welcoming was idealized as an action that approached them with the users and furthered the understanding of the motives that made them visit the health service.

[...] In that sense, I would like the welcoming to be something that approached us with the patient, that made him feel at ease to talk, so that we could assess the patient [...]. High-quality welcoming, understanding why the person is visit that kind of health service, what he is going through, what situation he is experiencing [...] (n1).

[...] if we had the sensitivity to see that in the other person like that, that sometimes he needs help, that he needs care, I think that if we put ourselves in the other person's place, I think that would help a lot [...] (n5).

For the nurses, welcoming as they idealize it only happened when factors external to care were present, such as work conditions and sufficient professionals to deliver care to the population.

[...] could provide much better and more qualified answers if we had a population the size of which we can handle or, on the opposite, if we had a team the size that could handle the number of people we attend to [...]. But the work condition, I think that's also a determinant factor for us to deliver better care (n3).

DISCUSSION

Nursing is the science of care. It is important for the nurse to engage with the user, characterizing a relation in which the acknowledgement of the implications of the health-disease process in the subject's life is prioritized.1

The nurse's work has changed as a result of the Unified Health System (SUS) and the Family Health Center, as these transform the nature of the work and the users' demand.24 The users' demands have confronted the nurses with complex and non-specific situations, for which their technical-scientific knowledge and activities have not been sufficient, which provokes new reactions or reproduces established practices.25

In line with the proposals of welcoming, the user's demand should be addressed through listening, understanding of the needs and dialogue, whose solutions could be found more easily, which does not necessarily boil down to a medical appointment.11,14 It is important to highlight that the first contact with the user is also emphasized in studies undertaken in the United Kingdom and Germany, in which the nurses should consider the family as the guiding axis of their actions and not just the individual, thus qualifying the referral to more complex specialties when necessary, prioritizing health and not disease.26-28

Welcoming should modify the daily reality at the service, become user-centered and target broader access, care quality and contribute to a universal and integral SUS that is committed to individual and collective defense, presupposing a better relationship between users and professionals.29 Nevertheless, the nurses consider it as an impediment for them to perform their functions, in the belief that the health center is basically active in health prevention and promotion.

Health prevention strategies should not be neglected, but the main function of the FHS is to relieve the user's suffering through individual and family care, that is, the specificities of the territory should also be considered.1,30 The organization of the work should depart from the identification of that community's health needs to get an appropriate response, articulated with other health services and responding to the population's needs.1

The FHS should move beyond the curative and preventive practices of the primary care model, attempting to grant the users access to better living conditions, including them as active agents in the defense of health.1 Therefore, it is important for the nurses to expand the restricted conception on the preventive goals of the practice towards a more comprehensive view on the purpose and actions, coherent with integrality in health.1 One possibility to change the practice consists in more effective relations between worker and user, one of which is welcoming.1

Like other studies,10,31 this research shows that, in practice, the nurse classifies welcoming as a screening of the spontaneous demand to assess acute complaints.

It is highlighted that attendance to the spontaneous demand in the FHS differs from the attendance in emergency care, as the FHS permits background knowledge on this population, its return to the same health team, monitoring of the situation and bonding.32 Nevertheless, as appointed in another study,33 the nurses perceive the spontaneous demand as a burden in the work routine. For them, the users do not know the proposal of the FHS and visit the service in search of medical care, but informing the users about the work of the health center is not part of their routine.

The welcoming of the spontaneous demand, which should aim to enhance the access and humanization, transform the work process and build relationships between professionals and users, takes the form of a punctual reception procedure.31

By revealing the welcoming as punctual attendance, focused on listening to acute complaints, the nurse demonstrated distancing, which means a relation of anonymity with the user. The experiences of the life world occur according to degrees of familiarity and anonymity. The relation of familiarity is experienced in the form of "we" and permits apprehending the other as unique in his individuality. On the other hand, the more anonymous a relationship is, the more distanced the individuality will be from its peer, and few aspects gain relevance in the problem to solve.34

The type of relationship that characterizes the other using a number, anonymous, differs from the intention of the welcoming, which through a face-to-face relationship looks for a "we" relationship, in which the other is considered endowed with subjectivity, and is understood beyond a physical body.34 In their life world, however, the nurses are confronted with social situations during the relationship and immediately capture a solution used. Their action is marked by habit and automatism.

In the idealization of what welcoming should be like, the nurses defend that this action should be a powerful space for the humanization of health services, based on listening to the user, identifying his needs and teamwork, in which knowledge sharing among the members favors the solution of the problem.

To take proper care, the nurses need to be accountable to the users, understanding their social context, their needs and expectations.7,26,28 This kind of abilities, according to the interviewed nurses, are idealized for welcoming through time to deliver care, demand, physical structure and appropriate human resources. In that sense, it is observed that the nurses hold external factors responsible for the quality of their work when, in fact, these should be components that help them to produce their care. A study undertaken during the national health system reform in the United Kingdom identified that the nurses remained an isolated group, with reduced skills to respond to opportunities to develop their role and highlighted empowerment as a possible evolution, favoring their understanding of the factors that limited them to produce care.35

In the statements, the nurses were capable of acknowledging the translation of the welcoming as qualified listening, humanization, accountability and commitment to the other person's needs. For this perspective to become real, the nurses need to translate the discourse into actions.

The nurses' search to qualify welcoming should be the theory of nursing care. Hence, when practicing welcoming as nursing care, the nurses can receive the users in a humanized manner, considering them as subjects and participants in the care process, enhancing the quality of the work offered.

FINAL CONSIDERATIONS

The theoretical-methodological approach of social phenomenology granted understanding of the nurses' experience, from a perspective that values the social dimension, circumscribed in daily experiences.

The development of the study permitted understanding that, in the nurses' daily reality, welcoming is not acknowledged as nursing care and is characterized by punctual, fragmented and complaint-oriented care. In addition, this study's contribution is characterized by the expectations the nurses reported, which can be considered a way to solve the problem of the distanced between welcoming and nursing care. For the nurses to be more than mere interventionists in the users' physical complaints, they need to acknowledge that welcoming goes beyond the biological model and the technical procedure, focusing on relational care in the first place.

The trajectory for welcoming to be acknowledged as nursing care requires that the nurses apprehend the reality and the conditioning factors involved in the interpersonal relationships. The use of light technologies, that is, the human relationships should be at the center of nursing practices, putting forward the person as the care object instead of the disease. It is important for this premise to be considered the central focus in other studies on welcoming in primary care.

This study was focused on nurses who worked in a specific health context, which can be considered a limitation of this research.

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1 Paper taken from the thesis - The experience of nurses in host: study focused on social phenomenology, presented to the Graduate Nursing Program at Universidade Estadual de Campinas (UNICAMP), in 2014.

Received: December 13, 2014; Accepted: September 11, 2015

Correspondence: Paula Cristina Pereira da Costa Rua Paulo Setúbal, 385 13.020-240 - Botafogo, Campinas, SP, Brasil. E-mail: paulinhapcosta@hotmail.com

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