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Revista Latino-Americana de Enfermagem

On-line version ISSN 1518-8345

Rev. Latino-Am. Enfermagem vol.17 no.6 Ribeirão Preto Nov./Dec. 2009

http://dx.doi.org/10.1590/S0104-11692009000600010 

ARTIGO ORIGINAL

 

Demonstrating nursing care as a social practice

 

 

Dirce Stein BackesI; Alacoque Lorenzini ErdmannII; Andreas BüscherIII

IPh.D. in Nursing, Professor, Centro Universitário Franciscano - UNIFRA, Santa Maria, RS, Brazil. Member, GEPADES Research Group, Universidade Federal de Santa Catarina, Brazil, e-mail: backesdirce@ig.com.br
IIPh.D. in Nursing, Full Professor, Universidade Federal de Santa Catarina. Coordinator, GEPADES Research Group, Universidade Federal de Santa Catarina, Brazil, e-mail: alacoque@newsite.com.br
IIIRN, Ph.D., Researcher and Professor, Institute of Nursing Science, University of Bielefeld, Germany, e-mail: andreas.buescher@uni-bielefeld.de

 

 


ABSTRACT

This study aimed to understand the meaning of nursing care as a social practice based on interactions and associations with complex-systemic thinking. Grounded Theory was the methodological framework used and 35 health professionals distributed in different sample groups were interviewed through a semi-structured questionnaire. Simultaneous data codification and analysis permitted the identification of the central category: "Evidencing nursing care as social practice". Nursing care as a social practice based on complex-systemic thinking constitutes a new paradigm of intervention, capable of strengthening social actions through interactive and associative networks, and of acting in a proactive, innovating and participative manner.

Descriptors: nursing care; nurse's role; social responsibility; nursing research


 

 

INTRODUCTION

There have been extensive and increasing discussions and studies on nursing care as a social practice, though it still represents a great challenge to knowledge. In order to deal with and follow the technical and scientific development for the full exercise of a profession tuned in with emergent social contradictions, in our point of view, one needs to go beyond institutionalized limits and traditional models of "nursing know-how".

Recent studies incited us to seek a better understanding of nursing care as social practice, when these studies report that the inclusion of nursing professionals is still very incipient(1-2) both in theory and in practice and in representation in social and health policies. Authors also mention that, although the nursing profession comprises the largest group of health workers, nursing plays a secondary role in terms of performing concrete health actions to contribute to and develop public policies, aimed at social development.

In this perspective, other studies question the role of nursing in the current political and social scenarios, considering increasing inequality in the social and health areas. Nursing needs to rethink its practice and social role and show its responsible commitment in discussions about growing injustice in the social and health areas(3). Nurses, as well as other health professionals, need to develop critical and reflexive attitudes with a view to putting in practice political-social actions that express their responsible participation, with a view to social development.

Another more recent study, which aimed to understand and analyze the conceptions of care addressed in doctoral dissertations defended between 1995 and 2005 in a Graduate Nursing Program, evidenced that, despite the richness of investigations and theoretical-practical approaches, the studies were mostly based on a situation of disease or on institutionalized practices of traditional know-how(2). In summary, results report that nursing is a field of social practice because it delivers care to the sick or healthy individual or community with technical-scientific knowledge. However, it is still focused on the traditional and institutionalized practice, that is, with little development of proactive actions of social intervention.

The perceptions of care evidenced through theoretical searches and appeals from emergent social issues made the desire to expand the meaning of nursing care beyond the traditional know-how and institutionalized practices even more pressing. Nurses, now more than ever, should be able to exceed the limits of disciplinary knowledge, of institutionalized systems, and especially of the outlines of physiological disease, so that they can understand and act towards the integration of a systemic, paradoxical and interactive view on social and health issues.

The perception that nurses can and are capable of proactive interaction in local social development and in the expansion of possibilities of action ultimately reflects the desire to move from the cartesian paradigm, still predominant in the health area, towards a systemic thinking of social intervention, capable of carefully considering the unique and the multiple, instead of simply looking at individual efficiency(4).

Systemic-complex thinking does not lead one toward evidences and certainties but to a global direction, to the uncertain, unknown and real(5). In the search for systemic thinking to understand the meaning of nursing care as social practice, we considered that there is no key to penetrate the universe of complexity. "What exists are different routes, paths, avenues that lead towards the challenges of knowledge"(6).

The perception that nurses have knowledge and a specific place in the scope of social practices(7) and that, through care as social practice, they are capable of contributing to social development related to increased opportunities for human beings to develop their potentialities, pressured us to seek a better understanding of the meaning of nursing care as social practice.

 

OBJECTIVES

To understand the meaning of nursing care as social practice, based on the interactions and associations of systemic-complex thinking.

 

METHOD

This qualitative study used Grounded Theory as the methodological framework(8-9). An important aspect in the Grounded Theory is the development of a theoretical sample. As opposed to other methods, the theoretical sample in Grounded Theory is not defined prior to data collection; it is defined during the collection and analysis processes, based on emergent concepts and hypotheses.

The data were collected by means of interviews with health professionals of different Institutions, distributed in different sample groups, aiming to maximize the variation among concepts and add new perspectives or hypotheses to the phenomenon under study. Interviewees included: nurses, physicians, dentists, nutritionists, pharmacists, psychologists, pedagogues, managers and health users.

The guiding question for the interviews, among others that were deepened during the process, was: What is the meaning of nursing care as social practice?

For theoretical sampling, we attempted to collect data that supported the theoretical construction so that, when simultaneously collecting, codifying and analyzing them, theoretical saturation would be achieved. This was accomplished after 35 interviews carried out between the months of May and December 2007.

After the data were transcribed and reviewed in detail for each interview, identification of conceptual units began. The data were codified line-by-line, compared and selected in categories. In the following stage, the researchers chose an open coding category - first stage of codification - and placed it as the central theme, comparing it with the remaining categories. In the following phase, called axial coding, the data were grouped in new forms, seeking to absorb the underlying data relations and interactions as much as possible. The Paradigm Model(8-9) was used to facilitate the data analysis and grouping categories processes.

Based on the integration of the elements and having conducted the theoretical connections between the subcategories and categories, it was possible to move in the direction of the selective codification, the third phase of the analysis, which resulted of the central category: "Evidencing nursing care as social practice".

All study participants were informed about the objectives and proposed methodology. Their right to access data and identity and information anonymity were guaranteed. The project was unanimously approved by the Research Ethics Committee of the Federal University of Santa Catarina.

The participants' contributions, registered in the present study, were identified with the letter "P", followed by a number corresponding to their speech, in order to remain nameless.

 

RESULTS

The category is composed of the following subcategories: Giving meaning to nursing care as social practice, Acknowledging the nurses' human-interactive potentialities and Acknowledging nurses' technical-political competences, which will be discussed based on the interactions and associations of systemic-complex thinking.

Nurses' social role is visible in the different practices and is expressed in different ways. For health professionals, nursing should be considered a profession that converges to the social context, that is, a profession that acts in a more direct and participative form in social practice.

Giving meaning to nursing care as social practice

More specifically for nurses, the meaning of nursing care as social practice is related to the understanding of the social context of health users, families or communities. With the nurses' more active and effective participation in the Family Health Program (PSF) and in Home Hospitalization Programs (PID), they perceive that their practice transforms and is transformed. Even though some nurses found it challenging to adapt to a new reality, which they had not been prepared for, the close contact with the users' social reality gives them satisfaction, motivation, and also promotes a professional and social feeling of well being.

Professionals experience a feeling of completeness, caused by the close contact with individuals in their family and communitarian contexts, much more than in the hospital setting, where the apparent technological safety and comfort limit professional autonomy.

I was very afraid when I got in the PID because I didn't know how it would be. Because, at the Intensive Treatment Unit, where I'd worked for 15 years, we felt very protected, we had everything...in the family, I didn't know how it'd be. There I need to use my full potential to be able to attend and interact...but I feel more satisfied now. There're limitations at the ITU. Not everything is solved and it leads to a feeling of frustration. I wasn't able to go deeper at the ITU. In the families' visits we go deeper... they call me at night and not because of a physical problem. We have a direct impact... Nowadays I'm a nurse. I feel more like a nurse. I'm a complete professional. We create stronger bonds. I dive in. I like very much what I do. I feel great (P13).

The social environment, in the nurses' point of view, expands interactions, strengthens bonds of trust between professionals and users and permits satisfaction of both professionals and users. I have a positive feedback. And it seems that this feeds and motivates a return to the community. When I retired, I felt I needed to do something... I went back to the community... I knew that I could be a nurse there (P12). The social environment, more specifically the family and the community environments, permit continuous learning and intense experience exchange. Besides, it is a place where the autonomy of professionals and health users is strengthened, encouraging the social role. I need to find places where I can strengthen autonomy and the community allows me to do it... (P9). In the family, we need to take into account the user's autonomy...there're possibilities of exchange, so that I can learn as well. So, there's interaction, he becomes the author and actor of the process (P4).

The meaning of social practice, in the nurses' perspective, is related to involvement, responsibility and the problem-solving capacity of health actions. As a consequence of this process, nurses perceive, beyond user satisfaction, the achievement of greater credibility and social acknowledgment.

Acknowledging nurses' human-interactive potentialities

One of the human-interactive potentialities of nurses' most acknowledged and highlighted by the interviewed professionals is related to the capacity to understand the human being as a whole. It is related to the capacity to understanding different dimensions and the frailty of the human being.

Nurses stand out by the comprehensiveness of health care, the capacity to understand the social context, to welcome and empathize with the needs and expectations of individuals, to enhance qualities of individuals, the capacity to interact directly with the user and community, as well as to promote interaction between users and the health team. The nurse is the professional who has the experience from the psychological, physical and technical point of view to act in different environments. He is the unifying element of care. He identifies himself with the patient's needs much more that other professionals (P29).

Because nurses understand the health user as an integral being and get involved with different situations related to care, they oftentimes face difficulties to identify the object of their practice, that is, to identify their specificity in the set of professional health actions. One of the nurses reported this difficulty when she was part of a multiprofessional health team. Each professional had to share his(er) evaluation in relation to a certain client, whose pathology resulted in a case study. Because she used to be always the last to talk in the first encounters, she would say there were no new aspects to be added since the remaining professionals had said it all. In other words, while other professionals talked about the parts, the nurse could only talk about the whole, as follows:

Everyone had to make an evaluation in their area. So, one of the things that I personally experienced was that the nutritionist, when presenting her diagnosis, would talk about the whole nutritional aspect of the patient. Then the social worker would talk about the social aspect of the patient. Then the psychologist would talk about the whole emotional aspect of the patient. Then the nurse, what would I talk about since everyone had talked about everything? So what was left for the nurse was to look at the whole, while the others talked about the parts (P24).

Nurses understand the individual, not as a sick individual but as a single, complex and multidimensional being.

Acknowledging nurses' technical-political competences

Nurses are acknowledged as the health professionals who possess more refined knowledge and a broader view of health issues. According to the interviewees, this fact is due to their capacity to establish a closer relation with health users in their social context. Because of their broader view, nurses are characterized by interviewees as articulators, a propelling force and, consequently, the reflex of health care. The nurse is the articulator of the health services in society or any other place he is in (P8). Nursing is the profession that makes the health service function (P25). For me, the nurse is that person in charge of any sector, whether in the health unit or hospital. She is the reflex of health care (P19). In the health team, the nurse is a link ... He is really a test tube, differently from other professionals (P29).

In other moments, nurses have been identified, more specifically in the social and health policy areas, as the patients' attorney or the people's spokesperson. This competence is more visible in professionals who exert a more specific public and political role. I started to work in the public area with a great number of people. I perceived that people needed an active voice, one that represented them and they saw I could be one to defend them in these areas (P5).

In this perspective, nurses stand out by their organization and involvement with health services as a whole. For health professionals in general, nurses have an education more focused on leadership and teamwork and are also skilled to manage and deal with different situations health users might present. Nurses will hardly miss the set of elements, that is, the user inserted in the social network as a whole. Nursing has a perspective that is innate to nursing and all those who work in collective health perceive it...nurses have a broad way of seeing things. Nurses are those who most of the times coordinate the health services. They have a specific education, a little different from physicians, dentists... The work itself makes nurses more committed with the system...I see management, participation and teamwork as important characteristics of the profession (P25).

Nurses' technical-political competence is highlighted, especially because of their responsibility and commitment to the client's cause. The way they see different movements in daily practice allows them to integrate, unify and articulate health services so that users have their problems solved.

The results of the present research expand and strengthen ideas developed earlier studies, which showed evidence that the nurse occupies important space in the filed of social and health policies. The nurse's abilities are expressed by ways of dealing with human fragilities, by educational and health promotion interventions and, especially, the ability to articulate the health services integrating individual-society-environment-health in different fields of professional activity(10-11).

 

DISCUSSION

By comprehending the individual as a whole, nurses, can establish a closer identification with the social needs. Nurses have, much more that the other health professionals, the capacity of maintaining a much more intense interaction with the individual, family and community. He/she is able to perceive and grasp social problems and necessities in a more concrete manner. For some professionals, the actual education and work connection favor nurses to have a greater commitment and social involvement.

Nursing care as social practice, more specifically care in the community, enriched by direct intervention with individuals and families, allows one to go deeper, despite uncertainties and insecurity. It allows creating complex relations, that is, multiple interactions in which professionals can devote all their creative, innovative and entrepreneurial potential, which is limited in simplified relations, as those in formal or traditional healthcare institutions. The professionals' thought and action find resonance in systemic-complex thinking(4-5), when authors stress that something is complex when it involves at least more than one interactive circumstance or possibility and a greater number of explanatory entities.

In everyday language, a complex situation "sounds confusing and difficult to be solved. It evokes a reality full of warps, in which several variables difficult to be understood are hidden"(12). However, in this author's point of view, it is in complex and apparently confuse and uncertain situations that the greatest creative and interactive possibilities are hidden, because these demand careful consideration and the constant search for the truth, which reveals to be increasingly complex.

It is clear for the interviewees that knowledge needs to be dialogued, shared and confronted. This idea is evident as professionals discuss that interventions that used to seem simple and easy to be identified and edited, now demand a multidimensional perspective. In other words, they started to require a "complex conjunction of the unique with the multiple and a look at the parts to understand the whole and at the whole to understand the parts"(13). Only a few years ago, a specialist with a minimum of personal and technological support, knowledge and competence acquired in school would deliberate and solve the majority of problems related to health(14). Nowadays, this process needs to be expanded and interconnected with different kinds of knowledge because, in all disciplines, at all levels and in society in general, health care is increasingly complex.

Systemic-complex thinking knowledge allows the human being to advance in the concrete and real world of social phenomena, in the attempt to better understand oneself, the other and reality. For systemic thinkers, "complex thinking makes an effort to unite, not in confusion, but by operating distinctions. [...] The vital need of the planetary age, of our time, is thinking capable of unifying, integrating and distinguishing"(15).

Thinking and acting based on the interactions and associations of systemic-complex thinking implies moving through uncertainties, discontinuities and partial knowledge, in other words, in a continuous and permanent search for the different and new(13).

Much beyond mere creation, innovation or simplified health problem-solving, "nursing care as social practice" requires that nurses are placed in the concrete reality and develop proposals that effectively show social participation. In this perspective, confronting with emergent social contradictions means acting with a view to rethinking traditional practices and postures and definitely assuming a new attitude in defense of life, threatened by the hegemonic and reductionist economic model(12).

Nursing has multiple competences and a broad and socially renowned field of action, but it needs to dare and explore opportunities and envisage new spaces, understanding that being a social entrepreneur means being capable of exploring opportunities and leading new professional fields and practices. It means being able to imagine, develop and make visions come true, where the concepts per se, synergy, leadership and relation/interaction system are essential elements (16).

Nursing care as a social practice based on complex-systemic thinking constitutes a new paradigm of intervention, capable of strengthening social actions through interactive and associative networks, and of acting in a proactive, innovating and participative manner.

Thinking about the individual and relative who is introduced to the health professional in a condition of vulnerability requires levels of comprehension, good reception, qualified listener and inter-subjective bonds of confidence, sustained in the light of references that conceive the multiple variable interrelations and interconnections that involve the health-disease process.

 

FINAL CONSIDERATIONS

Nursing care as social practice is strongly associated to the idea of community inclusion or community inclusion practices. For professionals in general, nursing is characterized as historical social practice and its practice is eminently social.

The nurses' social practice is also associated to the integrated and integrating community practices. It is clear, for nurses as well as for the remaining health professionals, that community practices are flexible and sensitive fields, capable of expanding interactive possibilities and ensure solving capacity in health. On the contrary, hospital facilities were described as limited spaces, associated to work division, hierarchical structure, rigidity and strict standards, among others.

Nursing care as social practice is highlighted and distinguished, in summary, by interactive and integrating care practices, which have acquired important repercussion, both in education as in the health promotion and protection of individuals. One may say, without much deliberation, that nursing is an eminently social profession and increasingly seen as the profession of the future, due to the possibility of understanding the individual, not as a sick individual but as a multidimensional being, with self-organizing potential and, thus, participant and author of his(er) own history. Therefore, nursing needs to invest in proactive attitudes, capable of promoting social development through the expansion of actual opportunities for human beings in their real and concrete context.

 

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Recebido em: 4.12.2008
Aprovado em: 13.8.2009

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