Clinical care in nursing: development of a concept in the perspective of professional practice reconstruction

Abstracts

Nursing is a praxis that has been defined from different epistemological plans; its history is marked by constructions and deconstructions. In the course of this, the care and its clinical practice have taken on constitutions influenced by the social, economic and ideological interests of each epoch. In this text, we aimed to reflect on the construction of the conceptual plan of the nursing clinical care in a perspective that allows a change from the traditional epistemic model based in the biomedical framework and in the Cartesian model of the subject. This is a theoretical reflection in which we developed this concept, based on the conceptions adopted in the lines of research of the Academic Master's degree in Health Clinical Care of the State University of Ceará (UECE). We concluded with the presentation of the proposal of the Academic Master's degree in Clinical Care of the UECE, showing how this concept strengthens its productions in the health and nursing area.

Nursing; Nursing Care; Professional Practice

A Enfermagem é uma práxis que tem se definido a partir de diferentes planos epistemológicos. Sua historicidade é marcada por construções e desconstruções. Neste percurso, o cuidado e a sua prática clínica assumem constituições atravessadas pelos interesses sociais, econômicos e ideológicos de cada época. Objetivamos, neste texto, refletir sobre a construção do plano conceitual do cuidado clínico em enfermagem, em uma perspectiva que permita o deslocamento do modelo epistêmico tradicional pautado no referencial biomédico e no modelo cartesiano de sujeito. Trata-se de uma reflexão teórica em que desenvolvemos este conceito, partindo das concepções adotadas nas linhas de pesquisa do Mestrado Acadêmico em Cuidados Clínicos em Saúde da Universidade Estadual do Ceará. Finalizamos com a apresentação da proposta do Mestrado Acadêmico em Cuidados Clínicos da Universidade Estadual do Ceará, exemplificando como este conceito tem sido potencializador de suas produções na área da saúde e da enfermagem.

Enfermagem; Cuidado de enfermagem; Prática profissional

La Enfermería es una praxis que tiene su definición a partir de los diferentes planes epistemológicos. Su historicidad es señalada por construcciones y desconstrucciones. En esta ruta, la atención y su práctica clínica asumen constituciones cruzadas por los intereses sociales, económicos e ideológicos de cada época. Nuestro objetivo es reflejar sobre la construcción del plan conceptual de la atención clínica en enfermería a fin de permitir el desplazamiento de un modelo epistémico tradicional, basado en el referencial biomédico y en el modelo cartesiano del sujeto. Se trata de una reflexión teórica, donde desarrollamos este concepto, partiendo de las concepciones adoptadas en las líneas de investigación del curso de Maestría Académica en Atención Clínica en Salud, de la Universidad Estadual de Ceará, Brasil. Así, llegamos al final con la presentación de la propuesta de esta Maestría Académica, ejemplificando, como este concepto se ha potencializado en sus producciones en el área de la salud y de la enfermería.

Enfermería; Atención de Enfermería; Práctica Profesional

INTRODUCTION

Nursing is a praxis that, over its historical development, has been defined based on different epistemological plans, influenced by the social, economic and ideological interests of each epoch.

From the XIX century onwards, more precisely, nursing practice began to make out its structuration in line with the scientific principles of modern science. Theoretically, this movement had historical importance because it permitted the maturing of its concepts and the delimitation of its conceptual theoretical field.

However, one of the confrontations which nursing has to establish in this space is the contradiction between the positivist scientific principles and the complexity of its object: human care.

In this confrontation, it was perceived that the theoretical corpus of the so-called natural sciences would not be enough to address the phenomena of health and illness. Thus, nursing passed to appeal to the frameworks arising from the human sciences and from philosophy and it is in this tension, promoted by these meetings, that the conceptions of care and clinic, which currently overarch nursing, have been delineated.

In addressing a specific object of knowledge, one cannot take it to be a unified field limited to its discipline; not only the object is historically constructed, but so is the subject itself and the theoretical and conceptual system with which it identifies. These are emergent effects from a plan of constitution which involves social, political, and aesthetic elements, among others¹.

The diversity of these elements constitutes a plan of consistence or conceptual plan. The conceptual plan is anterior to the concept, but at the same time, is what makes possible its creation. The concepts are happenings, but the plan is the happenings' horizon, the reservoir or the reserve of the happenings, which are purely conceptual².

The plan of consistency is the surface where the concepts are composed and insist. They outline lines of escape from their birth context to constitute the abstract thinking.

This article proposes the development of the concept of clinical care in nursing, as a conceptual plan which articulates the conceptions of care and clinic. The objective is to contribute to the production of new knowledges and new practices in the field of health, producing breaks with the biomedical paradigm, whose principles are delineated in modern science, corporified in care practices which objectify the illness and the ill subject.

The approaches adopted are of philosophers who propose discussions on the care^{3 , 4}; authors from the field of education⁵, as well as scientific productions from Brazilian nursing itself^{6 , 7}.

By means of a search through the Virtual Health Library, utilizing the terms "care, clinic, nursing" in an integrated search method, it was possible to identify 129 productions which, in some way, articulated these conceptions with nursing care. A first approximation of these publications, based on their abstracts, made it possible to identify the theoretical contributions which, in general, do not bring an epistemological reflection of these conceptions; even because this intention was not an objective of these productions.

As limitations, this study has the fact of being circumscribed in the methodological, theoretical space of a post-graduate nursing program; while its relevance and differential are considered, however, the construction of a conceptual plan based on some epistemological frameworks already worked on, including in scientific nursing production.

THE CARE AS HUMAN EXISTENTIAL AND NURSING

The contemporary studies which have discussed the epistemological bases of nursing converge, in pointing to the care as the essence of the profession^{6 - 8}. Nursing's current time passes directly through the need to discuss and question its knowledge, adopting plural approaches⁶. In this way, one can perceive that the concept of care is not being addressed in a homogenous way.

For presentation reasons, these conceptions of care were grouped in three theoretical approaches: the care in the humanistic perspective; the care in the emancipatory perspective, and the care in the perspectives of the "practices of the self".

a) The care in the humanistic-phenomenological perspective

The humanistic perspective has most strongly influenced the current reflections on nursing care. Its most representative framework is the work of Martin Heidegger³, based on which was developed the contribution of various other Brazilian authors such as Boff ⁷ and, in nursing, Waldow⁶.

The notion of care appears in Heidegger³ and is related to an ontological dimension, that is, its conception of Being (sein). The conception of dasein prevents one taking the human being as a pre-determined positive essence, but requires that we think of it as something which is always in play, seeking its possibilities of being in its existence in the world. The "individual beings" (das seiende) distinguish the way of being-in-the-world of human from the other beings, as it is not defined on the basis of an essence determined a priori, but is always defined in a relational context, in the being-in-the-world with itself, with the others and with the things.

The care appears as the human being's most suitable existential and, therefore, as that which permeates all the relationships he establishes with the world. According to Boff⁹, to speak of the ontological dimension of care means to say that it enters the essential definition of the human being and because of this determines the structure of its practice. It is also clear that the concept of care addressed by Heidegger³ does not essentially mean a zealous and concerned attitude with another being in the world.

The concept of care addresses the ontological dimension of being, but does not attribute to it a pre-determined positive essence. To care, therefore, is related to all the forms of relating to the world, including those which can be considered non-positive³.

In line with the Heideggerian foundation, the care must be conceptualized as commitment, helpfulness, diligence, zeal, attention and fairness. Also, according to the author, the concept of care includes two basic meanings: firstly, an attitude of commitment, of helpfulness and attention to the other. The second attitude, intimately related with the first, includes the worry and concern for the other, because we feel involved and affectively linked to the other.

In nursing, it is identified that the humanistic concept of care appears, for example, in the concept of care elaborated by Waldow⁶. For the author, "the action of caring always has a connotation to provide, or foster good for another being"^{6 :90}. In this way, the orientation of the care is for a being who suffers, "who is found in need, vulnerable"^{6 :90}. Further, according to this author,

The behaviors and the attitudes are understood as of care and are composed of a vast list, in which the following stand out: respect, kindness, friendliness, compassion, responsibility, availability, security, the offering of support, comfort^{6 :90}.

In this same line of thinking, one has the concept presented by Sales and Molina¹⁰, to care is "put oneself in the other's place and perceive his needs, both physiological and emotional, to give the other comfort and security, such that he may pass through 'difficult times' in the mildest and calmest way"^{10 :40}.

In Watson's Nursing Theory¹¹, also known as the humanistic theory, the care is understood as the essence of doing in nursing, characterized as the profession's own moral imperative.

In Silva¹¹, the care is understood as the utilization of a systematization of care mediated through scientific knowledge, with a view to performing a complex of actions geared towards the satisfaction of the human being's circumstantial needs. This systematization would be viabilized through the development of technical actions, with competences and skills, but without ceasing to show a humanistic attitude.

One can perceive that the notion of care presented by these authors revolves around ethics, which have as marking elements the valorization of the relationship with the other, of the positive feelings and emotions in relation to this other, and a moral ideal, which has as its ultimate purpose the preservation of human life.

b) The care in the emancipatory perspective

The care, in this perspective, has its main references in the work of authors such as Paulo Freire⁵ and Pedro Demo⁷. In nursing, the work of Pires⁷ marks the construction of a model called by the author the emancipatory triad of care.

Thus, taking Freirean ideas as a starting point, the ethical conception regards the values and the way of life of the other, where the history and the culture need to be contemplated, where the voice of the other may be heard in a singular and unique way, also taking into account its social context.

As a derivation from this context, one has an aesthetic conception which refers to the promotion of a liberating education, with criticality and curiosity in the perspective of widening creativity⁷.

In spite of Freire's theoretical and methodological proposal⁵ having been produced as a function of education, specifically in the teaching of literacy to adults, one can undertake the exercise of thinking about the care from this same theoretical perspective.

In this form of caring, one focuses on a political positioning in favor of liberty and in the ability to believe that the other has a knowledge and a doing which need to be considered. In this sense, this knowledge and its doing can be adopted as a starting point for the production of care, but, when it may be necessary to transpose them, it is necessary to adopt strategies such that this transposition should not occur through the overlapping of knowledges⁷.

The concept of care in the emancipatory perspective is characterized by rescuing the political dimension which is inherent to it. According to Pires⁷, the politicality of the care resides in recognizing the intrinsic ambivalence which accompanies the notions of help which, being power, both dominate and liberate. For this author,

[...] the characteristic of caring, while a gesture and attitude of solidarity, is inclined to protect and ensure life, rights and citizenship. However, the fraternal relationship generated there is also oppressive and subjugating, being able to use typically modern ethical universalities to maintain itself in a position of dominance^{7 :729}.

The characteristic of politicality potentializes the care, configuring it also as

[...] emancipatory or deconstructive of the structures which subjugate it itself. It redimensions the care as an ethical possibility of humanity, viabilizable through its intrinsic ambivalence. Such intent suggests a dialectical movement, where the relationship of dependence occurs more to construct the autonomy of the actors involved than to remain centered on oneself, as a self-centered exercise in power. The care as management of help-power has as its central fulcrum the dynamicity, both of the historical processes and of nature, assuming here a social, ecological and epistemological approach to care^{7 :731}.

Basing itself on this principle of uncertainty, inherent to the act of caring, it is possible to employ viewpoints which characterize it as much as political subversion as an action directed at submission and oppression. From this perspective, it may also be a catalyst for changes in the social relationships.

The liberty is manifested in the conception of coming to be constituted in the subversive potentiality of the care, expressed by the frivolity, evanescence and intrinsic transience of the power. The care, seen in the totality, involves not only the way of being, a more definable and capturable structure, as also the way of coming to be, a characteristic which makes it dynamic, permeated by sensuality and dialectical tension"^{7 :731}

The potentiality of the care in these meetings generates the mutual affection, implicators of new ways of learning the processes of living and falling ill, based on knowledge, creating movements of reflection and acts oriented by desires and meanings¹.

c) Care in the perspective of the "practices of the self"

The main reference for this approach of care in the perspective of the "practices of the self" is the work of Michel Foucault⁴, principally based on the approach of the Greek concept of epiméleia heautoû which the author translates as care of oneself.

According to Foucault⁴, the care of oneself is, firstly, a general attitude, a certain way of facing the things, of being in the world, of practising actions, of having relationships with the other.

Secondly, the epiméleia heautoû, is also a certain form of attention, of viewing [...] "it is necessary to convert the viewing, of the exterior, of the others, of the world, to oneself. To be attent to what one thinks and what passes in the thinking"^{4 :10}. Thirdly, it also designates some actions, "[...] actions which are exercised by oneself for oneself, actions through which we assume, we change, we purify, we transform and we transfigure"^{4 :10}.

Nevertheless, in the Foucaultian concept of "care of oneself", it is possible to perceive some elements which are also present in that which was called above the humanistic perspective of the care (the relationship with the world and with the exterior), it may be perceived that this concept may be distinguished radically from the anterior.

Firstly, in spite of understanding the care as a relationship with the other, this is not the purpose of care of oneself; much less is the agent of this practice another who comes to provide help.

The care of oneself is related to the practices which the subject himself carries out for himself, with a view to appropriating himself of himself, his wishes, his desires, his appetites. Only in this way could he relate himself to the others, govern and dominate the Pólis ⁴.

The course of this learning must involve the other: the master. However, its pedagogy is very distant from the ideal of the help and well-being, present in the humanistic perspective. On the contrary, the master is that responsible for disquieting, for awakening⁴.

As a consequence, there is the second characteristic which differs the care for oneself from humanistic care, where the relationships between the subjects are based in the desire for solidary help, the care of oneself is not necessarily based in actions of zeal, sympathy or affection, but in actions of disquiet and implication.

This is not about avoiding the confrontation, eliminate the pain, but rather to strengthen oneself so as to deal with it. The care of oneself is a sort of sting which must be planted in men's flesh, embedded in their existence, and constitutes a principle of agitation, a principle of movement, a principle of permanent concern in the course of life⁴.

This being so, the nursing actions are not restricted, only, to the use of clinical judgement, of diagnosis, of the prescription of care and the assessment of the therapy instituted. They must also involve the questions which may relate to the relationships which each one establishes with himself and with the other, the ways which the subject finds to appropriate one's own life history, one's signs and one's symptoms, the ways in which it has meaning for life itself. It is understood that it is important to undertake an articulation between the subject's history and his subjective constitution, as a being of language.

There is, however, a reason which is more essential than the paradoxes of moral history: the Cartesian thinking which disqualifies the epiméleia heautoû in favor of gnôthi seautó, as it privileges the knowledge of oneself as a form of conscience, placing the evidence of the subject's existence in the principle of access to being, as fundamental access to truth; while, for the "practices of the self", there can be no access to the truth without a transformation of the subject, an effect of returning the truth upon the subject.¹²

THE CLINIC

The hegemonic conception of the clinic, in the field of health and nursing, is that which takes itself as synonymous to the approach of the illness¹. This vision was historically constructed and is related to the social and economic composition, which approximated nursing to medicine and to positivist science. Therefore, to be possible to reinvent this concept, it is necessary to historicize it, opening a space for the construction of other meanings.

The clinic of spatialization of the body and of the illnesses, as it is known today, is not the only one nor is it the first. It was constructed through complex relationships of power and knowledge¹.

Based on the XVII century, Foucault affirms that the view of the clinic in this epoch was vehemently centered on the body, whose characteristics were imagined by rules and hypothetical suppositions. The illnesses were classified by similarities or disparities, in line with their manifestations in the body¹³.

In the XVIII century, an entirely new way of spatializing the illness appeared, centered principally on the institutionalization of the illness and the cares for the ill person. The hospital gained space in this new context, passing to be seen as a space of continuous vigilance¹³.

Under the view of the doctor, one could, from then on, "classify patients to such a point that each would find what was suited to his state without aggravating by his proximity the illness of others, and without spreading contagion, either in the hospital or outside it"¹³.

The idea is that the illness needs to be circumscribed so as to better display the truth of its nature. The medical teaching passes to be questioned regarding the necessity of its regulation, seeking to avoid that any person could authorize herself to practise medicine. The hospital is a space which is propitious to the control of this teaching, which has come to be given next to the ill person's hospital bed, guided by a new notion of the clinic, linked to an organization of the hospital domain.

The clinical viewpoint of the XVIII century valued the symptoms and signs. The first has prime position, as it is the form itself of how the disease is presented, and is the first transcription of the inaccessible nature of the illness. The signs, on the other hand, are valued by their ability for prognosis of what is to come, to guide the anamnesis of what has passed, and diagnose what is happening in that moment. The clinical task consists exactly of transforming the symptom into a significant element, unmasking the nature of the illness through clinical observation. In this action, the observation is an essential tool¹³.

Foucault¹³ referred his exploration of the lines which overarch the clinic until touching lightly on the XX century. Today however, as actors and spectators of the dawn of the XXI century, one may highlight certain aspects which overarch the clinic at the present time. One can perceive, for example, that the vertiginous expansion of the technological instruments has increasingly rendered destitute the apparatus created by the anatomical-clinical perspective around looking, touching and listening.

These senses are directed ever less at the patient, as technology proposes to substitute them with increasingly sophisticated examinations. The notion of the illness and death as something strange to life, caused by some causal agent, was taken to its extreme. Since then, there has been an attempt to explain all human behavior in terms of relationships of cause and effect.

Later, the objective will be to discover the cause so as to medicate it, as the drugs beckon with the promise of eliminating all human suffering, from sadness to impotence (existential, sexual, among others possible). And thus, humanity's relationship with itself becomes ever more distant.

Nursing has been profoundly overarched by these compositions originating from the plan of the clinic in medicine, always occupying itself in maintaining the organization of the spaces and of the bodies, such that the medical power may act.

THE CLINICAL CARE

The concept of clinical care appears as a possibility for provoking a meeting of other concepts of the clinic with the diverse conceptions of care explained here. It is focussed that, based on this tension, there may be a strengthening of the doing of nursing and a re-signification of these two concepts which, when confronted, produce a new conceptual field, where both the care and the clinic affect each other mutually.

In spite of not proposing a ready meaning for this new concept, it is understood that the clinical care is constituted in a perspective of establishing new relationships between the subjects involved in the process of care. In the creation of spaces where the subjectivization may be constructed based on these subjects' desires, and relating to the ways of conceiving of and signifying health and illness, outside the classifications and assistential fragmentations which historically have tried to frame the service users. This movement is contrary to the intention of, externally to the subject who is cared for, elaborating projects to meet her health needs, situating them beyond the plan of consumption of technologies and procedures.

This way of conceiving health care recognizes the listening as a tool which is essential for constructing a therapeutic project centered on the subject and on his perspectives of care. The processes of health work, and those of nursing in particular, pass to incorporate these same subjects' knowledges and values in the elaboration of actions directed at prevention, cure and rehabilitation.

Far from intending to discipline and condition the bodies and the affections ¹, this conception seeks to expand the subjects' possibilities and potentialities. It requires a movement away from the clinic of the observation, and to be influenced by the clinic of listening and by the clinic of the affections; thus actioning, in the healthcare settings, this capacity of affecting and being affected in the course of life.

This widening of the clinic, in relation to the clinic of the illness, seeks to grasp the health needs beyond the body, recognizing the multiple feelings and meanings which these needs may assume.

In this sense, the answers sought by the service users can require other configurations of the work processes and the interventions to be elaborated in the ambit of the health services, thus breaking with the ideals of cure and health, constructed by the biomedical model of health care.

This discussion overarches the proposal of the Academic Master's Course in Clinical Care in Health (CMACCLIS), of the State University of Ceará (UECE). This was authorized to function by the Coordination for the Improvement of Higher Education Personnel (CAPES) in 2005, and presents two lines of research, these being:

- Line 1: Theoretical philosophical conceptions of health and nursing.

- Line 2: Process of caring in health and nursing.

The course is structured in the perspective of developing a reflection on health care, as well as on nursing care, guided by the theoretical frameworks of the clinic and of care as explained above.

It is also concerned with instrumentalizing the students for functioning in lecturing and in research, with the aim of driving forwards new ways of systematizing nursing practice, centered on the subject and her desires for care, making possible the emergence of care technologies in nursing, with potential for innovating the assistential everyday, fostering the development and social legitimacy of the category¹⁴.

The theoretical-methodological proposal grasps the clinic as inherent to the care, which needs to be broadened, as do the ways of looking at, listening to and producing affections between the subjects who care, re-signifying also their purposes and ways of producing the health care in the assistential context of the Unified Health System (SUS), thus making possible new arrangements for the health care in nursing.

The conceptual, academic and curricular structure is linked to the need to construct methodologies of care which overcome the fragmentation of care and the exclusion of the subject. It is sought to integrate this subject in the context of production of care with his knowledges, his viewpoints and his subjectivity.

FINAL CONSIDERATIONS

The development of the clinic is marked by the theoretical conceptions which support it. These, in their turn, are influenced by the social, political, and ideological conceptions historically constructed.

Historically, the concept of the clinic has been marked by the anatomicalpathological inheritance, which is born in the field of medical knowledge and overarches the exercising of various disciplines in the field of health.

On the other hand, establishing a tension in the face of this model, there is in nursing a strong presence of the humanistic conceptions of care which, often, clash with the objectivist determination of the hegemonic clinic.

There is a plan where these two concepts co-exist, sometimes in contradiction, sometimes provoking displacements, whether in practices or in the way of thinking about the clinical practice.

The concept of clinical care appears as a new focus in the possibility of, based on this tension, strengthening the doing of nursing, contributing to a re-signification where the two concepts, in meeting, produce a new conceptual field, where both the care and the clinic affect each other mutually.

There is, here, no intention of delimiting a meaning, but, rather, of pointing out the diverse possibilities which have opened based on the lines of research developed in the Academic Master's Course in Clinical Care in Health.

It is believed that, in making the clinic dialog with the care (in its humanistic, emancipatory perspectives and in the "practices of the self"), it is possible to transform it in the perspective of becoming. The challenge imposed on the course, through its scientific production, has been that of showing the possibilities of this articulation.

Thus, the Academic Master's Course in Clinical Care in Health emerges as an important space for training in nursing, at the level of the north-eastern region of Brazil and of the country as a whole, taking as a triggering device the concept of clinical care in nursing, in the perspective of reconstructing the process of work and formation of the nurse.

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• ¹
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  Erdmann AL; Fernandes JD. Programas de pós-graduação em enfermagem no Brasil: desafios e perspectivas. Esc Anna Nery [on line] 2011 Mar [citado 2012 jun 12];15(1);07-09. Disponível: <http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1414-81452011000300027>.
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Publication Dates

• Publication in this collection
  Jul-Sep 2013

History

• Received
  08 Dec 2011
• Reviewed
  27 June 2012
• Accepted
  27 Nov 2012