Contribution of the nursing process for the construction of the identity of nursing professionals

Contribución del procedimiento de enfermería para la construcción identificación de los profesionales de enfermería

Abstract

Objective:

To understand the meaning of the nursing process for the identity construction of nursing professionals.

Method:

A qualitative study based on the data-based theory and symbolic interactionism, carried out with 12 nursing professionals from November 2015 to February 2016 in a reference hospital in the south of Brazil. The data were collected through an intensive interview, analyzed using Nvivo® software.

Results:

The data show that the Nursing Process enabled professionals to assume multiple identities that contributed to the construction of the institutional identity of the nationally and internationally recognized hospital.

Conclusion:

The multiple individual, collective, and institutional identities are fostered by the construction, deconstruction, and reconstruction movements that make up this model of care, allowing for the creation of a culture of appreciation of the nursing process as a working method, that is, the nursing process was the origin of the nursing identity of the hospital.

Keywords:
Nursing; Nursing process; Work engagement; Professional role

Resumen

Objetivo:

Comprender el significado del proceso de enfermería para la construcción identitaria de los profesionales de enfermería.

Método:

Estudio cualitativo a través de la Teoría Fundamentada en los Datos y del interaccionismo simbólico, realizado con 12 profesionales de enfermería, de noviembre de 2015 e febrero de 2016 en un hospital de referencia en el sur de Brasil. Los datos fueron recolectados por medio de una entrevista intensiva, analizados con ayuda del software NVivo®.

Resultados:

Los datos muestran que el Proceso de Enfermaría permitió a los profesionales a asumir múltiples identidades que contribuyeron a la construcción de la identidad institucional del hospital, reconocido en un escenario nacional e internacional.

Conclusión:

Las múltiples identidades, individual, colectiva e institucionalizada, son fomentadas por movimientos de construcción, deconstrucción y reconstrucción que componen ese modelo de cuidado, proporcionando la creación de una cultura de valorización del proceso de enfermería como método de trabajo, o sea, El proceso de enfermería dio la identidad de la enfermería del hospital.

Palabras clave:
Enfermería; Proceso de enfermería; Compromiso laboral; Rol profesional

Resumo

Objetivo: Compreender o significado do Processo de Enfermagem para a construção identitária dos profissionais de enfermagem.

Método:

Estudo qualitativo por meio da Teoria Fundamentada nos Dados e do interacionismo simbólico, realizado com 12 profissionais de enfermagem, de novembro de 2015 a fevereiro de 2016 em um hospital de referência no sul do Brasil. Os dados foram coletados mediante entrevista intensiva, analisados com auxílio do software NVivo®.

Resultados:

Os dados revelam que o Processo de Enfermagem possibilitou aos profissionais assumirem múltiplas identidades que contribuíram para a construção da identidade institucional do hospital, reconhecido em um cenário nacional e internacional.

Conclusão:

As múltiplas identidades, individual, coletiva e institucionalizada, são fomentadas por movimentos de construção, desconstrução e reconstrução que compõe esse modelo de cuidado, proporcionando a criação de uma cultura de valorização do Processo de Enfermagem como método de trabalho, ou seja, o Processo de Enfermagem deu a identidade da enfermagem do hospital.

Palavras-chave:
Enfermagem; Processo de enfermagem; Engajamento no trabalho; Papel profissional

INTRODUCTION

The Nursing Process (NP), from the perspective of nursing institutions, is a specific knowledge, necessary for the professionalization and constitution of a professional identity. In this context, the NP is an instrument to offer support to decision-making in the formulation of public policies aiming to organize work in the field of health, qualify the training of Nurses, and regulate it⁽¹⁾.

The NP is perceived as a methodological instrument for the organization of the process of work and care in nursing. It is regulated by Resolution n. 358/2009, from the Federal Nursing Council⁽²⁾.

In the field of professional activities, nursing, as a science, seeks to consolidate the profession with structured knowledge pertaining specifically to the field, which can give support to the know-how of daily nursing practices and working processes, using elements that represent the professional identity of the field. Therefore, it seeks more recognition and feelings of belonging that can allow for the definition of particular competences, autonomy, appreciation, and support to decision making when it comes to issues inherent to the attributions of the profession⁽³⁾.

The building of this identity has been the object of studies carried out by researchers from many fields, such as sociology, social psychology, anthropology, and philosophy. However, little discussion has been directed at the NP and its importance to build genuine nursing knowledge and develop the identity of these professionals.

It should be highlighted that all members of the nursing team should have an adequate knowledge of all stages of the NP and participate in the building and consolidation of the feeling of belonging to a professional group. After all, if the center of our profession is care, the NP is the best way to treat the subject with scientific rationality, highlighting the specificity of our know-how⁽⁴⁾.

In the professional field, human beings act by themselves and in relation to the world, based on the meanings they find in these interactions. In our postmodern times, identity is formed and constantly transforms. The subject adopts different identities in different moments. The identity is not one, fixed, permanently surrounding a coherent "I". It is born from social construction, in which it is built, and not a given, a finished thing. Our identities help us understand our selves, our subjectivity, which involves the human psyche. The identity tends to be represented, and from this representation, it gains meaning⁽⁵⁾.

This study aims to understand the meaning of the Nursing Process for the construction of the identity of nursing professionals.

METHOD

This is a qualitative research whose methodological approach is based on the interpretive and constructivist Data-Based Theory (TFD)⁽⁶⁾, guided by the theoretical framework of symbolic interactionism⁽⁷⁾. The study derives from the PhD thesis⁽⁸⁾ "Work Training With Regards to the Nursing Process from the Perspective of Teaching-Working Integration: the HCPA Model". The research was carried out in HCPA, a university hospital in the south of Brazil, which used the NP as a model for assistance and for the professional practice of nursing since 1972. It went through several phases during these three decades, becoming a reference for many national and international institutions for its nursing care model and for the excellence of its assistance processes and of the Nursing Work Process⁽⁹⁾. To consolidate this model of assistance, the hospital counts on a Service of Nursing Education (SEDE) and, specifically with regards to the NP, with a Commission for the Nursing Process (COPE).

Considering these specificities, the participation of subjects was defined according to what is proposed by the "formation prism"⁽¹⁰⁾, which is represented by: healthcare nurses (representing healthcare); professor nurses; nursing students; multiprofessional Residency nurses (representing teaching/learning); Technical Nurses in charge; SEDE nurse; COPE nurse (representing management); nurse representatives of the Nurse Association (representing social control), to a total of 12 interviewees.

The "formation prism" is a structure of social subjects who represent the segments of teaching/learning, management, healthcare, and social control, in a dialogic relation that translates the complexity, richness, and potency of the movements of health education⁽¹⁰⁾.

TFD does not require a predetermined number of participants. The number of people from each segment that composed the prism was defined per data saturation. The inclusion criteria for each representative group of the prism was determined, and the main criteria were: participants had to either be linked to a sector/service which uses the NP daily; actively act as professors; or be enrolled in the second-to-last semester of the graduation Nursing course and be in the residency. Were excluded those who were in vacation, on health or maternity leave, or about to retire.

For data collection, the intensive interview technique⁽⁶⁾ was used. Ten interviews were conducted in person, individually, in an environment which was adequate to maintain anonymity. Two interviews were conducted using information technologies, more specifically, the software Skype®, since there was a personal incompatibility between researcher and interviewee. The Skype® interviews were carried out with the same ethical and anonymity criteria of interviews in person and were positively evaluated by those involved.

The interviews were scheduled in advance, according to the availability of all participants, at a time before their shift started; after their shift finished; or during their breaks, meaning their work activities were not affected. Each interview lasted for approximately one hour.

Data collection via the intensive interviews took place from November 2015 to February 2016. They were recorded in audio after the participant authorized and later transcribed.

Guiding questions for the intensive interview included: a report about the experience of the participants with the NP; reports about what does the formation/teaching activities in health work entails, including their perception regarding the participation of the segments from the prism in the formation/learning/permanent education activities in health from the NP in HCPA; and a report about the NP and its formation in the service, in the context of a hospital, in its learning/working integration, and in the formation processes for NP in the HCPA.

The analysis of the interviews followed the methodological TFD recommendations. At first, the participants were carefully listened to and the interviews were transcribed by the researcher, meaning that data analysis, in the TFD, takes place simultaneously to the interviews. After each interview was transcribed, it was coded using the NVivo® software, version 10.

The coding was carried out in two different ways: an initial coding (which induces the study of the data rigorously and turns the ideas into concepts) and a focused coding (which allows for the separation, classification, and synthesis of great amounts of data)⁽⁶⁾.

Considering this context, this required the careful reading of all interviews, so that the maximum references possible could be extracted. 717 references in accordance to preliminary coding were coded; 374 nodes originated from these - both steps were a result from the initial coding. From these nodes, 24 conceptual codes emerged (focused coding) through the grouping process.

Considering the above and as a result from the grouping of the initial coding, the focused coding emerged, generating six sub-categories (Institutionalization of the Nursing Process in the HCPA; Implementation of the healthcare in nursing with safety and quality; Consolidating the learning-working integration; Building a professional trajectory; Revealing the elements and devices that make up the HCPA formation model; Stimulating critical thought for nursing care) and three categories (Historicizing the Nursing Process: getting to know the mosaic; Building the Mosaic: the stepping stones from graduation to work; Presenting the league that unifies the stepping stones to the process of learning-working integration at HCPA). From these categories, the phenomenon of the study emerged:

"Presenting the model of working formation with regards to the Nursing Process, as perfected by the learning-working integration in the HCPA setting".

Image 1
Flowchart of the model of service formation with regards to the Nursing Process, as perfected by the learning-working integration in the HCPA setting⁽⁷⁾.

The ethical aspects of researches involving human beings were taken into account, and the recommendations from Resolution 466/2012, From the National Council of Health, were followed. The study was approved by the local Research Ethics Committee (under protocol 1.283.695, CAAE: 48658015.1.0000.5327).

In the presentation of the results, we are only presenting the category "Historicizing the Nursing Process: getting to know the mosaic", from which emerged the identification of the multiple identities and of the institutional identity that this article discusses. To identify the statements transcribed, the codename "I", for "Interviewee", was used, followed by the letter that represents the segment of the prism the person is a part of, and an ordinal number, according to the chronological order of the interview. Specifically: IM (interviewee from the management segment); IT (interviewee from the teaching segment); IH (interviewee from the healthcare segment); and ISC (interviewee from the social control segment). Example: for the first interview in the segment "management", the codename "IM1" was used; for the second, "IM2", and so on.

RESULTS AND DISCUSSION

Many reflections that represent this category showed themselves in reports of individual and collective actions of resistance, especially through narratives about using the strengths and potentials of the NP to carry out the healthcare model. However, the issues regarding the production of identities permeated all subcategories, especially the institutionalization of the NP in the HCPA. In this process, the technologies used in specific activities, such as the act of caring, stand out, strengthening the construction of multiple professional identities and of an institutional identity. Considering this context, we will discuss the elements that give support to this category, starting with nursing care, something that is intrinsic to the profession and that requires specific activities based on a "reading" of the reality and of individual, collective, and community health needs. In this professional setting, the NP is the starting point of this process.

In this study, the care model adopted with the NP can be recognized as a space that was conquered and built. For that, many factors were relevant. Data revealed important moments and meanings in the history of the implanting and implementation of the NP, which, with time, became an institutionalized work method:

The general hospital is 42 years old, as is its use of the NP(IM3).

This is in the roots of those who planned this hospital, the precursors and it surely came with nursing training since, to teach nursing consultations to the students, you needed a field of practice where nurses would exercise this practice, do them (IM2).

The use of the term "precursor" in many different moments can be interpreted as the main responsible for initiatives of NP implementation, such as the working method which helped in the process of thinking and idealizing care, from the application of a scientific and systematized method, in addition to contributing to the adequacy to legal issues related to the assistance functions of the nurse. Another thing that should be highlighted is "nursing training" which can be perceived as an element that allows for the articulation between the idealized model and the model that effectively came into effect, as to create and cultivate the culture according to which the things taught must be put into practice.

Considering this, the institutionalization of this working method reflected on the practices of care, and this movement intensified the involvement of nursing professionals - from healthcare or management. In addition, the (co)participation of the Nursing School in the settings of the hospital led to the structuring of the NP, culminating in a higher quality for the healthcare being offered and in the strengthening of the professional identity.

From a historic perspective, the data indicate the path the hospital took to implement the NP and the challenges it faced to be recognized as a reference for the field of health and for the teaching of this method. Some difficulties were found and overcome, while others are still present, but they all aid professionals to broaden their field of action and their perspective on the process of healthcare, as the following statements indicate:

The nursing coordination of the hospital had to develop for a long period of time the NP issue and nurse prescriptions and also the nursing diagnoses she the nursing manager was the precursor of what she called study group (IM2).

... what ends up happening, the evolution, the transit, today no one bothers with diagnosing, this is something that is there, of course this has been happening for some time, but today when you talk about diagnoses it isn't a monster, even older people, we have 30, 35 year-old nurses, I'm an exception because I made the transition in the university, I learned diagnoses easier than many of the students my age that did not have this transit, but they are evolving, prescribing normally and understanding what it means, but it was an exercise, it was like 15, 20 years for them to understand, some of them understand better today... look it's a pleasure to see... I have the pleasure of working in an institution that makes you change, so you get out of your comfort zone (IH9).

The expressions "no one bothers", "the evolution", “the transit", "it isn't a monster", and "it's a pleasure to see" can be understood as references that indicate professional maturity from the implantation to the current consolidation of the NP. Time was a marker, revealed in the expressions as an element that aided in the process of understanding the meaning of the NP for the professionals and for the institution. It also helped consolidating and guiding this methodology of care and work.

The feeling of accomplishment was also emphasized, expressed by the mention of a state of "pleasure", meaning that throughout this experience, this setting offered satisfaction to the professionals for being a part of a recognized health institution that is concerned for offering healthcare with excellence, that is, these professionals feel identified to the institution and the methodology of care it adopts. This identity took a proportion that reflects the nursing care in a local, national, and international setting, and its construction was affected by the way in which nurses absorbed the care model.

An analysis from the perspective of symbolic interactionism⁽⁷⁾ indicates that human beings act in regards to the world based on the meanings that the world offers them. The postmodern identity is continuously formed and transformed. The subject takes on different identities in different moments. Identity is not unified, fixed, permanently surrounding a coherent "I"⁽⁵⁾. Therefore, the data indicate that, in the setting of the hospital being studied, we can find multiple identities, such as the identity of the nurse that works in the hospital; the identity of the nurse who believes in the NP as a healthcare methodology; the identity of the nurse who does not; the identity of the nurse who acts in the logic of integrating learning and working. Sometimes, the expressions revealed signs of a crisis of identity or feeling of not belonging to the identities revealed.

Identities are fruits of social construction, in which they are built. They are not a given, finished thing. The identities help us understand ourselves, our subjectivity, and involve human psyche. Identity tends to be represented and, from this representation, it acquires meaning⁽¹¹⁾.

From this context, data reveal that the NP aided nursing professionals to assume multiple identities and contributed in building the institutional identity of the hospital, since it transformed healthcare practices, producing movements that led it to be recognized in a national and international setting.

It stands out that these transformative moments, in addition to producing many identities, produced relations of power that contributed for the development of the autonomy of this professional category. This process of identity construction was stimulated by the interaction and inter-relation between the Nursing School and the hospital, both represented by the prism formation segments - mostly via teaching, service, and management, and, in a more incipient way, social control. In this setting, the many individual, collective, and institutional identities are fomented by movements of construction that made up this unique model of care, allowing for the creation of a culture of valuing the NP as a working method in the hospital.

It can be noted that, in this process, participants developed their identities from the ways in which the subjects involved articulated themselves in objective and subjective transactions, which culminated in multiple identities. The multiple identities revealed here line up well with the ideas from a previous study⁽¹²⁾ when they state that subjective identities are constructed in the molds opened up by the continuous trajectories in which individuals move. They build a professional identity projecting themselves in a plan for qualification that implies the recognition of a professionality that gives them structure and can be constructed via the projection in space of a hierarchical power, implying in a recognition of the responsibility that structuring this identity represents. Still, in an objective transaction, the identities can lead the institution that legitimates this identity to be socially recognized, since it is the place where the intents of recognition are met. The future of the institution is the future of individuals built continuously from their past.

From an interactional point of view, the recognition of the many identities of the hospital professionals is the fruit of an interaction that resulted in positive actions between equals, those who make up the prism, who have been legitimized by the institution.

The professional and social identities are associated to specific configurations of knowledge (practical, professional, organizational, and theoretical) which are built through processes of socialization throughout a trajectory⁽¹²⁾. Therefore, it can be said that identities are in constant movement, in a dynamic of (de)structuring/(re)structuring which may, sometimes, appear to be an "identity crisis".

From this perspective, the identities are neither the psychological expression of individual personalities, nor products of structures or imposed economic policies; they are social constructions that imply the interaction of individual trajectories to that of systems of employment, work, and that forms the setting from which one is a part of⁽¹²⁾.

Identity processes are expressed by a relationship of power from a relational perspective of symbolic interactionism, in which these process have a central place in the dynamic of producing differences and feelings of belonging⁽¹³⁾.

Data show that nursing professionals who act in the hospital have a feeling of belonging with regards to the NP, expressed in their recognition of the fact that they participated in the story of building and molding the NP, represented by the social image of the model of care.

For the constitution of the NP model in the hospital, some elements were required. Here, they were represented by knowledge about legislation, operationalization difficulties, among others, which demanded behavioral changes in the nursing team. The ways in which to think and carry out care imposed changes in the way the data of the patient were registered. The training of nurses regarding the theoretical and practical application of the NP also demand efforts, in addition to an intense involvement from the professionals and the commitment to the study of the stages that permeate the NP, as the statement below shows:

... we started thinking this differently and I started to disseminate, so we started to think about the first specific diagnostic for the patients we were attending so we could implant it, and then this diagnostic was studied, there was a literature review and the reality was updated, it already was in our system, but we updated and added new factors, signs and symptoms related to it, and then we went to each unit (IH9).

Such effort also aided in the process of qualification of care, using the NP as an element that could order the nursing working process, since it is seen as a methodological and management instrument that allows to quantify and qualify the study.

... the unique feature, the flagship of the nursing in this general hospital is the nursing process, so much so that it is noticed by other institutions, this model is referred to other institutions, so the great milestone was entering in a hospital with such a working process and work methodology (ISC10).

I always use the nursing process, I really believe in it, that it organizes the way the nurse has to evaluate the patient and you can clearly your plans (IT5).

Understanding that the nursing process as a work methodology adds value to the practice of the nurses (IH7).

The practical description of the NP as a working methodology is praised through the expressions "flagship" and "adds value", which indicate feelings of appreciation and of nursing activity development. The statements indicate the feeling of institutional belonging, which is represented by the NP.

The visibility provoked by the adopted model also stands out, in addition to the satisfaction of nursing professionals in the exercise of their function, and the contribution this offers to qualify the structure and organization in the working process, improving the public image of nursing in the hospital.

These considerations are in accordance to resolution 358/2009, since it prescribes that the operationalization of the NP clarifies the contribution of nursing in the healthcare of the population, increasing the visibility and recognition of the profession⁽²⁾. With regards to visibility, nurses have a self-perception of professional identity based on public image, the work environment, the recognition of their work and education, and on social and cultural implications, praising professional communications and using social media to show the public what this profession really is, since this contributes to increase visibility⁽¹⁴⁾.

The visibility of nursing certainly influences the health of the population positively. The social visibility of nursing encourages professionals to change the health system, increasing the quality of their work and the safety of patients. Strategies to increase said visibility are necessary, but there is a long way ahead, and only the sum of individual and collective initiatives can determine how far we will go. Nursing will have its own voice, as long as it is willing to disseminate it, and each of us is a cog in the machinery needed to increase the social recognition of nursing⁽¹⁵⁾.

However, a study developed in Brazil shows that the professional identity of nursing expresses conflicts and contradictions. There is an absence of analyses of the organizational matrix of professions, which is discussed in the emphasis given to the body of knowledge and professional values, which are guaranteed by university education. The organizational division of work shows that the professional identity of nursing is committed in its potency - healthcare - and emptied from its political strength as a profession of intangible value⁽¹⁾.

For many years, nursing was seen as a submissive profession, especially in regard to physicians. However, many things changed, and for some time nursing has been developing practices based on scientific evidence, getting further away from this myth. The NP is seen as an essential element for the science of nursing, with the awareness that, through planning, the patient receiving health care is treated with responsibility, since it guides the decision-making process in situations nurses go through. Healthcare is promoted through an organizational structure whose scope includes the specificities regarding both human care and the physical and material resources that are a part of the process. This evolution of nursing is linked to the changes experienced in society, leading the professionals to question and reflect on the practical situations from a scientific method understood as NP^(16-17).

The statements point out that the nursing professionals in this hospital gained visibility through the dissemination of a public image which translates the competence of professionals and their capacity to produce methods of work and models of care. The advances and the visibility of nursing care in the setting of the hospital were created and disseminated under the responsibility of the members of the formation prism, specifically, the nurses and nursing school professors, through the organization of the service - following the example of SEDE and COPE -, the educational actions carried out, the participation in events, the presentation of works and the publication of manuscripts.

In addition to organizing the working process, the data indicates that the implementation of the NP has been giving strength to the professionals and offering them greater autonomy. That shows that nurses must assume their essence to a greater degree as an autonomous profession, that is, a nursing care based on scientific knowledge that makes it possible to show the responsibilities and potentialities of nursing.

... We carry out the process, but in a very superficial way, I think we lack these fundamentals, the nurse needs to know these concepts, patterns, the issue of identifying what is this altered pattern? Is it a respiratory pattern, nutrition? What is interfering, what are the problems, so that they can identify the most likely diagnoses, the most precise, so that a more adequate intervention can be offered. I think it's not just seeing signs and symptoms; this patient has this or that or that other thing, ok, what do I do? I only carry out medical requirements, you must carry out procedures and so on. You really need to go deeper (IT6).

Considering this reflection, it is clear that the participants recognize nursing as a profession which has the capacity, autonomy, scientific features, body of knowledge, and in this context, it can be noted that one strategy would be to go back to the transit and to the changes in academic and work formation.

To this end, social reality is produced by social interactions in a relational perspective⁽¹³⁾. Therefore, the social interaction promoted by the NP education model was not implanted by itself. It counted on the managers, professors, students, and professionals.

The importance of priors and chains of actors and their interactions in the present and in the past contribute for the construction of these identity processes considering the importance of subjectivity as a dimension that can explain social relations⁽¹⁸⁾. Thus, this social interaction in the hospital contributes to build the professional identity of nurses and the identity of the institution as a national and international reference, both significantly provoked by the learning-working integration.

FINAL CONSIDERATIONS

Concerning the setting studied, the NP aided nursing professionals to assume multiple identities and contributed in building the institutional identity of the hospital, since it transformed healthcare practices, producing movements that led it to be recognized in a national and international setting. The many individual, collective, and institutional identities are fomented by movements of construction that made up this unique model of care, allowing for the creation of a culture of valuing the NP as a working method in the hospital, meaning that the NP gave an identity to nursing in the hospital.

To this end, the many movements sutured between COPE, SEDE, and Nursing School, which are represented by the subjects that constitute the segments of the formation Prism, made it possible for nurses to construct their many professional identities, acquired with time. The NP became a marker to (re)define the nursing professional identity and was molded by the technical and scientific knowledge about the profession.

The NP became the philosophy of work of the hospital. There was an institutional willingness on the part of the nurses, especially among the management and Nursing School professors. The NP became a scientific way to act that was recognized by nurses, since the results revealed that nurses no longer see themselves without using the NP.

The main limitation of this study is the inclusion of only one setting, albeit an internationally recognized one. Other studies about the theme are suggested, considering the "formation prism" in other settings of international recognition and accreditation.

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  Blumer HA. A sociedade concebida como uma interação simbólica. In: Birnbaum P, Chazel F. Teoria sociológica. São Paulo: Hucitec, EDUSP; 1977. p. 36-40.

• Funding:

  Coordination for Higher Education Personnel Improvement (CAPES). Edital Nº 01/2013 DINTER UFRGS/UDESC.

Publication Dates

• Publication in this collection
  25 Nov 2019
• Date of issue
  2020

History

• Received
  08 May 2019
• Accepted
  10 July 2019