Reflection on the organization of Nursing work in the milk bank: shared and multidisciplinary care

Abstract

Objective

reflect on the organization of nursing work in the Human Milk Bank based on shared care actions with the multi-professional team.

Method

this is a theoretical-reflexive study based on Pierre Bourdieu's concepts of field and habitus in order to understand the modus operandi of its agents in the field and subfield of health.

Results

it was evidenced that the Nursing Process is part of the health care procedures in the different performance spaces, however, it is important to point out that there is an interdependence of the services provided. The integrality of the proposal and the organization of the work of the HMB are perceived from a multi-professional team. For nursing, the habitus is set from the initial training of its professionals, since there is recognition of the knowledge of the field and that the actions are based on theoretical and scientific knowledge.

Conclusion and implications for practice

shared care is recognized as an important factor in equalizing care and other services performed in the field of HMB. By mobilizing the concepts of Pierre Bourdieu, it is possible to infer the habitus in the modes of care, considering also the specific habitus built throughout the history of Nursing.

Keywords:
Breastfeeding; Delivery of health care; Human milk bank; Multi-professional team; Nursing process

Resumo

Objetivo

refletir sobre a organização do trabalho de Enfermagem no Banco de Leite Humano a partir das ações de cuidado compartilhado com a equipe multiprofissional.

Método

trata-se de um estudo teórico-reflexivo com base nos conceitos de campo e habitus de Pierre Bourdieu de modo a compreender o modus operandi dos seus agentes no campo e no subcampo da saúde.

Resultados

evidenciou-se que o Processo de Enfermagem faz parte dos procedimentos de cuidado em saúde nos diferentes espaços de atuação, todavia, é importante pontuar que há uma interdependência dos serviços prestados. Percebem-se a integralidade da proposta e a organização do trabalho do BLH a partir de uma equipe multiprofissional. Para a Enfermagem, o habitus está posto desde a formação inicial dos seus profissionais, pois há o reconhecimento do saber próprio do campo e que as ações são pautadas em conhecimentos teórico-científicos.

Conclusão e implicações para a prática

o cuidado compartilhado é reconhecido como importante fator de equalização da assistência e demais serviços realizados no campo do BLH. Ao mobilizar os conceitos de Pierre Bourdieu, é possível inferir o habitus nos modos de cuidar, considerando-se, ainda, aquele específico construído ao longo da história da Enfermagem.

Palavras-chave:
Aleitamento materno; Assistência à saúde; Banco de leite humano; Equipe multiprofissional; Processo de enfermagem

Resumen

Objetivo

reflexionar sobre la organización del trabajo de Enfermería en el Banco de Leche Materna, a partir de acciones de cuidado compartido con el equipo multiprofesional.

Método

es un estudio teórico-reflexivo basado en los conceptos de campo y habitus de Pierre Bourdieu, con el fin de comprender el modus operandi de sus agentes en el campo y en el subcampo de la salud.

Resultados

mostraron que el Proceso de Enfermería es parte de los procedimientos de atención en salud en diferentes áreas de actuación, sin embargo, es importante señalar que existe una interdependencia de los servicios brindados. La integridad de la propuesta y la organización del trabajo del BLM se puede ver desde un equipo multiprofesional. Para la Enfermería, el habitus se establece a partir de la formación inicial de sus profesionales, pues se reconoce el conocimiento del campo y que las acciones se basan en conocimientos teórico-científicos.

Conclusión e implicaciones para la práctica

la atención compartida se reconoce como un factor importante en la igualación de la atención y otros servicios realizados en el campo del BLM. Mediante la movilización de los conceptos de Pierre Bourdieu, es posible inferir el habitus en los caminos de cuidado, teniendo en cuenta incluso el específico construido a lo largo de la historia de la Enfermería.

Palabras clave:
Amamantamiento; Prestación de atención de salud; Banco de leche materna; Equipo multiprofesional; Proceso de enfermería

INTRODUCTION

The presence of Nursing in the Human Milk Bank (HMB) brings an assistance practice in a field of action to promote, protect, and support breastfeeding, a care that goes beyond this space, often reaching other sectors of the maternity ward and hospital, and even the homes of the families that are assisted there. This space requires that the health professionals who work there are grounded in research, in technical and scientific knowledge, understanding that these dimensions are interdependent and interrelated with empathetic care and aiming at human responses in all their dimensions¹.

In Brazil, the HMB develops their actions in a network, a model that is configured in the development of strategic actions of the National Breastfeeding Policy, thus being called the Brazilian Network of Human Milk Banks (HMBn-BR)^a. All 224 HMB in the national territory are part of an integrated management system, i.e., integrated together with the network, which allows them to organize and work in unity with common objectives. The HMB are considered breastfeeding support centers that work towards the Promotion, Protection, and Support (PPS) of breastfeeding, besides being a multi-professional work space².

In a previous study on the knowledge and wisdom of nurses at the HMB about nursing care for the organization of the work process³, The relevance of nursing care in the NICUs of the State of Espírito Santo was evidenced, in which the Nursing Process (NP) can be considered an organizer of the work in this space. The importance of systematizing nursing care was revealed, imbricated in the observation of the knowledge contained in the Technical Manual and Standards of the HMB, and also the nursing diagnosis, since it expresses the nurses' ability to use clinical judgment to understand the data collected, enabling nursing interventions to achieve positive health outcomes of the binomial on the different fronts of professional action in the HMB.

When it comes to the actions at the HMB, the work of Nursing in direct care with the PPS, initially met the needs of clinical management and its guidelines, expanding its scope of action in health education, in the assessment and nursing diagnoses, in the planning of collective actions and in the extension of the territory of the HMB. Thus, the sustainability of shared care is made possible from the donation of milk present in the various settings of the HMB, in the collection route of Milked Human Milk (MHM), where there is Nursing consultation only in non-hospital spaces^b, in teaching the technique of collecting MHM at home and the correct storage^4,5.

Shared care corresponds to a model of care recommended by the World Health Organization (WHO) and the United Nations Children's Fund (UNICEF) that strengthens the affective bond, encourages breastfeeding, and involves parents in caring for their newborn. Thus, it is considered an extremely important practice in the PPS to breastfeed⁶.

Shared care needs to be aligned with care practices supported by valid theoretical and scientific knowledge, following a model that encourages contact and joint permanence of the mother and the baby during the entire hospitalization under the care of the Nursing team. This practice provides integral assistance and the full attention of health professionals to the binomial performed by a multi-professional team in which nurses act, in an integrated way, in the actions of care and guidance to the families.

The work developed in the space of the HMB requires this sharing of care actions, in view of the optimization of benefits, both for the patient and for Nursing itself, contributing to the effective work developed by the team that operates in this specialized space, bringing reliability and security in the process instituted by observing the standards contained in the technical manual, as well as the execution of the NP.

The proposal of teamwork can be considered a strategy to face the intense specialization process in the health area. However, it does not guarantee, by itself, the desired articulation and integration of actions and knowledge. The author says that “this process tends to vertically deepen knowledge and intervention in individualized aspects of health needs”^7:103.

In the guidelines concerning the National Primary Care Policy⁸, care must be centered on the person and built with them. The forms of collectivity are relevant elements for the effectiveness of care, often conditioning or determining factors in people's lives. Care coordination requires articulation through shared management of comprehensive care. Therefore, it is relevant that the work be interdisciplinary and team work, integrating technical areas and professionals from different backgrounds. Thus, it is advocated that the same perspective be adopted in the HMB, a concept of teamwork from the perspective of integration of specialized work.

The theme of this study corresponds to the actions of shared care in a multiprofessional team of a HMB. In the practices of breastfeeding promotion, protection, and support in this specialized space, the study focuses on care, how it is performed, and how the NP is mobilized in this field. The axis of care and, consequently, the organization of the nurse's professional work based on the NP are investigated, that is, how data collection, the use of the nursing diagnosis, the planning of these actions, the implementation of these actions, and their evaluation are imbricated within a multi-professional team.

From the perception, from the approach to the field through research^9-11 that there are different ways to mobilize care actions, the autonomous actions exercised by the nurse in professional practice and the process of interlocution in the multiprofessional team are questioned. Because of the organization of the work at the HMB, its agents share knowledge, spaces, and obligations in the process of caring for the users seen in this specialized space and related sectors (maternity ward, emergency room, neonatology, and others).

There is a work dynamic with Nursing diagnoses, care actions, implementation of the NP, that is, there is a habitus cultivated in the space of the HMB. These actions in this field reveal the dispute for the symbolic and cultural capital of this collective and, in this case, there are ways of thinking, acting, and operationalizing this set of actions of the NP. Thus, it is understood that “this space is a space of struggles, an arena where competition is at stake among the agents who occupy the various positions. The objective of these struggles lies in the appropriation of the specific capital of the field [...] and/or the redefinition of this capital”^12:65.

The presence or performance of nurses raises reflections on the interweaving of actions and the regulations that exist both for the professional practice and for the services performed at the HMBs. It is understood that the NP, in some way, reaches all those involved in the sharing of care actions, even though it is a private action of Nursing, since it corresponds to a multi-professional field of action and reveals its habitus of being a nursing practices¹³.

Thus, the study aimed to reflect on the organization of nursing work at the HMB based on care actions shared with the multi-professional team.

METHOD

This is a theoretical reflection based on the concepts of field and habitus proposed by Pierre Bourdieu. In this way, the investigative process seeks to understand the ordinary social practices that accommodate the everyday life and create the symbolic structures that establish the order of things, the power relations and the habitus. It is argued that the dialogue with the theoretical and methodological assumptions of Pierre Bourdieu allows us to go through several areas of knowledge in order to understand the structures that form society¹⁴.

RESULTS AND DISCUSSION

Dialogues with Pierre Bourdieu: the field and the habitus

Sociologist Pierre Bourdieu (1930-2002) is considered one of today's great thinkers. Among the various concepts elaborated and established throughout his trajectory, the notions of habitus and field make it possible to recognize the conditioning factors of nurses in HMB and their consequences for public policies on breastfeeding care. Faced with a vast production in the field of Sociology, Bourdieu sought to maintain a posture of convergence of discourses, but also to imprint his own marks and develop his own concepts for his research in the production of knowledge.

Bourdieu defined his concept of field, which occupies a central place in his Sociology, in dialogue with different theoretical universes, in particular those of Durkheim and Weber¹². For the sociologist,^15:119 “fields present themselves to synchronic apprehension as structured spaces of positions (or ranks) whose properties depend on their position in those spaces and which can be analyzed independently of the characteristics of their occupants.” He further argued that there are some general laws of fields: they are different from each other; they have a functioning that is particular; they have specific properties; struggle is present in any field; “A field is defined by defining 'stakes at stake' and to the fields' own interests”^15:120.

The characterization of the HMB dialogues with the concept proposed by Bourdieu¹³ in which the social is characterized as microcosms or spaces of objective relations, which have their own logic marked by struggles in which the field is both a structure that constrains the agents involved in it and a game in dispute, since “Bourdieu understands the field as a place of competitive struggles that aim to preserve or transform the relations of forces present there”^16:231. In this sense, the field has a history and a memory that need to be recovered in order to understand the actions of its agents.

As can be seen, this is not a continuous line of history, but a process that involves the construction of strategies to face difficulties and overcome barriers, seeking the quality of service and the higher goal, which is to save lives, especially when the infant mortality rates have shown retreat with the new practices of handling the MHM. These transformations were also experienced in the different professions incorporated into the dynamics of work of the HMB, in the specialization of services and in the advancement of science.

Thus, Nursing has built a theoretical and practical body that is the basis for its care actions. The NP is part of the health care procedures in the different spaces of performance, however, it is important to point out that there is an interdependence between the services provided. The integrality of the proposal and the organization of the work of the HMB are perceived from a multidisciplinary team, adapting to the reality and contexts of each region, with: “doctors, nutritionists, nurses, pharmacists, food engineers, biologists, biomedical, veterinarians, psychologists, social workers, speech therapists, occupational therapists, assistants and technicians [...], among other professionals^1:23”.

Thus, the agents that act in the field share common interests and collaborate in the maintenance of the field. The result is, then, an objective complicity that tensions the antagonisms about what does or does not justify the struggle^15,17. In Pierre Bourdieu's theory of fields, a field is a microcosm included in the macrocosm constituted by the social space and each field has specific rules of the game and challenges^12:65..

As noted, “Bourdieu seeks to overcome the opposition between subjectivism and objectivism through a supplementary, vertical relationship that mediates between the system of objective positions and subjective dispositions of individuals and collectivities”^18:35. In this sense, habitus is alluded to as a field between the imperceptible system of structural relations, which adapt actions and institutions relationally by and in the visible actions of these actors. “Fields are not fixed structures. They are products of the history of their constitutive positions and the dispositions they privilege”^19:129.

For Pierre Bourdieu, “habitus are principles that generate distinctive and distinctive practices”^13:22. In this way, habitus is a set of social knowledge and dispositions acquired and incorporated over time that constitutes an identity. One can, then, understand habitus as the result of interactions, perceptible or not, that define the individual's way of being in a given society.

For Nursing, this habitus is established since the initial training of its professionals. There is recognition of the field's own knowledge and that actions should be based on theoretical and scientific knowledge, that is, a set of social dispositions acquired and incorporated into their identity. In the Nursing oath itself²⁰, has the commitment to dedicate himself to the service of humanity, to exercise his functions with conscience and respect for the dignity and rights of the human being, not to practice acts that put at risk the physical or psychic integrity of the human being, and to practice Nursing with the health team, obeying the precepts of ethics, legality and morality.

Therefore, it is an Aristotelian philosophical notion that was rescued by Bourdieu in the 1960s “to forge a dispositional theory of action capable of reintroducing into structuralism anthropology the inventive capacity of agents”^21:213. In Aristotle's philosophy, habitus means “an acquired and firmly established state of moral character that guides our feelings and desires in a situation and, as such, our conduct” ^21:5.

Habitus is a mediating notion that helps to break through the common sense duality between individual and society by capturing “the interiorization of exteriority and the exteriorization of interiority”^22:47, that is, the way society becomes deposited in people in the form of durable dispositions or trained capacities and structured propensities to think, feel, and act in particular ways, which then guide them in their creative responses to the constraints and demands of their existing social environment.

According to the sociologist, the philosophy of action condensed in some fundamental concepts has, as its central point, the relationship between the objective structures of the social fields and the structures embodied in the habitus^13:10. Its function is to account for the unity of style that binds the practices and goods of a singular agent or a class of agents. It is a generating and unifying principle that re-signifies the intrinsic and relational characteristics of a position in a univocal lifestyle, that is, in a univocal set of choices of people, goods, and practices. For the author, “habitus are generating principles of distinctive and distinctive practices. [...] establishes the differences between what is good and bad, between good and evil [...]”, maintaining their singularities^13:22.

Bourdieu's concept of habitus is extremely important for understanding the practices assimilated as legitimate and illegitimate in a given society and at a given historical time. By choosing this concept to dialogue with the practices of nurses at the HMB, especially regarding shared care, it is important to point out that some misconceptions may occur that indicate the agent as directly responsible for the work conditions in this specialized space.

In this sense, Bourdieu cited that the notion of habitus can “fail” and clarified that the habitus is never a replica of a single social structure; it is not necessarily coherent and unified; it is no less prepared to analyze crisis and change than it is to analyze cohesion and perpetuation, and it is not a self-sufficient mechanism for generating action²¹. According to this author²¹, “[...] the summoning and employment of the cognitive and motivational schemas that make up the habitus is accessible to methodical observation” ^21:216.

The author's different works allow us to identify the fundamentals of this concept, namely: a field is a microcosm included in the macrocosm built by the global social space, which has specific rules of the game and challenges irreducible to the rules of the game and challenges of other fields. It is constituted with a “system” or a structured “space” of positions occupied by the different agents of the field. In this case, it corresponds to a space of struggles that lies in the appropriation of unequally distributed capital within the field. And to each field corresponds a habitus (system of incorporated dispositions) and every field has a relative autonomy¹².

Thus, the HMB can be considered a field with all its constituent elements. It is evident that the NP, private of nurses, coexists with the care actions shared by the multiprofessional team. The NP can collaborate to equalize the differences and help nurses to appropriate the symbolic and cultural capitals present in this field, expanding their possibilities to qualify the attention and care to the public assisted, the breastfeeding practices, and the nursing care at the HMB.

It is understood that the NP, even though it is an action exercised by its professionals, reverberates in the work done by the team. In this sense, in the execution of their legal functions, the nurse mobilizes theoretical and scientific knowledge and has autonomy in conducting the process of care for users at the HMB, in the diagnosis, and in the nursing prescription. However, these users are also served by other professionals of the HMB team according to the needs of each case. When it comes to the MHM, there is a chain of actions that invites its execution to include a collaborative and cooperative work until the final delivery of its product, adequate and fit for consumption. It is also noticed that the collection of data for the purposes of care and monitoring of users is an action that allows the conduct and decision-making with the HMB team.

The work process of a multi-professional team is organized based on the care actions shared by Nursing at the HMB and linked to a hospital/maternity with maternal and child care. It is inferred that there is an organization and a division of labor. Each professional knows what their functions are and performs them either routinely, i.e., there is a work routine to fulfill, or by demand. A managerial structure of care is perceived in which the patient, upon entering the hospital or the HMB, has a team that seeks an answer to that health issue until a definitive solution or necessary referrals are found. Teamwork becomes clear when communication and accessibility are effective, or when the ways of triggering the necessary care for the binomial are incorporated as a habitus in this field.

Thus, it is possible to maintain this dialogue between the social conditions that govern the use of NP in the spaces where nurses work, according to COFEN Resolution 358/2009, and the actions that make up the habitus of these subjects. This perspective is corroborated by Pontes²³ by using Pierre Bourdieu's theoretical referential^13,17,19,22 to analyze the actions and participation of Nursing in the consolidation of the space of the HMB in a public university of Espírito Santo.

Therefore, Nursing actions are structured through the historical process that structures the habitus present in the field. Care is considered one of the main actions of nursing^24,25. It has strengthened the construction of knowledge in the area, being the essence of the profession, the basis of nursing teaching and practice. It is perceived that there are changes of habitus and field with the integralization of care sharing among health professionals²⁶.

A habitus incorporated by the HMB team is the training for service as a constant need. This movement requires the articulation of the team to foster this process of continuing education. In this case, each professional can collaborate with their specialty and experience in the HMB. Both Nursing is invited to organize and teach courses and training, and the other professionals perform this function of organizing moments of knowledge exchange in the team. The more trained and integrated the team is, the better the articulation of the service and the attention to the care of the binomial in the HMB and other sectors.

CONCLUSION AND IMPLICATIONS FOR PRACTICE

Shared care is recognized as an important factor in equalizing the assistance and other services performed at the HMB. There is a partnership and complicity in the actions developed in which each professional knows exactly what their role is, their responsibility, and at what moment or demand their presence is necessary. The clinical evaluation of each case requires the ethical and professional awareness of the agents to offer the best possible treatment at the HMB. There is the habitus of work distribution, which follows a flow incorporated in the dynamics of teamwork. The strategy is to keep communication open, and also to maintain a predisposition to attend to events that arise in the routine or emergencies that arrive at the HMB.

By using the concepts of Pierre Bourdieu, referring them to shared care; it is possible to infer the habitus in the modes of care, considering, still, the specific one built throughout the history of Nursing. In this case, the NP can be taken as a “generating and unifying principle of the set of practices and ideologies characteristic of a group of agents”^27:191, that is, the Nursing and its habitus in the field of HMB.

This is the great challenge posed to the shared care at the HMB: to converge care actions while respecting and valuing the knowledge and expertise of each professional that makes up the team; to mobilize knowledge in favor of offering a quality public service committed to the promotion, protection, and support of breastfeeding; to invest in continued training to optimize care actions for the binomial in the different areas in which the HMB team operates, and to continue to collaborate with the reduction of infant mortality by offering human milk, with control and quality in the process carried out by many hands.

The limitation of this study is the difficulty in operating with other concepts of Pierre Bourdieu, especially the notion of cultural capital and symbolic capital, which are closely related to the field and the habitus. New reflections are required to understand the nuances of the scientific field, the social space, and the domination that cross the field of public health policies, especially regarding breastfeeding and the HMB.

• a
  The Brazilian Network of Human Milk Banks (HMBn-BR) is a strategic action of the National Breastfeeding Policy and, besides collecting, processing, and distributing human milk to premature and low-birth-weight babies, the Human Milk Banks (HMB) provide breastfeeding guidance and support. [...] The Brazilian model is recognized worldwide for its unprecedented technological development that combines low cost and high quality, and distributes human milk according to the specific needs of each baby, increasing the effectiveness of the initiative to reduce neonatal mortality (Source: https://rblh.fiocruz.br/quem-somos).
• b
  Nursing Consultation supported by Article 1, paragraph 2 of COFEN Resolution No. 358/2009.

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Edited by

ASSOCIATED EDITOR

SCIENTIFIC EDITOR

Publication Dates

• Publication in this collection
  10 Dec 2021
• Date of issue
  2022

History

• Received
  26 May 2021
• Accepted
  31 Oct 2021