Symbolic effects capitalized by nurses from the National Institute of Cancer in Brazil ( 1980 – 1990 )

Objective: to describe the strategies of nurses in the National Institute of Cancer to disseminate its scientifi c capital and discuss the symbolic effects capitalized in the fi eld of oncology in the 1980s. Method: historical social studies, with primary sources consisting of written documents and oral reports, and as secondary sources, articles and books on the subject, based on the French sociologist Pierre Bourdieu’s concepts of scientifi c capital and habitus. Results: it revealed the effective performance of nurses in this Institute on policies of cancer prevention and control and strategies used in the teaching of oncology nursing at the undergraduate level. In conclusion, nursing stands out in this context, through the dissemination of its scientifi c knowledge, as a participant in the construction of a scientifi c fi eld of oncology nursing in Brazil, highlighting the occupation of important social areas.


INTRODUCTION
In the 1980s in Brazil, the Ministry of Health intensified its policies in the war on cancer in accordance to the guidelines defined in the Alma-Ata Conference, which supported the development of basic health care actions.At the time, cancer was the second main cause of death in Brazil and the disease mortality coefficient remained practically the same in the period, despite technological advances and the inclusion of modern resources for diagnostic and treatment (1) .
In Brazil, still in the 1980s, chronic-degenerative diseases, including cancer, had specifically curative actions that were performed in clinics or specialized hospitals, which were equipped with advanced and high-priced technology for the treatment of patients with established diseases, which were frequently in an advanced states or had already been treated and relapsed.The problem was intensified by the lack of comprehensive programs for continuing education with the goal of capacitating professionals to diagnose and treat diseases in early stages (2) .
In this period, there was the creation of a co-management process among the Ministry of Health, the Ministry of Social Security and the National Institute of Cancer (INCA) -an official health care institution specifically responsible for the control of cancer.Under these circumstances, the INCA started receiving human and financial resources destined for activities of management, research, education and care.The alluded measures gave higher visibility for the institute as a center of excellence and as a national reference in the war on cancer.Along with this expansion in activities, a scenario of development of the nurse's knowledge through participation in care and education processes was envisioned (3) .
The acquired knowledge represented an incorporation of symbolic capital that contributed for the recognition of INCA nurses in the field of oncology nursing in Brazil, which was translated into the creation of courses, standardization of procedures, rules and routines and the dissemination of work in scientific spaces, which gathered nursing professionals interested in cancer care and prevention.
In the scientific scenario, in addition to disseminating and incorporating specialized knowledge, the INCA nurses established a national and international network of relations with their peers, which offered them significant social capital and generated recognition for those nurses' achievements beyond INCA's physical limits.Under this perspective, this study had the objective of describing the INCA nurses' strategies to disseminate their scientific capital and the discussion of the symbolic effects capitalized in the oncology field in the 1980s.

METHOD
This is a historical social study, with the 1980s as a time frame, because that was the INCA co-management period.The primary written sources were articles; books; reports; commemorative books and newsletters from the National Campaign against Cancer (CNCC) and from the INCA Center of Studies, which belonged to the library of the INCA.
Reports from five nurses were used as primary oral sources, with inclusion criteria that considered their participation in the study's time frame, their strategic and important positions in the INCA structure and their participation in the education field, effectively participating in education processes and institutional committees.The deponents were identified with the letter D and a sequential number.A script of open-ended questions guided the semi-structured interviews, which were conducted from March 2010 to March 2011.This made it possible to elaborate on the theme without losing the original query.
The secondary sources were Brazilian and nursing history books, national nursing journals, theses, dissertations and articles related to oncology nursing; books and theses related to social, education and health care politics in the field of Brazilian oncology.We performed searches in the annals of conferences and national journals produced in the 1980s whose themes were linked to oncology nursing or to the oncology field.
As taught by the historical method, this study had three essential phases: data gathering; critical analysis of data and conclusions.Thus, after the phase of gathering and cataloguing document sources, we determined the quality and relevance of information contained in the sources for the proposed historiographical work, which enabled the construction of the study's categories.
In the data analysis phase, the scenario of political and social facts was taken into account for the interpretation of historical RESUMEN Objetivo: describir las estrategias de los enfermeros en el Instituto Nacional de Câncer (Instituto Nacional del Cáncer) para difundir su capital científico y discutir los efectos simbólicos capitalizados en el campo de la oncología en la década de 1980.Método: estudio sociohistórico, cuyas fuentes primarias consistieron en documentos escritos y testimonios orales, y las secundarias, de artículos y libros sobre el tema, en base a los conceptos de capital científico y habitus del sociólogo francés Pierre Bourdieu.Resultados: se presentó el desempeño eficaz de los enfermeros en este Instituto en las políticas de prevención y control del cáncer y de las estrategias utilizadas en la enseñanza de la enfermería oncológica a nivel de graduación.Se concluyó que la enfermería se destaca, en este contexto, a través de la difusión de su capital científico, como participante en la construcción de un campo científico de la enfermería oncológica en Brasil, destacando la ocupación de algunos espacios sociales importantes.Palabras clave: Enfermería; Historia de la Enfermería, Enfermería Oncológica.data, enabling historical exhibition from the selected documents.In order to perform analysis, French sociologist Pierre Bourdieu's (4) concepts of scientific capital and habitus were used.
The concept of capital, borrowed from economics, has a nodal role for Pierre Bourdieu's thinking.Pure scientific capital is acquired, mainly, by contributing to the progress of science.Scientific capital, which is this study's focus, is acquired, essentially, by specific strategies such as participation in boards, meetings, commissions and scientific events, among others (4) .
Therefore, the concept of scientific capital guided the comprehension that its accumulation demanded a large personal investment from the INCA nurses, since all accumulation of capital presupposes an assimilation work that costs time, which must be personally invested by the investor (4) .Because of its personal nature, work for capital acquisition is work from the subject towards themselves.In other words, it is a property that becomes part of the person, a habitus.Therefore, the habitus that operates as generative grammar of practices that conform to objective structures from which it is a product was useful for the understanding of the strategies employed by the INCA nurses to accumulate and invest the capital they held, aiming at the possibility of obtaining good yields (5) .
The research was approved by the Research Ethics Committee of INCA under protocol 16/10 on February 22, 2010, observing the legal and ethical recommendations from the National Health Care Council through Resolution 196/96.All interviews were conducted after the subjects signed an informed consent form.
In the data analysis process, the following themes were identified: dissemination of scientific capital in the field of oncology nursing, the nurse's role in the prevention and control of cancer, strategies for education in oncology nursing and organization of an Oncology Nursing Society.

RESULTS
The primary written sources listed above and the reports from the five nurses who participated in the research enabled the construction of two categories, described as follows.

The nurses' roles in policies of cancer prevention and control
In March 1987, the Oncology Program (PRO-ONCO) was established in conjunction with the Regional Coordinating Body of the National Campaign against Cancer (CNCC), with management and executive structures.It had the goal of coordinating actions for cancer control through two basic lines of work: information regarding cancer and education, aiming for a better use of care resources to improve prevention and treatment and stimulating measures of promotion and research.
The PRO-ONCO went back to the basic aims that justified the creation of the CNCC and that, because of the lack of an executive structure, was limited to the national level.Its mission was to develop, disseminate and evaluate the technical bases for cancer control actions.The program management was performed by oncologist doctor Magda Rezende and, afterwards, by doctor Ernani Saltz, who cooperated with a technical team, two INCA nurses, Mariangela Freitas Lavor and Anna Maria Carvalho Schneider (6) .
Regarding the goals of the National Department of Chronic Degenerative Diseases / National Secretariat of Special Programs (DNDCD/SNPES) and of the CNCC, the priorities were organized according to the following types of cancer: cervix uteri, breast, skin and mouth.The characteristics that were taken into account during planning were epidemiologic factors, shapes and types that could be prevented or detected early, work experience of the service network and cost-benefit, as reported by one of the research's participants: In those days, we did not even talk about protocols, and the Pro-ONCO started that proposal.It is not by accident that all prevention projects, health promotion, started with smoking.We started working the issue of prevalent cancers that could be detected early, more so than prevented.The issue of cervical and breast cancer records, which we did not perform.When it started, the first thing we had was the National Registry of Tumor Pathology.[…] and after that, there was the population-based registry, the education project that was the Instructor-Care Integration Project in the Cancer Field (PIDAAC) and the embryo of the Palliative Care project.It all happened at that time.(D2) In 1987, with the creation of the Cervical Cancer Prevention Project in Campos do Goytacazes, a municipality in the Brazilian state of Rio de Janeiro, an INCA nurse was invited, who at the time was performing the hospital's leading role.This nurse collaborated with a multi-professional team, external to the hospital scenario, which showed a new perspective for nursing performance in the oncology field, and the recognition of its scientific capital in the field of cancer control and prevention.In that regard, the information contained in the following reports is eye opening:

I think that when you take what you do seriously and with quality, that which you are offering to do, with severity, with commitment, you end up being accepted into the group. Even if I was not a part of this group before, or if they were not expecting a nurse in the group, I think that it happened little by little. […] I kept participating, I practically ended up as the nursing reference […], because I was from PRO-ONCO and everything that PRO-ONCO needed in relation to nursing, I was the one they looked for. I was the nurse over there. (D2)
The following report makes it clear that the occupation of that space resulted from strategies for the recognition of the nurses' performance capacity in the government policies for cancer control: Afterwards, care policies by the PRO-ONCO started, through campaigns, always involving nurses.I believe that was where we showed we also had strength for it.[…] So many things were achieved and in some political way.(D4) In parallel, there were discussions on the international level that promoted the need for actions of cancer prevention and health promotion (7) .Thus, the INCA nurses' performance met the guidelines proposed at national and international levels.

Strategies for Oncology Nursing Education in the undergraduate course
In this period, the Ministry of Culture and Education (MEC) created the Instructor-Care Integration Program (PIDA), defining it in 1981 as (8) : A process of increasing articulation between educational institutions and health care services that are ready for the production of knowledge and the formation of human resources, in a determined context of health care practice and education […].
As a strategy for teaching and education, the PIDA was adequate, considering the goals they had.However, in reality, there was no effective integration among the sectors responsible for the education and utilization of health professionals.
In this context, in February 1987, the Subprogram for Education in Oncology, under the coordination of oncologist doctor Maria Inez Pordeus Gadelha, was created.It had the aim of producing the educational bases for actions of cancer prevention and control, to be developed by the CNCC's PRO-ONCO, through the PIDAAC.
Inez [doctor Maria Inez Pordeus Gadelha] was responsible for the Medicine PIDAAC.And she always thought nothing worked without nursing.That was when we started thinking about a project for nursing.We conducted a study on these seminars about how oncology was presented in undergraduate courses, which was practically nonexistent.And we started organizing the PIDAAC in the nursing field.(D2) In 1987, the I Brazilian Symposium about Oncology Education, under coordination of the DNDCD/MS, happened in Brasília (Federal District).In that opportunity, the themes were Oncology Education, Medicine, Nursing and Odontology graduations.The event had the aim of discussing: the objectives and goals of oncology education in undergraduate education; the levels of information and competence; organization and teaching methodology with multidisciplinary focus; evaluation of training results and discussion of didactic materials.That is confirmed by the report of an event participant: We began with seminars, the content proposal.The focus was on prevention, promotion and early diagnosis.There never was the idea of teaching content for specialists.For that, there were specializations, residency.For the undergraduate course, that was all that could be done in non-specialized units.And the project began to take off.[ For this event, a study group for the nursing field was composed, which found that care practice nurses did not have acceptable qualifications to administer oncology care.According to nurses who participated in it, who were subjects of the mentioned study, the contents were specific and were spread out among many disciplines in the undergraduate curriculums.
In order to fill in these gaps and, with the aim of preparing the nurse to perform cancer control actions, the study group proposed the following actions: emphasis on primary, secondary and tertiary prevention content; Coordination actions for oncology education, to be conducted by the Ministry of Health, with participation of the MEC and the MPAS, allowing for continuity in the discussions and extension through continuing education, residency, specialization and community education; participation of teaching and caregiving nurses involved in this symposium, in the building of a Group of Clinic Interest in Oncology through the ABEn, at local, regional and national levels; reinforcement of oncology information by the MS through reports for schools and care institutions; reformulation of the minimal curriculum for undergraduate courses, adopting as guiding axes the epidemiologic focus and teaching-service integration; creation of a Subprogram for Oncology Education, through the SNPES and the Oncology Education Program (CNCC), with the goal of defining undergraduate competencies and the creation of mechanisms for technical, pedagogical and research education by the Ministries of Health and Education through exchanges with national and international institutions.The report transcribed below shows the event's importance: We wanted oncology to be better known not only in residency, but also in undergraduate courses.It was not mandatory.First, it started with medicine, but when we conducted this research, it was medicine, pharmacy and nursing.(D4) In this line of thought, guidelines were defined for the inclusion of oncology in the curriculums of the above-mentioned courses, keeping in mind the compatibility between the professionals' education and the needs of the population and of health care services (9) .It is relevant to mention that, in 1988, the only residency in oncology nursing in Brazil was offered by the INCA.
After participating in the I Brazilian Symposium about Oncology Education and in the research regarding the situation of oncology teaching in nursing undergraduate courses, the study group of the nursing field proposed the inclusion of a specific discipline that addressed prevention, early detection and aspects related to treatment and rehabilitation in cancer control.
With this measure, there was the definition of the strategies for dissemination of technical and scientific knowledge of oncology in the field of nursing, which was produced by the nurses working in oncology institutions in Brazil, particularly in the INCA.compatible with the scientific field, as a universe in which the agents are inserted -in this study, represented by the INCA nurses -and the institutions that produce, reproduce or disseminate science.This is an advancement that represents the incorporation of a symbolic capital that gave them prestige in the field of oncology and nursing (4) .
With the disclosure of their care practice and accumulated scientific capital, the INCA nurses left marks in the field of oncology nursing when they took part in specialized events.It should be noted that scientific work has the aim of establishing an adequate knowledge not only of the space of the objective relations among different constitutive positions of the field, but also of the necessary established relations, through the mediation of their occupants' habitus, among the occupied positions in this space and the points of view regarding this space (5) .
In these scientific spaces, in addition to disseminating and gathering knowledge of the field, the INCA nurses established a network of national relations with peers, which gave them a significant social capital, since the existence of a network of relations is product of a work of establishment and maintenance that is needed to produce and reproduce enduring and useful relations, which are able to result in material or symbolic profits (11) .
On the other hand, the technical and scientific neglect for oncology in courses limited other nurses' ability to take on defined roles in cancer control programs.It is worth noting that their work in collective health care, in communities, gave them responsibility for a large part of the successes of control and prevention actions (12) .
The requirement for the nurse's ability to prevent and detect cancer early, especially because of the interpersonal relationship with the clients, demanded guidance and education, as well as gathering data and information about possible risks and stimulating prevention measures (13) .Such commitments were foreseen in the terms of the law 7498, of July 25, 1986, which addresses nursing work, whose article 8 th , subparagraph 2, line I, establishes as an obligation for the nurse, as part of the health care team, to participate in programs and activities of comprehensive care for individual health and in specific groups, particularly those that are priorities and of high risk (14) .
There was an increase in the movement of INCA nurses in external participations, such as for nurse Silvia Beatriz de Assis, who cooperated in the creation of an evaluation instrument for oncology hospitals, made possible by the Ministry of Health, through the National Division of Health Care Services Organization (DNOSS) and the National Secretariat for Basic Health Care Actions (SNABS) (15) .After becoming references in the field of oncology, the nurses bring to light the recognition of their symbolic capital as spokespeople of the authorized discourse.The authorized spokesperson can act with words on other agents, and through his or her work, act on things themselves, as their speech concentrates the symbolic capital accumulated by the group that gave them mandate, of which he is the agent (16) .
From that, there is the emanation of conditions of possibilities for the nurses' work in oncology.The correspondence between positions and choice of positions is established through In the same year, there was the I Brazilian Oncology Nursing Congress, in Florianópolis, where themes related to oncology education were discussed.There was a recommendation to implement curriculum content for oncology nursing in undergraduate courses, reinforcing the previous proposal from the nursing group of the Oncology Education Program from the DNDCD.
The Implementation Project for Oncology Teaching in Nursing Undergraduate Courses began in 1988, through the PRO-ONCO, after the formalization of the National Commission for Oncology Teaching in Nursing Undergraduate Courses, which was composed of nursing professors and caregivers who came from the five Brazilian macroregions.The commission first met in December 1987, when it discussed the guidelines for oncology nursing teaching and defined the required skills for nurses in the field.
In the same year, the Implementation Project for Oncology Teaching in Nursing Undergraduate Courses was implemented by the Coordinating Body for Cancer Control Programs of the INCA and by the Nursing Department of the Federal University of São Paulo (UNIFESP), through a Technical Scientific Cooperation Agreement, in which there was an arrangement to continuously monitor and evaluate the activities and phases to be performed in order to make the process possible.The alliance with the nursing department of the UNIFESP enabled the integration of different agents and institutions in a collective project, through systematic organization of information dissemination through national seminars, as remembered by one of the speakers: The INCA nurses began an important thing, which was the first seminar executed by the PIDAAC, with the UNIFESP.

DISCUSSION
The implementation model for cancer control actions in the 1980s was a reflection on the health care field of the Brazilian political movement.It coincided with the year of creation of the Unified and Decentralized Health Care System (SUDS), which formalized the decentralization of part of the decision power to the states.The SUDS had as goals the universalization of care, redefinition of the principles of integration, comprehensiveness, hierarchy and regionalization of the health care system, and social control, as well as promoting the efficiency of the administrative machine, aiming for higher efficacy in a short period of time (10) .
After the implementation of the SUDS, the states' governments took on command responsibility, leaving coordination, regulation and the monitoring of activities related to cancer control to the Ministry of Health, through the PRO-ONCO (2) .
In order to integrate the teams for the creation and execution of policies for cancer control in the country, the nurses needed to highlight the incorporation of a capital that was strategies of the agents who have habitus and specific capitals and, because of them, what can and what must be done is announced (17) .In Bourdieu's understanding, social agents are differentiated by habitus, and the agents' position in social space can be defined by the position he or she occupies in different fields.In other words, in the distribution of powers that act on each one of them, be it in economic capital, cultural capital, social capital and symbolic capital (5) .
In order to guarantee the nurses' participation in cancer control actions effectively, it was necessary to define teaching strategies with the goal of adjusting the education of future professionals to the needs of the policies in the oncology field.When we think about Brazilian tendencies in undergraduate courses in relation to oncology teaching in the 1980s, we can observe a lack of adequate measurement of the problem, which resulted in a distorted view, disassociated from the country's reality.Therefore, the professionals who graduated from most nursing schools were not skilled to participate in activities of promotion, prevention and control in the oncology field (18) .
In the context of teaching in the nursing field, there were important gaps between curriculum content regarding the theme and the demands and requirements of the nursing work market.The curriculums of the nursing courses were structured according to principles of the Sanitary Reform, prioritizing the formation of generalist nurses (19) .
Investments regarding the restructuring of oncology teaching in the nursing field considered transversality and interdisciplinarity in a way that made cancer-related contents affect disciplines from that era's curriculum matrixes and that, in addition to convergence in educational goals and knowledge integration, stimulated integration movements between courses and services and continuous updating of knowledge and experiences.The proposals were part of a document whose copies were sent to the country's nursing courses, to the Secretariat of the Commission of Specialists for the Teaching of Nursing of the MEC, then responsible for the reformulation of the minimum curriculum, and to the ABEn (20) .
Starting in 1990, the INCA became the body responsible for normalizing cancer control actions in Brazil, which included, among other attributions, the creation of care models, and the performance of research and data gatherings and the development of educational programs, which were, up to that time, responsibility of the PRO-ONCO.At this pace, in March 1990, PRO-ONCO was absorbed by the INCA as one of its coordinating bodies, coming to be known as Coordination of Programs for Cancer Control (1) .This coordinating body and the Department of Nursing of the Federal University of São Paulo, together, implemented the project for implementation of oncology teaching in nursing undergraduate courses in Brazil, through a technical scientific cooperation agreement.The importance bestowed upon this partnership with UNIFESP, a widely recognized institution in the country, added a symbolic and social value to the recognition of INCA's nursing in the scientific field of oncology nursing.
Among the actions under responsibility of the PRO-ON-CO/INCA, the dissemination of the program to nursing courses deserves special mention, as well as the organization of seminars for the implementation of the program.With this intention, professionals gathered for the creation of a textbook that contemplated the programmatic content suggested in the teaching proposal (21) .An important instrument and reference for oncology nursing, the publication of the book Nursing Actions for Cancer Control [Ações de Enfermagem para o Controle do Câncer], released during the II Regional Seminar, which happened in June 1995, in São Paulo, was due to the need for specific didactic material for nursing education (22) .
The production of the book, a symbolic product of the agents in the oncology nursing field, was coordinated by the PRO-ONCO team, and its content was created by the nurses who participated in the I Seminar, most of them part of the INCA, in addition to other guests.This textbook resulted from the goals proposed in 1987 by the DNDCD, which planned actions for promotion and control through professional education, with the goal of using technical publications (22) .The book represented the materialization of the scientific capital of the nurses in the oncology field and the standardization of the habitus proposed for cancer control, as part of the work performed by the multi-professional team.

FINAL CONSIDERATIONS
The INCA reached the end of the 1980s as a reference center for treatment and prevention of cancer in Brazil.The recognition was not only due to the quality and quantity of available care services, but also to the knowledge transmitted and disseminated by its professionals throughout Brazil.Therefore, the INCA must be understood as a catalyzing center for scientific competencies.
Nursing came forward, in this context, through the dissemination of its scientific capital, as part of the construction of a scientific field for oncology nursing in Brazil, with special attention given to the occupation of some social spaces, such as the INCA's nursing residency, the PRO-ONCO, the Brazilian Society of Oncology Nursing (SBEO), the PIDAAC and scientific events.
The countless possibilities for work were a result of the position built through actions and strategies by the agent group in the INCA's internal and external spaces.The best strategies, as time went on, ended up adopted by the groups and, therefore, were incorporated by the agents as part of their habitus.
The recognition of INCA nursing's competency, product of a large investment in the materialization of the nurses' professional habitus, gave it authority to define the rules of the game, through standardizations and participations in the main processes of the institutions.The wholly unique capital acquired rests on the recognition of a competence that, beyond the effects it produces, brings authority and contributes to define the rules and uniformity of the game.
The INCA co-management process brought improvements and created demands for nursing care and teaching, which invested strategies for the revitalization of its professional habitus, capitalizing symbolic profit through the recognition that gave credentials for the INCA nurses as references in the field of oncology.
…] At the time, I was in Campos, involved in the cervix cancer project.I used to go to all nursing schools.I began a parallel work, teaching the so-called "Basic Oncology Course".[…] And we travelled a lot throughout Brazil.[…] With these courses [Basic Oncology Course] we began to expose INCA's nursing internationally.Afterwards, in some situations, we invited INCA professionals to talk about their field, forming the embryo of another project [Expand Project].(D2)