NURSING, ENVIRONMENT AND HEALTH CONCEPTIONS: AN ECOSYSTEMIC APPROACH OF THE COLLECTIVE HEALTH PRODUCTION IN THE PRIMARY CARE

The present study aimed to understand the meanings of the conceptual environment category, produced by nurses acting in the primary health care. A total of 30 nurses participated in the study. Data were collected through semi-directed interviews. The analysis was performed through the thematic method of the empirical meanings, based on the ecosystemic approach of work. The study showed the meanings of environment in the space limits of the human relations, whether they are produced at work, in the family scope or in the general community, in a transversal system that allows relationships of mutual exchange by the human condition itself in the society. Concluding, the development in the nursing area, in an ecosystemic approach of the human health, demands the construction of management strategies integrated to the environment for the promotion of health. The nursing science can be an ally in the construction of healthy and sustainable environments.

The present study aimed to understand the meanings of the conceptual environment category, produced by nurses acting in the primary health care.A total of 30 nurses participated in the study.Data were collected through semi-directed interviews.The analysis was performed through the thematic method of the empirical meanings, based on the ecosystemic approach of work.The study showed the meanings of environment in the space limits of the human relations, whether they are produced at work, in the family scope or in the general community, in a transversal system that allows relationships of mutual exchange by the human condition itself in the society.Concluding, the development in the nursing area, in an ecosystemic approach of the human health, demands the construction of management strategies integrated to the environment for the promotion of health.The nursing science can be an ally in the construction of healthy and sustainable environments.DESCRIPTORS: public health nursing; environment; primary health care

INTRODUCTION
Privileging nursing work as an action area in the ecosystemic domain, in which the conceptual nuclei health, work and environment are implied in a dialectic syllogism, with work as the central term, this interpretive explanation study of the health and nursing phenomenon was based on the guiding inquiry about which are the main meaning designs of environment expressed in relation to the work of nurses in the basic health care network, based on the ecosystemic approach (1) in health production (2-3)   .
This approach adopts the premise of decomposing the elements of work (purpose, need, object/subject, instrument and product) as components that structure, in a systemic way in action, health production in collective work organization, from a nursing focus.In this sense, the elements that possess ecosystemic characteristics before action in work, acquire a concrete meaning when they are assumed and transformed in the process.In its interior, work is made concrete through the ecosystemic approach of its elements, externalizing its systemic components, in the attempt to overcome the predominant "bioclinical" premise in health care.
Thus, in this study, the notion of work as a social ecosystem is being applied as an analytic unit of the phenomenon and not as a biological entity (1) .
In the content of the text, presupposing that knowledge about sociohistorical and environmental phenomena constitutes a technological instrument to achieve work in health production (2-4)   , the objective is to identify the meanings of environment related with health production, as expressed by basic care nurses who work in the Municipal Health Secretaries that are part of the Third Regional Health Coordination Office (3 rd CRS), in the South of the State of Rio Grande do Sul.
Assuming health work as a broad environmental field, health production in itself, therefore, exhibits gaps to understand the vital relations of the human being/ecosystemic environment complex and constitutes a beneficial space for nursing and other professions interested in issues related to the health of humanities, in knowledge production and in the adaptation of different practices, based on broad strategies (1) to improve the quality of life of human beings and the sustainability of natural and social biota.Thus, all efforts in this study privilege the insertion of collective health nursing work (5) into the model structure of health production (as materiality present in the Public Health System, in the particularity of the basic care network), within the ecosystemic focus (1) , in which health and environment are intrinsic categories of human beings' survival and are related in the concrete spaces of human actions, like in the space of health work.
In the analysis process, traffic exposes that different systemic, historical, social and environmental health production and reproduction processes, in the coordinated set of their actions at work (3)(4) , only appear and are possible in the physical environments (physical ecosystems) and in human relations based on individual and collective structure (social ecosystems).This means affirming that work is seen as a complex ecosystem (6) that produces and reproduces health (3) , which reveals itself, in its concrete abstract concept (3) , as a phenomenon whose materiality is apprehended in the biophysical and social environments, in the individual subject and in different social structures and groups.
In the result presentation and discussion, the system of meanings is privileged in the understanding of the phenomena based on the nurses' work, that is, in the object/agent of work, approaching the conceptual nuclei of the syllogism that involves health and the environment, developed in the relation with the product of work, materialized as health production.
In the final considerations, a reflection is presented on the relation between knowledge of the environment, in a socioenvironmental approach, as instrumental knowledge in the field of nursing science and its applicability at work.It is highlighted that the analysis of specific knowledge about acting in the environment as a broad object and about the work process is discussed in another publication, as the nature of the theme, the introductory characteristic of this text and the restricted number of pages limit this text.

METHODOLOGICAL DESIGN
We carried out an exploratory, descriptive and analogical study, adopting a dialectic approach of the sociohistorical phenomenon.The dialectic approach (7) to the study object demands an understanding of the exteriority relation between the subject (researcher) and the object (the configuration of the relation of environment meanings in nurses' work in health production), whose terms are separated and mutually opposed, as a need of the research process itself.In this sense, the object is constructed so as to belong to that mutual development process between the object and the world, in which the subject itself starts to be a part (7) .What we intend to say is that the analysis represents a theoretical and philosophical context that draws the research object in a spatialized and, therefore, socially constituted and transformed time.19) cities in the regional office each cover about 1% of the sample, this impaired the option to select participants according to the numerical representativeness criterion.A complementary criterion was chosen, that is, we selected those cities that were most distant from the referral center of the 3 rd CRS, located in Pelotas, which are: Amaral Ferrador, Arroio Grande, Chuí, Cristal, Herval, Jaguarão, Pedras Altas, Pinheiro Machado, Piratini and Santana da Boa Vista.
After delimiting the cities, the subjects/agents were selected through a simple draw among the nurses, who were identified and coded by numbers.Thus, we constituted a representative sample of the population in the study focus, as this assumes the object as being historical-social (7-8)   .
Tape-recorded semistructured interviews (9) were used to obtain empirical data., a free and informed consent term was elaborated for the nurses, which included the study object, the research objective, the implementation strategy and the way the subject/ agent would be inserted in the research.The fact that this study did not involve any direct risk to the subjects' physical integrity was also explained.The subjects' anonymity was guaranteed, as well as their right to leave the research group at any time if they wanted to.The thirty (30) nurses who participated in this study expressed their post-informed consent in writing.
The testimonies were transcribed and extracts of interest were selected, which illustrated the text and motivate the analysis below.The extracts were selected through sequential steps in accordance with thematic analysis (8) , in which the meanings expressed in the examples represent the possible set of meanings in the analysis that was carried out.Thus, the group of data obtained in the field research is the research's primary source and supports the analyses, based on the concept of health (2)(3)(4) as a sociohistorical and environmental system of health production and reproduction (2)(3) through work, and the concept of environment/ecosystem, based on the content of environmental knowledge (11-13)   .broadest way, also considering the limited possibility of presenting the statements in the space of this text.
At the end of each quotation, without identifying the interviewed subject/agent, the order of the interview is indicated between brackets (N.No).

RESULTS PRESENTATION AND ANALYSIS
The ecosystemic approach of human health imposes "a process of developing specific knowledge and integrating actors and approaches, subjects and sectors, scientists, regulatory authorities, politicians and managers; and all of these with the public in general and with the organized civil society" (1) .In this sense, the proposal presented here constitutes an introduction to this approach, addressing the health, environment and conditions, situations and lifestyles of specific social groups (1) as apprehended elements In their vital processes, human beings develop social relations, based on spaces that are ecosystemic contexts (1,6) , so as to provoke, directly or indirectly, states that are adequate or inadequate to life in and of the ecosystem itself, as an interaction system between living and non-living beings that constitute communities, interacting with a view to producing and reproducing favorable situations for the construction of the environment, based on the sustainability of vital components.
The testimonies contain relevant references to the meaning of environment, as a space for human relations, in which the conditions, situations or lifestyles appear as its predicates.Thus, the environment, as highlighted by the statement below, has a meaning in the limits of the space of human relations, whether these are produced at work, in the family range or even in the context of the community in general, with a view to producing and reproducing favorable situations for the construction of healthy interactions with the object/subject of work.In the statements, the environment reveals the meaning of relations between human beings, whether in harmony or not, in view of their possible distancing from different phenomenal senses.The understanding of the environment approaches it to the meaning of ecosystem, and can be perceived as "a system of interactions between populations from different species that live in the same site, and between these populations and the physical environment [...] ecosystems are structured in space and time..." (6) .In this sense, the environment has the meaning of social space -a social ecosystem (1) , in the relationship structure established between living beings and physical-social environments, with natural characteristics constructed by human actions, as the space of work itself.The latter is part of human beings' creative process and, thus, work can result in healthy or unhealthy effects for the vital process, in this particular case for the workers and the other subjects involved ("the clients") in the community health care process.
The structures are composed of components and relations that are produced in the ecosystem and concretely constitute a singular unit in space and in time, which puts the organization of work in action for the construction of the health universal (2)(3)(4) ; a content that is expressed in countless forms, but always maintaining its identity and unity, also determining the development logic its different historical forms will assume up to its maximum limit and its self-organization (4) , given the socioenvironmental and historical conditions.In this relation, the environment appears as a singular element to nurses, that is, the environment itself is the spatialization (4) expressed in the relations of the practical work action.
However, both the practical action and the needs are part of a technological universe that constitutes the health care structures, materialized in the public health system under study, in which the way of constructing the health problems and intervention models ends up being modeled around the determinant structural goals of social practices Nursing, environment and health conceptions... Cezar-Vaz MR, Muccillo-Baisch AL, Soares JFS, Weis AH, Costa VZ, Soares MCF.
Rev Latino-am Enfermagem 2007 maio-junho; 15(3):418-25 www.eerp.usp.br/rlae(health work).Thus, the environment lies in the meaning of the conditions the agents/clients live in and the nurses "should" know this reality in order to be able to communicate with the individuals.
The extract below clarifies the importance of approaching the clients by "arriving at the home" of each particular client.This relation is directly contained in the way of apprehending the work object, as a cultural agent and in the validation of this approach action, as well as through the doubt expressed in the extract about the possible value it can acquire for the object/agent (agent/client) of the work.

I kept on visiting the patients at their homes. At first I didn't know that I had to do that, they hadn't warned me [...]
these people, to achieve this communication with me, at first it was difficult, also because they thought it was silly, they ironically said that I was going to 'ask some questions'.So then I went to do the research, not only to advise the patient, but to see his conditions, how he was doing?Now there is communication

[...] if it is like I told you, there, in the work environment, in my communication with the patient, I think it is the result of work. I think that each place, each site, the people are different, one place's culture is different from the other, if they didn't consider something important here, they could attribute a different value in another place and it would already be easier to work (N. 24).
The approach of the situational environment of the work object/agent is related with another dimension of the work action, which covers the productive possibility of the set of health care actions.
Productive in the sense that the reason justifies the fact through the satisfaction of the agent/client's needs instead of the worker agent's.Thus, the action can work in the same sense as the goal of work, wanting to approach in the situation, through language, possibilities of dialogues between different agents in one and the same situation, someone with care needs with his/her conditions of manifestation and organic feeling.
Action, however, does not withdraw from this construct -care in the individual's cultural environment -its maximum value of exchange in the relation, in which the instigation lies in the reach provoked by the nursing action, as a health agent included in the sick individual's private environment, appearing in this agent/object's cultural scenario, which is acknowledged as being of common language.
To develop the intended work, the aspect in the reference of the necessary communication presupposes the conception that "the relations between the human being and the surrounding environment have a common characteristic: while human beings can communicate directly with one another, through language, they cannot do this directly with non-human environments" (14) .Therefore, the environments appear with the meaning of social spaces (social ecosystems) in which the communication needed for care is put in practice, assuming an indirect form of basic instrument of productive activity.This means affirming that the environment "is neither the 'outside' world nor the human being's pure subjectivity and interiority [...] it is the exteriorized nature, the deterritorialized identities [...] (13) , that is, there exists an apparent human productive activity, "refers to nature to the extent that man does not give up being natural when he positions himself as a subject towards the nature outside him, now objectified in the condition of work object and/or means" (15) .
[...] I always use the environment, according to how patients relate.How could their life be?Giving importance to their problems, because everyone has problems!I stimulate This statement evidences nursing practice, in linking aspects related with the culture of human beings and the privilege of natural questions, in an attempt to naturalize cultural customs through human relations with nature.This represents subsuming the human meaning of nature, which only exists for the social human being, "because it is only in this case that nature emerges as a link with man, as an existence from oneself to the others and from the others to oneself, and also as a vital element of human reality: it is only here that nature reveals itself as the intuition, as the actual spirit of social existence, as a totality of the human manifestation of life" (16) .
Nursing adopts the relational environment questions to act on the agents/clients of their work.
In this naturalization process, there exists an intention that is strongly marked by the need for communication among human beings, that is, aimed at unifying nature and culture into a cross-sectional systematic, which naturally makes possible mutual exchange relations, due to the human condition itself in society.Society has a history and the potential to allow for the objectification of different subjectivities in "the perfect union of man and nature, the true resurrection of nature, the integral naturalism of man and the integral humanism of nature" (16) .
The construction of the subjectivity intrinsic to social processes is developed within the system of individual life" (16) .
Thus, the meaning of environment, assumed in the relation with the health and disease phenomenon, is clearly understood as collective in its sociobiological dimension and the challenge is to apprehend it in an expanded ecological dimension of human health promotion* in relation with his constructed (social ecosystem) and natural environment.This challenge affects a "collective process of knowing, in which each person learns from his 'naturally' different particular [...] perspective, to resignify and recodify the environmental knowledge to imprint it with his personal mark, to inscribe his cultural style and to reconfigure collective identities" (13)   .
The incorporation of human beings in their environments into nursing actions, as objects/agents of work, permanently needs adequate technological instruments (knowledge transformed into action) for observation and intervention, so as to produce poweraction in different social and historical environments.
In the daily work space, looking at the environment with a view to satisfaction, that is, to achieve the product's goal, refers to the range of the object that nursing will transform to produce its product.If the desired product contains the socioenvironmental (ecosystemic) dimension, even if incipiently, the work process will get organized according to the set of actions that allow for the materialization of the desire, of the idealized action (the project), of the concrete act turned into product.And therefore, achieving the satisfaction for its transformation into product requires interdisciplinary instruments for this desire, collectively transformed into a product of work, as a complex product, which needs multiple exchange relations.
Exchanges in the sense of making possible conditions produced by the different agents of the action, i.e.
the worker agent and the client agent, in their different social positions that approximate the presented historical requirements.
As this required product is complex and the produced substance is something constructed in the work process itself, but not only at this particular moment in life in general, the characteristics of the transformation process of the agent/client demand at least an interdisciplinary content, whether in the relation with the projected elaboration of the transformation object, or in the elaboration of this transformed object's instrumental knowledge.
Therefore, the complexity of the work object and its transformation require "knowledge about the environmental complexity, whose construction requires a dialogic process, in the exchange of knowledge, in the hybridization of science, technology and popular knowledge" (13) .

FINAL CONSIDERATIONS
The human being, including his different relational environments, constitutes the main object/ subject of nursing action and its knowledge, which are part of the work related to the health and wellbeing of individuals and environments (11)(12)(13) .Thus, the theoretical and operative constructs of this science should conjuncturally address general environmental questions as components of their knowledge.
Hence, if the proposal is for nursing science to be the first question to discuss the concept of environment and its expansion into a set of coordinated actions -nuclear and collective workwhich represents a challenge to the scientific research area, the look has to be prepared for the complex set of initial observations with a view to the formulation and construction of research objects that include these questions.
With respect to the complexity inherent in scientific research processes, we inquire whether the predominant profile in science has one appearance related to scientific discoveries, that is, IF these are reflexes of the pure physical reality of the natural world and, also, if in a relatively direct way.It is observed that, if this is the case, "thus, science would seem to be an investigation of the truth, in which the global objective is to obtain a clear reflection of nature, as detached as possible from any social and subjective influences that could distort the facts" (17) .And this ambiguity stimulates the counter-action of learning the environment, as a work object, based on "the ecologic potential of nature and the cultural meanings that mobilize the social construction of history" (13) .
It is on the basis of the microsituations of life, as sociohistorical and social phenomena, that nursing structures and produces its research and intervention actions, in which the phenomena's reproduction and interactive nature are expressed.
These repetitions/reproductions possess, at the same time, differences in meanings, which are given by the reflexive context included in the elucidated phenomena, in which the social differences interact with different worlds in one and the same historical time.The phenomena assume determinant and complex characteristics, discovering knowledge that advances in the form and function of the elements and processes that constitute the research object, seeking for expansion in the sense of knowledge about the socioenvironmental context the knowledge object is integrated in (natural and social) (18)(19) .
Thus, like in other fields of health action, nursing knowledge and practices express and exteriorize the human world and are included in the interdisciplinarity needed to produce/construct adequate sciences for the well-being of human beings and the sustainability of social ecosystems (10) .Thus, its knowledge and practices are not restricted to one single phenomenon (health disconnected from the physical and/or social environment).They are constructs that, in this time/space, are potentialized for human health and the environments (a sustainable society as part of a vital ecosystem that is larger than itself) and in themselves reveal to be coherent or not with the return to the spaces they were produced in.
Phenomena and processes that require "learning the environmental complexity by knowing how to be with the otherness, which goes beyond 'know yourself', as the art of life (...) integrates the knowledge about the limit and the meaning of existence" (13) , that is, about belonging to the vital ecosystem.Consequently, this provokes social materiality, which includes the minimization of differences between different social groups.In this process, health is understood as a condition and conditioning factor of concrete life realities, for which nursing science can be an ally in the construction of healthy and sustainable environments.
The research was developed in the nursing work environment in the Basic Public Health Service Network of the Third Regional Health Coordination Office (3 rd CRS) in Rio Grande do Sul -whose headquarters are located in Pelotas and, on the occasion, consisted of twenty-two (22) cities, located on the South coastal plain of the State, at the margins of the Lagoa dos Patos and Lagoa Mirim estuaries.During the field research, in the first semester of 2003, the 3 rd CRS included a basic health care network structured in one hundred forty-six (146) Basic Health Units (BHU), where one hundred forty-three (143) nurses were active.In order to select the subject/agent group to participate in the study, we considered criteria like: theoretical and methodological design, numerical representativeness (percentage) of each city in the total number of nursing professionals active in the basic network, timetable to carry out the field research, financial resources available for transport, as well as access to some locations.The size of the study group was defined as 30 subjects/agents, corresponding to 21% of the total population.According to the cities' representativeness, initially, we included nine (9) nurses from Pelotas, nine (9) from Rio Grande and two (2) from Santa Vitória do Palmar.As the other nineteen ( of meaning by the unitary study element -health work.For this textual presentation, these elements are extended into health, materialized by the work developed by the study agents -the nurses in the basic care network; into environment, identified in the work as determining and conditioning environments of the workers themselves and other subjects of work, exposed as the object/agent of work, which entail different actual characteristics that appear in the possible product of the work that is developed. disfiguration of individuals' particular characteristics due to the lack of knowledge itself of these characteristics.The client's cultural dimension appears in most participating nurses' statements, with the characteristic of not necessarily adhering to their acknowledgement as cultural agents.Nurses integrate this dimension into the set of transformations of the sociohistorical environment (work in basic care) which, due to its consequent indefinitions and even gaps, contribute to negative evidences with respect to the understanding of the goal of the work process and, why not, of the problem-solving capacity of the health care intended by nursing.In the reality analyzed in this study, in its constitution as structured social action to respond to historical lacks, the meaning of cultural environment, as a concrete category, is like the particular example presented below, in the core of the relation with nature.The object/subject is apprehended through the knowledge transformed into action, in this case with the meaning of knowing in the sense before the work, that is, as a certain characteristic present in Professional knowledge, but not to the extent of turning into technological knowledge, given that collective work itself does not require this transformation, unless when it has the meaning of direction in the situational environment of the human condition.Consequently, work, as a of human experience itself.It is only in this case that man's natural existence turned into his human existence and that nature became human to him [...].Although man thus reveals himself as a particular individual, it is exactly this particularity that makes him into an individual and an individual communal being [...].He also exists in reality as health production and reproduction itself, in the interior of this construction of actions (basic care work) which, in turn, affects the subjectivity of the individual and the occupied spaces.Hence, the process of constructing this subjectivity is understood here as the simultaneous construction of possible intersubjectivities that occur in collective activities, in which individuals construct, based on syncretisms through relational life, their own living spaces, in the social ecosystems.And it is in these spaces that the collective and the social are objectified.It should be highlighted that the individual is a social being and that "the manifestation of his life -even if it does not appear directly in the form of a community manifestation, realized jointly with other menconstitutes, then, an expression and a confirmation of social life.Man's individual and generic lives are not different, no matter whether -and this is necessary -individual life is a more specific or more general way of existence of generic life, or no matter whether generic life constitutes a more specific or more general Work is the place, it is the site [...] the work environment is everything where we are inserted in...We are the majority here, we are women!The city is also a hospitable city, the people here are very hospitable [...] they try to be more pleasant [...] it's everything, but here in the work place there are disagreements, it's like that within normal standards, if it has to be done it has to be done... (N.23).
Nursing, environment and health conceptions... Cezar-Vaz MR, Muccillo-Baisch AL, Soares JFS, Weis AH, Costa VZ, Soares MCF.Rev Latino-am Enfermagem 2007 maio-junho; 15(3):418-25 www.eerp.usp.br/rlaeFinally, we emphasize that the development of knowledge in the health area and particularly in nursing, within an ecosystemic approach of human health, demands the construction of integrated environmental management strategies in health promotion.Apprehending health promotion in the process sense, at bottom, practices and knowledge are constituted by the requirement to produce interdisciplinary action, in which promotion is representing not only action power for biosocial problems, but social transformation power.