CONCEPTUAL DIFFERENCES IN TERMS USED IN THE SCIENTIFIC PRODUCTION OF BRAZILIAN NURSING

This is a bibliographic research about Brazilian scientific production in the last 17 years, carried out in the Virtual Health Library. This study aimed to analyze conceptual differences for the terms conceptual framework, reference framework, care method, assistance model, care model, care process and nursing process, proposing definitions for these terms based on the similarities described by the authors of the publications studied. Fifty-three (53) scientific productions were analyzed, which showed a lack of conceptual clarity among the terms, as well as similarities, differences, and use of synonyms, which can hamper the understanding of their meaning. The definition of the terms listed was based on the selected literature, in order to clarify them and contribute to their deeper understanding. In conclusion, it is needed to present proposals need to be presented that define and analyze the concepts, in order to be able to expand the knowledge base of nursing in Brazil, contributing to its advancement and consolidation. DESCRIPTORS: Knowledge. Nursing. Nursing care. Nursing process. DIFERENCIAS CONCEPTUALES EN TÉRMINOS UTILIZADOS EN LA PRODUCCIÓN CIENTÍFICA DE LA ENFERMERÍA BRASILEÑA RESUMEN: Esta es una investigación bibliográfica de la producción científica en Brasil de los últimos 17 años, llevada a cabo entre los meses de agosto y septiembre de 2010, en la Biblioteca Virtual en Salud. El estudio tuvo como objetivo analizar las diferencias conceptuales de los términos marco conceptual, marco de referencia, metodología del cuidado, modelo de asistencia, modelo de cuidado, el proceso de cuidar y el proceso de enfermería y proponer definiciones para los mismos teniendo por base las semejanzas descritas por los autores de las publicaciones estudiadas. Se analizaron 53 producciones que evidenciaron la inexistencia de claridad conceptual entre los términos, además de algunas similitudes, divergencias y uso de sinónimos, lo cual puede dificultar su comprensión. Se ha propuesto la definición de los términos sobre la base de la literatura seleccionada con el objeto de aclararlos y de contribuir a su profundización. Se concluye que es necesario presentar propuestas que definan los conceptos y los analicen con el fin de ampliar la base de conocimientos de la enfermería brasileña, contribuyendo a su avance y consolidación. DESCRIPTORES: Conocimiento. Enfermería. Atención de enfermería. Procesos de enfermería. 534


INTRODUCTION
Mainly due to the work that nursing scientists, theorists and scholars have accomplished in the last four decades, nursing has been acknowledged as an emerging profession, an academic discipline and a science. 1 The theoretical development that took place during that period largely derived from the efforts to construct its own set of knowledge, in an organized manner, which resulted in the creation and development of the nursing theories.
The theory of nursing can be defined as the conceptualization of some aspect of the nursing reality, with a view to describing the phenomena, explain the relations among them, foresee consequences or prescribe care. 2 Thus, theory is a symbolic representation of aspects of reality, discovered or invented to describe, explain, foresee or prescribe answers, events, situations, conditions or relations.The theories contain concepts related to the phenomena within the discipline, and these concepts are mutually related to constitute theoretical assertions. 2 Based on the theories, nursing care processes are established, which direct the routes that need to be followed to put the theoretical premises in practice in care delivery by baccalaureate nurses and other nursing team members.When the care process is theoretically underpinned and methodologically structured, it can be considered as different structures with a varying degree of abstraction and be classified as a care model, conceptual model, care method, among others. 3n general, the difference between conceptual model and theories is merely semantic.] These conceptual issues are also present in other studies, including one undertaken almost 20 years ago, in which the authors already affirmed that there existed no clear definition for many terms used, neither in nursing practice nor in theory, but considered that: the terms 'framework', 'model' and 'system' are equivalent.:84-5 Hence, "the terms that name the knowledge structures, such as theory, conceptual model, care model, among others", 3:8 indicate that there exists no consensus among the authors, mainly considering their uniqueness.
With a view to clarifying these conceptual issues, which are important and necessary to understand the knowledge structures in Nursing and, thus, to contribute to advances in knowledge construction, the aim in this study was to analyze the conceptual differences for the terms conceptual framework, reference framework, care method, assistance model, care model, care process and nursing process, as well as to propose specific definitions for each of the terms selected, based on the similarities described by the authors who were reviewed.
This justifies the initiative to construct definitions for the different concepts involved in nursing care practices and studies, with a view to expanding knowledge in the area and enhancing its understanding and the comprehension of its importance, as the existence of clear concepts in a discipline are fundamental for the advancement of the profession.

METHOD
A bibliographic research was undertaken about Brazilian scientific production between August and September 2010, in which the entire Brazilian production on the theme developed until the date of the research was investigated.The period between the first (1993) and the final (2010) text selected totaled 17 years.The following phases were followed: 8 1) elaboration of the research project; 2) investigation of the solutions; 3) explanatory analysis of the solutions; and 4) integrative synthesis.
After the elaboration of the project, the investigation of the solutions started, which involved a bibliographic survey, besides initial, exploratory, selective, reflexive and interpretative reading to select the studies for analysis in the subsequent phase, understand the ideas each author present them and relate them with the research question.
The bibliographic survey was undertaken in the Virtual Health Library (VHL) and considered the following inclusion criteria: publications in Portuguese and originating in Brazil; full texts available on-line; and material available until the end of the data collection.The exclusion criteria were: repeated publications, from other countries or in other languages, whose full version was not available, and which did not address the concepts under analysis.
As none of the terms selected in considered a descriptor in the VHL's Health Sciences Descriptors, the related words -conceptual framework, reference framework, care method, assistance model, care model, care process and nursing process -were used for the search, without any combination.
After the initial reading, 8 which refers to rapid reading to select the material that may contain information that is relevant for the theme, initially, 283 papers and one thesis were selected.The exploratory reading, which also involves rapid reading to verify whether the information is of actual interest to the study, resulted in the exclusion of 164 papers.After the selective reading, which serves to dispose of secondary data, another 50 repeated articles were removed.After the reflexive or critical reading, when the selected material is fully read in order to understand the authors' assertions, 9 another 17 papers were excluded as they were conceptually inappropriate and evaded from the theme.Conceptual inappropriateness is considered as the use of a concept beyond the context that defines it, like publications that used care model to refer to the hegemonic medical model predominant in Brazilian health.
Thus, the final sample consisted of 52 articles and one thesis, to which further interpretative reading was applied.This is considered the most complex moment, aimed at relating the ideas the authors expressed about the research problem. 9o organize the reading process, an instrument was elaborated to collect information to identify the publication, data on the author and publication, data characteristic of the text, such as key words, objective, method and concepts used, as well as their definition.
Among the 53 scientific publications selected, seven were papers resulting from master's theses; three from doctoral dissertations; six were elaborated by Ph.D. graduates and stricto sensu graduate students; one was produced in a subject as part of an M.Sc.program; one thesis; two papers elaborated by undergraduate nursing faculty and students; four were part of research projects funded by the Brazilian Scientific and Technological Development Council (CNPq), one of which was also taken from a thesis; one was developed with funding from the São Paulo Research Foundation (FAPESP); three were written by Ph.D. graduates and clinical nurses; and 26 papers deriving from research by Ph.D. and M.Sc.graduates affiliated with academic institutions.
After detailing the investigation phase of the solutions, which prioritized the search for and verification of information relevant for and suitable to the research problem, the third phase started, called explanatory analysis of the solutions. 8Therefore, the information in the selected studies was analyzed, distinguishing between the data presented and any associated justifications.
Nevertheless, the origins, effects or goals of these data also need further explanation, which can be done empirically, based on common sense. 8herefore, next, the data will be presented that were collected from the selected studies after complying with the specific orientations described for that phase.

RESULTS
Next, the different concepts are presented as defined by the authors of the selected publications under analysis, in accordance with the research problem.It should be highlighted that some authors use synonyms or other names for the selected terms and that few of them provide their own definitions, but instead use definitions elaborated by other authors to compose their theoretical-conceptual description.
This phase, called explanatory analysis of the solutions, 8 is presented in Picture 1, which addresses the themes listed under the research problem, as well as other names and synonyms the different authors have used.
In addition, some observations should be indicated which emerged from the conceptual analysis process, including the fact that, for some concepts, definitions were presented that are linked with specific situations, which were used by other health areas to refer to the aspects of their practice.
Hence, in collective health, conceptual framework was understood as the result of the theoretical-epistemological elaboration and the scientific production, articulated with social practices, and of criticism against the different health reform movements and projects that have taken place in capitalist countries. 10

Concepts and definitions *
:35 Reference framework: 30/03 the authors did not provide any definitions.
Conceptual framework: the authors did not provide any definitions.:200 Assistential method and methodological model: concepts used as synonyms of Nursing process.
Assistance model: 86/24 predetermined formulae for care; 16 "are representations of the world that is experienced, which are expressed verbally or through symbols, schemes, designs, graphs, diagrams.:557 Technical-assistential model: "corresponds to the organization of service production based on a certain arrangement of knowledge in the area, as well as of specific social action projects, as political strategies in a certain social grouping " . 17:348 Assistential model: "is a historical, political and social construction, organized in a dynamic context, to respond to the interests of social groups.:349 Care delivery model: "is a deliberate intellectual activity, through which nursing practice is implemented in a systematic and ordered manner, in the attempt to improve care.:184 Concepts and definitions * Synonyms used by the authors * Care process: 20/02 "the way care takes place or should take place.[...] relates to the care encounter that happens between the caregiver and the being who receives care.[...] comprises, besides procedures and technical activities, actions and behaviors that privilege not only spending time with, but truly being with someone". 24:2 -Nursing process: 88/12 "a method to organize and deliver nursing care"; 25:186 "an approach that aims to identify problems, setting priorities, establishing targets and results to be achieve, through a continuous assessment.It is a dynamic and permanent method to organize nursing actions, whose aim is to solve the nursing problems an individual presents"; 26 "presupposes a range of dynamic and interrelated actions for its accomplishment, that is, indicates the adoption of a certain method or way of doing [...] based on a system of moral values and beliefs and on technical-scientific knowledge in the area [...]"; 27:189 understood as a system that "involves a sequence of specific steps [...], with a view to delivering professional care to clients, whether these are individuals, families or communities, so as to take into account their singularities in a broader sense.Demands theoretical based from Nursing and other areas.:650 Nursing Care Systemization (NCS): "presupposes the organization into a system, which in turn implies a set of dynamically interrelated elements.:555 * Due to space constraints, only those definitions used in the integrative synthesis of the concepts and definitions that best represent the synonyms were presented.† Number of products found after initial reading/number of products selected and analyzed for this concept.
As regards the term "care model", some authors consider that care model is a synonym of the hegemonic medical model, 31 of assistance model, 32 or of assistential model. 33:348 The definitions for the term care model were reduced, due to the fact that some texts used, elaborated, cited and even presented diagrams representing care models.The authors, however, did not present any definitions, so that the readers had to understand and interpret them.
[37][38] In addition, many other names were found, including, 27,39 as-sistential method or care method, 25,29,36,39 nursing care, 16 organizational process, 16 nursing care and intervention, 39 caregiving or care process, 29,36 care method, 16,36 care planning, care process, nursing consultation and nursing care process. 36nally, other important and frequently used concepts in nursing, like theoretical model and nursing theory, were also found after the textual analysis but, as they had not been selected in advance, they were not addressed.

DISCUSSION
To present the fourth and final phase 8 , called integrative synthesis, which involves reflection and the proposal of solutions, based on the research material, initially, we present some definitions for the model concept, based on the literature.This option is justified in the belief that this concept permeates many others the authors of the selected studies presented and, sometimes, is mixed up with the method concept, which also deserves a specific conceptual definition.
The word model is constituted by definitions of concepts 40 and does not exist in the physical world, but exists in the abstract world and represents different forms of seeing nursing 41 and refers to theoretical bases that underpin an activity area. 42n general, model can be understood as an abstraction of reality, that is, a way of visualizing it and facilitating reasoning. 11A model needs a structure of ideas and concepts, which can vary in their conceptions and in the way central nursing concepts are described.But model is not a theory, predicting care outcomes.Instead, it is a structure of ideas that guides care practice and should reflect this practice.:79 The term method, then, refers to the way care is accomplished, applied, delivered to the client/family under the professional's responsibility.][35][36]37,39 To propose solutions, as the adopted method requests, and contribute to advances in the construction of nursing knowledge, next, we present a proposal that joins the definitions presented by the different authors of the Brazilian studies selected for the study concepts.

Contributions to the advancement in the definitions
In view of these considerations, figure 1 displays a mental construction, elaborated based on the definitions found for each of the terms focused on in this research.

Figure 1 -Integrative synthesis of the concepts
As described, these definitions were based on the authors included in the references selected for this study, and some points should be highlighted.
The term "Care method" refers to the way care should be accomplished, a route to follow to accomplish care, which should be sustained by the reference framework used.When citing this concept, however, many authors used it as a synonym of nursing process, which explains the similarity between the two concepts' definitions.
The term "Assistance model" was characterized by the definition based on different views.Be-sides the view presented for nursing, the definition in public health is cited; set of organized actions, based on political, social, economic and cultural strategies, articulated with physical, technological and human resources aimed at intervening in the health-disease process of a population.
In the researchers' understanding, the concept attributed to the term Care model was limited, and did not address all of its dimensions.Therefore, it did not receive the necessary and fair importance it represents for the profession.Thus, we defend the concept that a care model is a theoretical set of the four central concepts in nursing: nursing, health-disease, society/environment, human beings, besides others necessary, as well as premises based on a theoretical and philosophical framework that serves to guide nursing care through systemized actions.It is a theoretical structure that interrelates concepts, premises and a care method, represented by a diagram. 4inally, the absence of the definition for the term "Reference framework" is justified, as all texts that methods this concept did not present an explicit description, so that its analysis, condensation and presentation was impossible.

FINAL CONSIDERATIONS
Constructing the knowledge in a discipline is a hard task, but which nevertheless needs to be accomplished constantly.Aspects previously addressed need to be taken into account, but advances are fundamental.
The use of nursing concepts remits to the importance of clarifying the knowledge itself developed in the area, and further elaborating the theoretical aspects is fundamental to guarantee greater visibility, acknowledgement of the discipline and the possibility of certified and qualified practical intervention.
The collection of the conceptual definitions in this research, based on the different views of the authors of the Brazilian publications involved, revealed that, besides similarities, particularities and divergences regarding the theme under analysis, inappropriate conceptual elements are relatively common.There is a lack of understanding in the use of some terms, which are mistakenly considered as synonyms in some situations and do not receive the depth and density to guarantee their range, individuality and subjectivity.Such inappropriate elements can further increase the conceptual confusion, a fact that hampers the understanding of theoretical aspects in nursing knowledge.
Hence, this research contributes as it permits visualizing conceptual differences and similarities in the Brazilian publications, and also presents a proposed conceptual definition deriving from the literature under analysis, provided for each term investigated and studied here.
This reveals the need to further elaborate concepts, establish meanings for practice, as knowledge construction involves operational as well as conceptual issues.Proposals need to be presented that define and analyze concepts, with a view to enhancing the knowledge base of Brazilian nursing, contributing to its advancement and consolidation.