DEMONSTRATI NG NURSI NG CARE AS A SOCI AL PRACTI CE
Dir ce St ein Back es1 Alacoqu e Lor en zin i Er dm an n2 An dr eas Bü sch er3
Backes DS, Erdm ann AL, Büscher A. Dem onst rat ing nursing care as a social pract ice. Rev Lat ino- am Enferm agem 2 0 0 9 n ov em br o- dezem br o; 1 7 ( 6 ) : 9 8 8 - 9 4 .
This st udy aim ed t o under st and t he m eaning of nur sing car e as a social pr act ice based on int er act ions and associat ions w it h com plex - sy st em ic t hink ing. Gr ounded Theor y w as t he m et hodological fr am ew or k used and 3 5 h ealt h pr of ession als dist r ibu t ed in dif f er en t sam ple gr ou ps w er e in t er v iew ed t h r ou gh a sem i- st r u ct u r ed quest ionnair e. Sim ult aneous dat a codificat ion and analy sis per m it t ed t he ident ificat ion of t he cent r al cat egor y : “ Ev iden cin g n u r sin g car e as social pr act ice” . Nu r sin g car e as a social pr act ice based on com plex - sy st em ic t hinking const it ut es a new paradigm of int ervent ion, capable of st rengt hening social act ions t hrough int eract ive and associat iv e net w or ks, and of act ing in a pr oact iv e, innov at ing and par t icipat iv e m anner .
DESCRI PTORS: nur sing car e; nur se’s r ole; social r esponsibilit y ; nur sing r esear ch
COLOCANDO EN EVI DENCI A EL CUI DADO DE ENFERMERÍ A COMO PRÁCTI CA SOCI AL
El ob j et iv o d e est e est u d io f u e com p r en d er el sig n if icad o d el cu id ad o d e en f er m er ía com o p r áct ica social ex am in ado baj o la per spect iv a de las in t er accion es y asociacion es del pen sam ien t o sist ém ico com plej o. La m et odología ut ilizada fue la t eor ía fundam ent ada en los dat os, con ent r ev ist a sem iest r uct ur ada, r ealizada con t r eint a y cinco pr ofesionales de la salud, dist r ibuidos en difer ent es gr upos de m uest r eo. La codificación y el análisis sim ult áneo de los dat os posibilit ar on la ident ificación de la cat egor ía cent r al: “ colocando en ev idencia el cuidado de enfer m er ía com o pr áct ica social” . El cuidado de enfer m er ía com o pr áct ica social, or ient ado por el pensam ient o sist ém ico com plej o, se const it uy e en nuev o par adigm a de int er v ención, capaz de pot encializar las accion es locales por m edio de las r edes in t er act iv as y asociat iv as, así com o act u ar de for m a pr oact iv a, in n ov ador a y par t icipat iv a.
DESCRI PTORES: at ención de enferm ería; rol de la enferm era; responsabilidad social; invest igación en enferm ería
EVI DENCI ANDO O CUI DADO DE ENFERMAGEM COMO PRÁTI CA SOCI AL
O obj et ivo dest e est udo foi com preender o significado do cuidado de enferm agem com o prát ica social à luz das int erações e associações do pensam ent o sist êm ico- com plexo. A m et odologia ut ilizada foi a t eoria fundam ent ada nos dados, com ent r ev ist a sem iest r ut ur ada, r ealizada com t r int a e cinco pr ofissionais da saúde, dist r ibuídos em difer ent es gr upos am ost r ais. A codificação e a análise sim ult ânea dos dados possibilit ar am a ident ificação da cat egor ia cent r al: “ evidenciando o cuidado de enfer m agem com o pr át ica social” . O cuidado de enfer m agem com o p r át ica social, or ien t ad o p elo p en sam en t o sist êm ico- com p lex o, se con st it u i em n ov o p ar ad ig m a d e int er v enção, capaz de pot encializar as ações locais por m eio das r edes int er at iv as e associat iv as, bem com o at uar de for m a pr oat iv a, inov ador a e par t icipat iv a.
DESCRI TORES: cu id ad os d e en f er m ag em ; p ap el d o p r of ission al d e en f er m ag em ; r esp on sab ilid ad e social; pesqu isa em en f er m agem
1Ph.D. in Nursing, Professor, Cent ro Universit ário Franciscano - UNI FRA, Sant a Maria, RS, Brazil. Mem ber, GEPADES Research Group, Universidade Federal
de Sant a Cat arina, Brazil, e- m ail: backesdirce@ig.com .br. 2Ph.D. in Nursing, Full Professor, Universidade Federal de Sant a Cat arina. Coordinat or, GEPADES
Research Group, Universidade Federal de Sant a Cat arina, Brazil, e- m ail: alacoque@newsit e.com .br. 3RN, Ph.D., Researcher and Professor, I nst it ut e of
Nursing Science, Universit y of Bielefeld, Germ any, e- m ail: andreas.buescher@uni- bielefeld.de.
I NTRODUCTI ON
T
h er e h av e been ex t en siv e an d in cr easin g discu ssion s an d st u dies on n u r sin g car e as a socialpr act ice, t hough it st ill r epr esent s a gr eat challenge
t o k n ow ledge. I n or der t o deal w it h an d f ollow t h e
t e ch n i ca l a n d sci e n t i f i c d e v e l o p m e n t f o r t h e f u l l
exercise of a profession t uned in wit h em ergent social
cont r adict ions, in our point of view , one needs t o go
bey ond inst it ut ionalized lim it s and t r adit ional m odels
of “ nur sing k now - how ”.
Recen t st u d ies in cit ed u s t o seek a b et t er
underst anding of nursing care as social pract ice, when
t h ese st u d i es r ep o r t t h at t h e i n cl u si o n o f n u r si n g
pr ofessionals is st ill v er y incipient( 1- 2) bot h in t heor y an d in pr act ice an d in r epr esen t at ion in social an d
healt h policies. Aut hor s also m ent ion t hat , alt hough
t h e n u r sin g pr of ession com pr ises t h e lar gest gr ou p
of healt h w or k er s, nur sing play s a secondar y r ole in
t e r m s o f p e r f o r m i n g c o n c r e t e h e a l t h a c t i o n s t o
con t r ibu t e t o an d dev elop pu blic policies, aim ed at
social dev elopm en t .
I n t his perspect ive, ot her st udies quest ion t he
r o l e o f n u r si n g i n t h e cu r r en t p o l i t i cal an d so ci al
scen ar ios, con sid er in g in cr easin g in eq u alit y in t h e
social and healt h ar eas. Nur sing needs t o r et hink it s
p r a ct i ce a n d so ci a l r o l e a n d sh o w i t s r esp o n si b l e
com m it m ent in discussions about growing inj ust ice in
t he social and healt h areas( 3). Nurses, as well as ot her h eal t h p r o f essi o n al s, n eed t o d ev el o p cr i t i cal an d
r eflex iv e at t it udes w it h a v iew t o put t ing in pr act ice
polit ical- social act ions t hat ex pr ess t heir r esponsible
par t icipat ion, w it h a v iew t o social dev elopm ent .
Anot her m or e r ecent st udy, w hich aim ed t o
u n d e r st a n d a n d a n a l y ze t h e co n ce p t i o n s o f ca r e
addressed in doct oral dissert at ions defended bet ween
1 9 9 5 a n d 2 0 0 5 i n a Gr a d u a t e Nu r si n g Pr o g r a m ,
evidenced t hat , despit e t he r ichness of invest igat ions
and t heoret ical- pract ical approaches, t he st udies were
m o s t l y b a s e d o n a s i t u a t i o n o f d i s e a s e o r o n
inst it ut ionalized pr act ices of t r adit ional k now - how( 2 ). I n sum m ar y, r esult s r epor t t hat nur sing is a field of
social pr act ice because it deliver s car e t o t he sick or
h e a l t h y i n d i v i d u a l o r co m m u n i t y w i t h t e ch n i ca l
-scien t if ic k n ow ledge. How ev er, it is st ill f ocu sed on
t he t r adit ional and inst it ut ionalized pr act ice, t hat is,
w it h lit t le dev elopm ent of pr oact iv e act ions of social
in t er v en t ion .
Th e p er cep t ion s of car e ev id en ced t h r ou g h
t h e o r e t i ca l se a r ch e s a n d a p p e a l s f r o m e m e r g e n t
social issues m ade t he desire t o expand t he m eaning
of nursing care beyond t he t radit ional know - how and
i n s t i t u t i o n a l i z e d p r a c t i c e s e v e n m o r e p r e s s i n g .
Nurses, now m ore t han ever, should be able t o exceed
t he lim it s of disciplinary knowledge, of inst it ut ionalized
syst em s, and especially of t he out lines of physiological
disease, so t hat t hey can underst and and act t owards
t h e i n t e g r a t i o n o f a s y s t e m i c , p a r a d o x i c a l a n d
int er act iv e v iew on social and healt h issues.
Th e p e r ce p t i o n t h a t n u r se s ca n a n d a r e
c a p a b l e o f p r o a c t i v e i n t e r a c t i o n i n l o c a l s o c i a l
dev elopm ent and in t he ex pansion of possibilit ies of
act ion ult im at ely reflect s t he desire t o m ove from t he
car t esian par adigm , st ill pr edom in an t in t h e h ealt h
a r e a , t o w a r d s a s y s t e m i c t h i n k i n g o f s o c i a l
i n t er v en t i o n , ca p a b l e o f ca r ef u l l y co n si d er i n g t h e
unique and t he m ult iple, inst ead of sim ply looking at
indiv idual efficiency( 4 ).
Syst em ic- com plex t hinking does not lead one
t o w a r d ev i d en ces a n d cer t a i n t i es b u t t o a g l o b a l
dir ect ion , t o t h e u n cer t ain , u n k n ow n an d r eal( 5 ). I n t h e sear ch f or sy st em ic t h in k in g t o u n der st an d t h e
m e a n i n g o f n u r s i n g c a r e a s s o c i a l p r a c t i c e , w e
co n si d er ed t h at t h er e i s n o k ey t o p en et r at e t h e
u n iv er se of com p lex it y. “ Wh at ex ist s ar e d if f er en t
r o u t e s , p a t h s , a v e n u e s t h a t l e a d t o w a r d s t h e
challenges of k now ledge”( 6 ).
The per cept ion t hat nur ses hav e k now ledge
and a specific place in t he scope of social pract ices( 7) an d t h at , t h r ou gh car e as social pr act ice, t h ey ar e
capable of cont r ibut ing t o social developm ent r elat ed
t o i n cr e a se d o p p o r t u n i t i e s f o r h u m a n b e i n g s t o
dev elop t h eir pot en t ialit ies, pr essu r ed u s t o seek a
bet t er under st anding of t he m eaning of nur sing car e
as social pr act ice.
OBJECTI VES
To u n der st an d t h e m ean in g of n u r sin g car e
a s so ci a l p r a ct i ce, b a sed o n t h e i n t er a ct i o n s a n d
associat ion s of sy st em ic- com plex t h in k in g.
METHOD
This qualit at ive st udy used Gr ounded Theor y
as t h e m et h odological f r am ew or k( 8 - 9 ). An im por t an t aspect in t he Grounded Theory is t he developm ent of
t h e t h eor et ical sam p le in Gr ou n d ed Th eor y is n ot
defined pr ior t o dat a collect ion; it is defined dur ing
t h e co l l e ct i o n a n d a n a l y si s p r o ce sse s, b a se d o n
em er gen t con cept s an d h y pot h eses.
Th e d a t a w e r e c o l l e c t e d b y m e a n s o f
i n t e r v i e w s w i t h h e a l t h p r o f e ssi o n a l s o f d i f f e r e n t
I n st it u t ion s, dist r ibu t ed in dif f er en t sam ple gr ou ps,
aim ing t o m axim ize t he variat ion am ong concept s and
a d d n e w p e r s p e c t i v e s o r h y p o t h e s e s t o t h e
p h en o m en o n u n d er st u d y. I n t er v i ew ees i n cl u d ed :
nurses, physicians, dent ist s, nut rit ionist s, pharm acist s,
p sy ch o l o g i st s, p ed a g o g u es, m a n a g er s a n d h ea l t h
u ser s.
Th e g u i d i n g q u e st i o n f o r t h e i n t e r v i e w s,
am ong ot hers t hat were deepened during t he process,
w as: What is t he m eaning of nur sing car e as social
p r act ice?
For t h eor et ical sam p lin g , w e at t em p t ed t o
collect dat a t hat support ed t he t heoret ical const ruct ion
so t hat , when sim ult aneously collect ing, codifying and
a n a l y zi n g t h e m , t h e o r e t i ca l sa t u r a t i o n w o u l d b e
achiev ed. This w as accom plished aft er 35 int er v iew s
carried out bet ween t he m ont hs of May and Decem ber
2 0 0 7 .
Aft er t he dat a were t ranscribed and reviewed
in det ail for each int erview, ident ificat ion of concept ual
u n i t s b eg a n . Th e d a t a w er e co d i f i ed l i n e- b y - l i n e,
com pared and select ed in cat egories. I n t he following
st age, t he researchers chose an open coding cat egory
- first st age of codificat ion - and placed it as t he cent ral
t h em e, com par in g it w it h t h e r em ain in g cat egor ies.
I n t he follow ing phase, called ax ial coding, t he dat a
w er e gr ou ped in n ew f or m s, seek in g t o absor b t h e
u n der ly in g dat a r elat ion s an d in t er act ion s as m u ch
as p o ssi b l e. Th e Par ad i g m Mo d el( 8 - 9 ) w as u sed t o f acilit at e t h e dat a an aly sis an d gr ou pin g cat egor ies
p r o cesses.
Based on t he int egrat ion of t he elem ent s and
having conduct ed t he t heoret ical connect ions bet ween
t he subcat egor ies and cat egor ies, it w as possible t o
m ove in t he direct ion of t he select ive codificat ion, t he
t hird phase of t he analysis, which result ed of t he cent ral
cat egory: “ Evidencing nursing care as social pract ice”.
All st u d y p ar t icip an t s w er e in f or m ed ab ou t
t he obj ect ives and proposed m et hodology. Their right
t o access dat a and ident it y and inform at ion anonym it y
w e r e g u a r a n t e e d . Th e p r o j e ct w a s u n a n i m o u sl y
appr ov ed by t h e Resear ch Et h ics Com m it t ee of t h e
Feder al Univ er sit y of Sant a Cat ar ina.
The par t icipant s’ cont r ibut ions, r egist er ed in
t he present st udy, w ere ident ified w it h t he let t er “ P”,
follow ed by a num ber cor r esponding t o t heir speech,
in or der t o r em ain nam eless.
RESULTS
Th e cat eg or y is com p osed of t h e f ollow in g
su b cat eg or ies: Giv in g m ean in g t o n u r sin g car e as
social p r act ice, Ack n ow led g in g t h e n u r ses’ h u m an
-in t er act iv e pot en t ialit ies an d Ack n ow ledg-in g n u r ses’
t e c h n i c a l - p o l i t i c a l c o m p e t e n c e s , w h i c h w i l l b e
discussed based on t he int er act ions and associat ions
of sy st em ic- com plex t h in k in g.
Nur ses’ social r ole is v isible in t he differ ent
pract ices and is expressed in different ways. For healt h
p r o f e s s i o n a l s , n u r s i n g s h o u l d b e c o n s i d e r e d a
pr ofession t hat conv er ges t o t he social cont ex t , t hat
i s , a p r o f e s s i o n t h a t a c t s i n a m o r e d i r e c t a n d
par t icipat iv e for m in social pr act ice.
Giv ing m eaning t o nur sing car e as social pr act ice
Mor e specifically for nur ses, t he m eaning of
n u r si n g ca r e a s so ci a l p r a ct i ce i s r e l a t e d t o t h e
under st anding of t he social cont ex t of healt h user s,
fam ilies or com m unit ies. Wit h t he nurses’ m ore act ive
and effect ive part icipat ion in t he Fam ily Healt h Program
( PSF) an d in Hom e Hospit alizat ion Pr ogr am s ( PI D) ,
t h ey p er ceiv e t h at t h eir p r act ice t r an sf or m s an d is
t r a n sf o r m e d . Ev e n t h o u g h so m e n u r se s f o u n d i t
challenging t o adapt t o a new realit y, which t hey had
not been prepared for, t he close cont act wit h t he users’
social realit y gives t hem sat isfact ion, m ot ivat ion, and
also prom ot es a professional and social feeling of well
b ein g .
Pr o f e s s i o n a l s e x p e r i e n c e a f e e l i n g o f
co m p l e t e n e ss, ca u se d b y t h e cl o se co n t a ct w i t h
individuals in t heir fam ily and com m unit arian cont ext s,
m u ch m or e t h an in t h e h ospit al set t in g, w h er e t h e
a p p a r e n t t e ch n o l o g i ca l sa f e t y a n d co m f o r t l i m i t
pr of ession al au t on om y.
I w as v er y afr aid w hen I got in t he PI D because I
didn’t know how it would be. Because, at t he I nt ensive Treat m ent
Unit , w her e I ’d w or k ed for 15 y ear s, w e felt v er y pr ot ect ed, w e
had ev er y t hing…in t he fam ily , I didn’t k now how it ’d be. Ther e
I n eed t o u se m y f u ll p ot en t ial t o b e ab le t o at t en d an d
t he I TU. Not ev er y t hing is solv ed and it leads t o a feeling of
fr ust r at ion. I w asn’t able t o go deeper at t he I TU. I n t he fam ilies’
v isit s w e go deeper … t hey call m e at night and not because of a
phy sical pr oblem . We hav e a dir ect im pact … Now aday s I ’m a
nur se. I feel m or e lik e a nur se. I ’m a com plet e pr ofessional. We
cr eat e st r onger bonds. I div e in. I lik e v er y m uch w hat I do. I
feel gr eat ( P13) .
The social env ir onm ent , in t he nur ses’ point
of v iew , ex pands int er act ions, st r engt hens bonds of
t r u st b et w een p r of ession als an d u ser s an d p er m it s
sat isfact ion of bot h pr ofessionals and user s. I hav e a
posit ive feedback. And it seem s t hat t his feeds and m ot ivat es a
ret urn t o t he com m unit y. When I ret ired, I felt I needed t o do
som et hing... I went back t o t he com m unit y… I knew t hat I could
be a n u r se t h er e ( P1 2 ) . Th e social en v ir on m en t , m or e s p e c i f i c a l l y t h e f a m i l y a n d t h e c o m m u n i t y
environm ent s, perm it cont inuous learning and int ense
ex p er ien ce ex ch an g e. Besid es, it is a p lace w h er e
t h e au t on om y of p r of ession als an d h ealt h u ser s is
st r en gt h en ed, en cou r agin g t h e social r ole. I n eed t o
find places where I can st rengt hen aut onom y and t he com m unit y
allows m e t o do it … ( P9) . I n t he fam ily, we need t o t ake int o account t he user’s aut onom y…t here’re possibilit ies of exchange,
so t hat I can learn as well. So, t here’s int eract ion, he becom es t he
aut hor and act or of t he process ( P4) .
The m eaning of social pract ice, in t he nurses’
per spect iv e, is r elat ed t o inv olv em ent , r esponsibilit y
an d t h e pr oblem - solv in g capacit y of h ealt h act ion s.
As a con sequ en ce of t h is pr ocess, n u r ses per ceiv e,
bey ond user sat isfact ion, t he achiev em ent of gr eat er
cr edibilit y and social ack now ledgm ent .
A c k n o w l e d g i n g n u r s e s ’ h u m a n - i n t e r a c t i v e
pot en t ialit ies
On e of t h e h u m an - in t er act iv e pot en t ialit ies
of nurses’ m ost acknowledged and highlight ed by t he
int erviewed professionals is relat ed t o t he capacit y t o
underst and t he hum an being as a whole. I t is relat ed
t o t he capacit y t o underst anding different dim ensions
and t he frailt y of t he hum an being.
Nur ses st and out by t he com pr ehensiv eness
of healt h car e, t he capacit y t o under st and t he social
con t ex t , t o w elcom e an d em pat h ize w it h t h e n eeds
and ex pect at ions of indiv iduals, t o enhance qualit ies
of in div idu als, t h e capacit y t o in t er act dir ect ly w it h
t h e u se r a n d co m m u n i t y, a s w e l l a s t o p r o m o t e
int er act ion bet w een user s and t he healt h t eam . Th e
n u r se is t h e pr ofession al w h o h as t h e ex per ien ce fr om t h e
psy chological, phy sical and t echnical point of v iew t o act in
different environm ent s. He is t he unifying elem ent of care. He
ident ifies him self wit h t he pat ient ’s needs m uch m ore t hat ot her
pr ofession als ( P2 9 ) .
Becau se n u r ses u n der st an d t h e h ealt h u ser
as an int egr al being and get inv olv ed w it h differ ent
si t u a t i o n s r e l a t e d t o ca r e , t h e y o f t e n t i m e s f a ce
difficult ies t o ident ify t he obj ect of t heir pract ice, t hat
is, t o ident ify t heir specificit y in t he set of professional
h e a l t h a ct i o n s. On e o f t h e n u r se s r e p o r t e d t h i s
d if f icu lt y w h en sh e w as p ar t of a m u lt ip r of ession al
healt h t eam . Each pr ofessional had t o shar e his( er )
e v a l u a t i o n i n r e l a t i o n t o a ce r t a i n cl i e n t , w h o se
pat hology result ed in a case st udy. Because she used
t o be alw ay s t he last t o t alk in t he fir st encount er s,
she would say t here were no new aspect s t o be added
since t he r em aining pr ofessionals had said it all. I n
ot h er w or ds, w h ile ot h er pr ofession als t alk ed abou t
t he part s, t he nurse could only t alk about t he whole,
as follow s:
Everyone had t o m ake an evaluat ion in t heir area. So,
one of t he t hings t hat I personally experienced was t hat t he
nut rit ionist , w hen present ing her diagnosis, w ould t alk about
t he whole nut rit ional aspect of t he pat ient . Then t he social worker
w ould t alk about t he social aspect of t he pat ient . Then t he
psychologist would t alk about t he whole em ot ional aspect of t he
pat ient . Then t he nurse, what would I t alk about since everyone
had t alked about everyt hing? So what was left for t he nurse was
t o look at t he whole, while t he ot hers t alked about t he part s
( P2 4 ) .
Nu r ses u n der st an d t h e in div idu al, n ot as a
s i c k i n d i v i d u a l b u t a s a s i n g l e , c o m p l e x a n d
m u lt idim en sion al bein g.
Acknowledging nurses’ t echnical- polit ical com pet ences
N u r s e s a r e a c k n o w l e d g e d a s t h e h e a l t h
p r of ession als w h o p ossess m or e r ef in ed k n ow led g e
and a broader view of healt h issues. According t o t he
i n t er v i ew ees, t h i s f act i s d u e t o t h ei r cap aci t y t o
est ablish a closer r elat ion w it h healt h user s in t heir
social cont ext . Because of t heir broader view , nurses
ar e ch ar act er ized by in t er v iew ees as ar t icu lat or s, a
propelling force and, consequent ly, t he reflex of healt h
care. The nurse is t he art iculat or of t he healt h services in societ y
or any ot her place he is in ( P8) . Nursing is t he profession t hat
m akes t he healt h service funct ion ( P25) . For m e, t he nurse is
t hat person in charge of any sect or, whet her in t he healt h unit or
hospit al. She is t he reflex of healt h care( P19). I n t he healt h t eam , t he nurse is a link … He is really a t est t ube, different ly from
I n o t h e r m o m e n t s , n u r s e s h a v e b e e n
ident ified, m or e specifically in t he social and healt h
policy areas, as t he pat ient s’ at t orney or t he people’s
sp ok esp er son . Th is com p et en ce is m or e v isib le in
pr of ession als w h o ex er t a m or e specif ic pu blic an d
polit ical role.I st art ed t o work in t he public area wit h a great
num ber of people. I perceived t hat people needed an act ive voice,
one t hat represent ed t hem and t hey saw I could be one t o defend
t hem in t hese areas ( P5) .
I n t his perspect ive, nurses st and out by t heir
or ganizat ion and involvem ent w it h healt h ser vices as
a w hole. For healt h pr ofessionals in gener al, nur ses
h av e an edu cat ion m or e f ocu sed on leader sh ip an d
t eam w or k an d ar e also sk illed t o m an age an d deal
w it h differ ent sit uat ions healt h user s m ight pr esent .
Nur ses w ill har dly m iss t he set of elem ent s, t hat is,
t h e u ser in ser t ed in t h e social n et w or k as a w h ole.
Nursing has a perspect ive t hat is innat e t o nursing and all t hose
who work in collect ive healt h perceive it …nurses have a broad
way of seeing t hings. Nurses are t hose who m ost of t he t im es
coordinat e t he healt h services. They have a specific educat ion, a
lit t le different from physicians, dent ist s… The work it self m akes
nurses m ore com m it t ed wit h t he syst em …I see m anagem ent ,
part icipat ion and t eam work as im port ant charact erist ics of t he
pr ofession ( P2 5 ) .
Nu r se s’ t e ch n i ca l - p o l i t i ca l co m p e t e n ce i s
highlight ed, especially because of t heir r esponsibilit y
and com m it m ent t o t he client ’s cause. The w ay t hey
see different m ovem ent s in daily pract ice allows t hem
t o in t egr at e, u n ify an d ar t icu lat e h ealt h ser v ices so
t hat user s hav e t heir pr oblem s solv ed.
Th e r esu lt s of t h e pr esen t r esear ch ex pan d
and st rengt hen ideas developed earlier st udies, which
sh ow ed ev iden ce t h at t h e n u r se occu pies im por t an t
space in t h e filed of social an d h ealt h policies. Th e
n u r se’s ab ilit ies ar e ex p r essed b y w ay s of d ealin g
w i t h h u m an f r ag i l i t i es, b y ed u cat i o n al an d h eal t h
pr om ot ion int er vent ions and, especially, t he abilit y t o
ar t icu lat e t h e h ealt h ser v ices in t egr at in g in div idu
al-so ci e t y - e n v i r o n m e n t - h e a l t h i n d i f f e r e n t f i e l d s o f
pr ofessional act iv it y( 10- 11).
DI SCUSSI ON
By com prehending t he individual as a whole,
nur ses, can est ablish a closer ident ificat ion w it h t he
social needs. Nurses have, m uch m ore t hat t he ot her
h ealt h p r of ession als, t h e cap acit y of m ain t ain in g a
m u ch m or e in t en se in t er act ion w it h t h e in d iv id u al,
fam ily and com m unit y. He/ she is able t o perceive and
g r a sp so ci a l p r o b l e m s a n d n e ce ssi t i e s i n a m o r e
concr et e m anner. For som e pr ofessionals, t he act ual
educat ion and w or k connect ion fav or nur ses t o hav e
a gr eat er com m it m ent and social inv olv em ent .
N u r s i n g c a r e a s s o c i a l p r a c t i c e , m o r e
specifically care in t he com m unit y, enriched by direct
int er v ent ion w it h indiv iduals and fam ilies, allow s one
t o go deeper, despit e uncer t aint ies and insecur it y. I t
allow s cr eat in g com p lex r elat ion s, t h at is, m u lt ip le
int eract ions in which professionals can devot e all t heir
cr eat iv e, in n ov at iv e an d en t r ep r en eu r ial p ot en t ial,
w h ich is lim it ed in sim p lif ied r elat ion s, as t h ose in
f o r m a l o r t r a d i t i o n a l h e a l t h ca r e i n st i t u t i o n s. Th e
pr of ession als’ t h ou gh t an d act ion f in d r eson an ce in
sy st em ic- com plex t h in k in g( 4 - 5 ), w h en au t h or s st r ess t hat som et hing is com plex w hen it inv olv es at least
m or e t han one int er act ive cir cum st ance or possibilit y
and a gr eat er num ber of ex planat or y ent it ies.
I n ev er y d ay lan g u ag e, a com p lex sit u at ion
“ sounds confusing and difficult t o be solved. I t evokes
a r eal i t y f u l l o f w ar p s, i n w h i ch sev er al v ar i ab l es
difficult t o be underst ood are hidden”( 12). However, in t h i s a u t h o r ’ s p o i n t o f v i e w , i t i s i n co m p l e x a n d
appar ent ly confuse and uncer t ain sit uat ions t hat t he
g r ea t est cr ea t i v e a n d i n t er a ct i v e p o ssi b i l i t i es a r e
hidden, because t hese dem and car eful consider at ion
and t he const ant sear ch for t he t r ut h, w hich r ev eals
t o be incr easingly com plex .
I t is clear for t he int erviewees t hat knowledge
needs t o be dialogued, shar ed and confr ont ed. This
i d e a i s e v i d e n t a s p r o f e s s i o n a l s d i s c u s s t h a t
int er v ent ions t hat used t o seem sim ple and easy t o
b e i d e n t i f i e d a n d e d i t e d , n o w d e m a n d a
m u lt idim en sion al per spect iv e. I n ot h er w or ds, t h ey
st art ed t o require a “ com plex conj unct ion of t he unique
wit h t he m ult iple and a look at t he part s t o underst and
t he whole and at t he whole t o underst and t he part s”( 13). Only a few years ago, a specialist wit h a m inim um of
per son al an d t ech n ological su ppor t , k n ow ledge an d
com pet ence acquir ed in school w ould deliber at e and
solv e t he m aj or it y of pr oblem s r elat ed t o healt h( 14). Now aday s, t h is pr ocess n eeds t o be ex pan ded an d
i n t er co n n ect ed w i t h d i f f er en t k i n d s o f k n o w l ed g e
because, in all disciplines, at all levels and in societ y
in gener al, healt h car e is incr easingly com plex .
Sy st em ic- com plex t hink ing k now ledge allow s
t he hum an being t o advance in t he concret e and real
w or ld of social phenom ena, in t he at t em pt t o bet t er
t hinkers, “ com plex t hinking m akes an effort t o unit e,
n ot in con f u sion , bu t by oper at in g dist in ct ion s. [ …]
The v it al need of t he planet ar y age, of our t im e, is
t h i n k i n g c a p a b l e o f u n i f y i n g , i n t e g r a t i n g a n d
dist inguishing”( 15).
T h i n k i n g a n d a c t i n g b a s e d o n t h e
in t er act ion s an d associat ion s of sy st em ic- com p lex
t h i n k i n g i m p l i e s m o v i n g t h r o u g h u n c e r t a i n t i e s ,
d i s c o n t i n u i t i e s a n d p a r t i a l k n o w l e d g e , i n o t h e r
w or d s, in a con t in u ou s an d p er m an en t sear ch f or
t h e d if f er en t an d n ew( 1 3 ).
Mu ch b ey on d m er e cr eat ion , in n ov at ion or
sim p lif ied h ealt h p r ob lem - solv in g , “ n u r sin g car e as
social pract ice” requires t hat nurses are placed in t he
concret e realit y and develop proposals t hat effect ively
s h o w s o c i a l p a r t i c i p a t i o n . I n t h i s p e r s p e c t i v e ,
confront ing wit h em ergent social cont radict ions m eans
act ing w it h a v iew t o r et hink ing t r adit ional pr act ices
and post ur es and definit ely assum ing a new at t it ude
in defense of life, t hr eat ened by t he hegem onic and
r educt ionist econom ic m odel( 12).
Nu r si n g h a s m u l t i p l e co m p e t e n ce s a n d a
broad and socially renowned field of act ion, but it needs
t o dar e and ex plor e oppor t unit ies and env isage new
s p a c e s , u n d e r s t a n d i n g t h a t b e i n g a s o c i a l
e n t r e p r e n e u r m e a n s b e i n g ca p a b l e o f e x p l o r i n g
oppor t unit ies and leading new pr ofessional fields and
pr act ices. I t m ean s bein g able t o im agin e, dev elop
and m ake visions com e t rue, where t he concept s per
se, synergy, leadership and relat ion/ int eract ion syst em
ar e essent ial elem ent s ( 16).
Nu r sin g car e as a social p r act ice b ased on
com plex- syst em ic t hinking const it ut es a new paradigm
of int ervent ion, capable of st rengt hening social act ions
t hr ough int er act iv e and associat iv e net w or k s, and of
act in g in a p r oact iv e, in n ov at in g an d p ar t icip at iv e
m an n er.
Thinking about t he individual and relat ive who
is int roduced t o t he healt h professional in a condit ion
o f v u l n er ab i l i t y r eq u i r es l ev el s o f co m p r eh en si o n ,
good r ecept ion, qualified list ener and int er - subj ect ive
b o n d s o f c o n f i d e n c e , s u s t a i n e d i n t h e l i g h t o f
r e f e r e n c e s t h a t c o n c e i v e t h e m u l t i p l e v a r i a b l e
in t er r elat ion s an d in t er con n ect ion s t h at in v olv e t h e
h ealt h - disease pr ocess.
FI NAL CONSI DERATI ONS
Nu r sin g car e as social p r act ice is st r on g ly
asso ci at ed t o t h e i d ea o f co m m u n i t y i n cl u si o n o r
com m u n it y in clu sion p r act ices. For p r of ession als in
gener al, nur sing is char act er ized as hist or ical social
pr act ice and it s pr act ice is em inent ly social.
The nur ses’ social pr act ice is also associat ed
t o t he int egrat ed and int egrat ing com m unit y pract ices.
I t is clear, f or n u r ses as w ell as f or t h e r em ain in g
h ealt h p r of ession als, t h at com m u n it y p r act ices ar e
f lex ib le an d sen sit iv e f ield s, cap ab le of ex p an d in g
in t er act iv e possibilit ies an d en su r e solv in g capacit y
in h ealt h . On t h e con t r ar y, h osp it al f acilit ies w er e
d e scr i b e d a s l i m i t e d sp a ce s, a sso ci a t e d t o w o r k
d i v i si o n , h i er ar ch i cal st r u ct u r e, r i g i d i t y an d st r i ct
st an dar ds, am on g ot h er s.
Nur sing car e as social pr act ice is highlight ed
an d d ist in g u ish ed , in su m m ar y, b y in t er act iv e an d
i n t e g r a t i n g ca r e p r a ct i ce s, w h i ch h a v e a cq u i r e d
im por t ant r eper cussion, bot h in educat ion as in t he
h ealt h pr om ot ion an d pr ot ect ion of in div idu als. On e
m ay say, w it hout m uch deliberat ion, t hat nur sing is
an em inent ly social pr ofession and incr easingly seen
as t he profession of t he fut ure, due t o t he possibilit y
of underst anding t he individual, not as a sick individual
but as a m ult idim ensional being, w it h self- or ganizing
pot ent ial and, t hus, par t icipant and aut hor of his( er )
ow n h ist or y. Th er ef or e, n u r sin g n eed s t o inv est in
p r o a ct i v e a t t i t u d e s, ca p a b l e o f p r o m o t i n g so ci a l
d e v e l o p m e n t t h r o u g h t h e e x p a n s i o n o f a c t u a l
o p p o r t u n i t i es f o r h u m a n b ei n g s i n t h ei r r ea l a n d
con cr et e con t ex t .
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