THE NURSI NG W ORK PROCESS I N CARE FOR HEALTHY
CHI LDREN AT A SOCI AL SECURI TY I NSTI TUTI ON I N MEXI CO
1Yolanda Flor es Peña2 Mar ia Cecília Punt el de Alm eida3 Rafael Luis Cast illo Dur anza4
Flor es Peña Y, Alm eida MCP, Cast illo Duranza RL. The nur sing w or k pr ocess in car e for healt hy childr en at a social secur it y inst it ut ion in Mex ico. Rev Lat ino- am Enfer m agem 2006 set em br o- out ubr o; 14( 5) : 651- 7.
We aim ed t o analyze t he nursing work process direct ed at care in t he Nut rit ion, Growt h and Developm ent Surveillance and Cont rol Program ( VNCD) for children under five years at a social securit y inst it ut ion in Mexico. The st udy adopt ed a qualit at iv e appr oach and w as based on t he w or k cat egor y , on concept ions of t he w or k pr ocess in healt h and on inst it ut ional analy sis. We car r ied out dir ect sy st em at ic obser v at ions and int er v iew s w it h a gr oup of nur ses and t heir assist ant s and w it h m ot her s w ho at t ended nur sing appoint m ent s w it h t heir ch ild r en . Th e car e p r ocess w as id en t if ied as p r oced u r e- cen t er ed an d b ased on car e p r ot ocols, w it h r ap id appoint m ent s and lit t le room for int eract ion bet ween nurses and m ot hers. However, on som e occasions, nurses w er e capable of pr oducing liv e w or k as a r esult of t heir self- gov er nm ent , w hich allow ed t hem t o est ablish a m ot h er / ch ild- cen t er ed car e n u cleu s.
DESCRI PTORS: child car e; m at er nal- child nur sing; biom edical t echnology
EL PROCESO DEL TRABAJO DE LA ENFERMERA EN EL CUI DADO AL NI ÑO
SANO EN UNA I NSTI TUCI ÓN DE LA SEGURI DAD SOCI AL DE MÉXI CO
El obj et iv o fue analizar el pr oceso de t r abaj o de la enfer m er a en el Pr ogr am a de Vigilancia y Cont r ol de la Nut rición, Crecim ient o y Desarrollo ( VNCD) del m enor de cinco años, en la Seguridad Social de México. El est udio, de apr ox im ación cualit at iv a, se fundam ent ó en la cat egor ía t r abaj o, en los concept os de pr oceso de t rabaj o en salud y en enferm ería, en la m icropolít ica del t rabaj o vivo en salud, así com o en el análisis inst it ucional. Se r ealizar on obser v aciones sist em át icas dir ect as y ent r ev ist as a un gr upo de enfer m er as, sus asist ent es y a las m adr es que acudier on con sus hij os a la consult a de enfer m er ía. El pr oceso de cuidado ident ificado fue procedim ient o- cent rado, basado en prot ocolos de at ención con consult as rápidas y con poco espacio de int eracción ent re la enferm era y la m adre. Sin em bargo, la enferm era fue capaz de producir, en ocasiones, t rabaj o vivo a par t ir de su aut ogobier no, per m it iéndole est ablecer un núcleo de cuidado m adr e/ hij o- cent r ado.
DESCRI PTORES: cuidado del niño; enfer m er ía m at er no- infant il; t ecnología biom édica
O PROCESSO DE TRABALHO DA ENFERMEI RA NO CUI DADO À CRI ANÇA
SADI A EM UMA I NSTI TUI ÇÃO DA SEGURI DADE SOCI AL DO MÉXI CO
O obj et iv o foi an alisar o pr ocesso de t r abalh o da en fer m eir a or ien t ado ao cu idado n o Pr ogr am a da Vigilância e Cont role da Nut rição, Crescim ent o e Desenvolvim ent o ( VNCD) do m enor de cinco anos na Seguridade Social do México. O est udo, de abor dagem qualit at iva, se fundam ent ou na cat egor ia t r abalho, nas concepções do processo de t rabalho em saúde e em enferm agem , na m icropolít ica do t rabalho vivo em saúde assim com o n a an álise in st it u cion al. Realizar am - se ob ser v ações sist em át icas d ir et as e en t r ev ist as com u m g r u p o d e en fer m eir as, su as assist en t es e as m ães qu e com par ecer am com seu s filh os à con su lt a de en fer m agem . O processo de cuidado ident ificado foi o procedim ent o- cent rado baseado em prot ocolos de at enção, com consult as rápidas e pouco espaço de int er ação ent r e enferm eira e m ãe. No ent ant o, a enferm eira foi capaz de produzir, em ocasiões, t rabalho vivo a part ir do seu aut o- governo, o que lhe perm it iu est abelecer um núcleo de cuidado m ãe/ f ilh o- cen t r ad o.
DESCRI TORES: cuidado da cr iança; enfer m agem m at er no- infant il; t ecnologia biom édica
1
Paper ex t r act ed fr om t he Doct or al Disser t at ion; 2 Ph. D. in Nur sing, Pr ofessor at Nuev o León Aut onom ous Univ er sit y Facult y of Nur sing, e- m ail: y olaflo@hot m ail.com ; 3 Ph.D. in Public Healt h, Full Pr ofessor, e- m ail: cecilia@eer p.usp.br ; 4 Ph.D. St udent ,, e- m ail: r cast illoduranza@yahoo. com . br. Universit y of São Paulo at Ribeirão Pret o College of Nursing - WHO Collaborat ing Cent re for Nursing Research Developm ent .
I NTRODUCTI ON
Childr en const it ut e a pr ior it y gr oup in global
h eal t h car e ef f o r t s. D u r i n g t h e Wo r l d Su m m i t f o r
Children 1990, a Declarat ion and an Act ion Plan were
adopt ed, w it h 27 goals for t he survival, developm ent
an d pr ot ect ion of ch ildr en an d adolescen t s. Am on g
t hese, newborn care, breast feeding prom ot ion,
follow-up of child gr ow t h and dev elopm ent , im m unizat ions,
as w ell as p r ev en t ion an d con t r ol of d iar r h eic an d
acut e r espir at or y diseases st and out .
Th e f o l l o w - u p o f c h i l d g r o w t h a n d
dev elopm en t , w h ich h ealt h pr of ession als an d u ser s
a l so i d e n t i f y a s He a l t h y Ch i l d Ca r e , i s a ce n t r a l
com pon en t in com m u n it y h ealt h ser v ices. Th is car e
cont ains t hr ee m ain elem ent s: im m unizat ion, gr ow t h
and dev elopm ent assessm ent and healt h educat ion.
I t can b e p r act i ced b y p h y si ci an s o r n u r ses( 1 ). I n
Mex i co , t h ese act i o n s ar e co v er ed b y t h e Of f i ci al
Mex ican St andar d for Child and Adolescent Nut r it ion,
Gr ow t h an d Dev elop m en t Con t r ol, issu ed in 1 9 9 4 .
Ch ild car e im p lies im p lem en t in g h ealt h p r om ot ion ,
diagnosis, t reat m ent and m aint enance act ivit ies which,
in t he case of t he Mexican Social Securit y I nst it ut ion,
ar e par t of t h e Nu t r it ion , Gr ow t h an d Dev elopm en t
Sur v eillance and Cont r ol Pr ogr am for childr en under
five years ( VNCD) . The VCND is a st rat egy for int egral
car e d eliv er y, aim ed at r aisin g h ealt h lev els in t h e
p o p u l a t i o n u n d e r f i v e y e a r s o l d , d e c r e a s i n g
m alnut rit ion rat es in t he child and preschool populat ion
and reducing m orbidit y and m ort alit y in t his group( 2).
Social Securit y is t he m ain com ponent of t he
Mex ican Healt h Sy st em an d at t en d s ab ou t 5 0 % of
t h e popu lat ion . Th e VNCD pr ogr am is dev eloped at
Fam ily Medicine Unit s ( FMU) by t eam s t hat consist of:
fam ily phy sician, social w or ker, psychologist , dent ist ,
nut r it ionist , m edical assist ant of t he m at er nal- infant
n u r se ( AEMI ) a n d m a t er n a l - i n f a n t n u r se ( EMI )( 2 ).
Newborns are assessed by t he fam ily physician during
t he first t hree m ont hs, who refers t hem aft erwards t o
t he EMI t o cont inue VNCD care up t o t he age of five.
The m ain EMI act ivit ies include: deliver VNCD care t o
childr en under five year s, det ect r isk fact or s, com ply
w i t h f a m i l y p h y s i c i a n ’ s i n d i c a t i o n s a n d e d u c a t e
m ot h er s or r esp on sib le f am ily m em b er s t o ach iev e
fav or able habit s and behav ior( 2).
Research has assessed t he qualit y of EMI care
t o ch i l d r e n i n t h i s p r o g r a m t h r o u g h q u a n t i t a t i v e
in dicat or s, su ch as t h e n u m ber of v isit s du r in g t h e
fir st year of life and im m unizat ions. How ev er, t hese
st udies hav e not per for m ed a qualit at iv e assessm ent
o f h o w t h i s ca r e i s d e l i v e r e d , i t s g o a l s a n d h o w
accom pany ing m ot her s per ceiv e it( 3 ).
Th i s r e s e a r c h a i m s t o a n a l y z e t h e w o r k
process of m at ernal- infant nurses ( EMI ) in a Nut rit ion,
Gr ow t h an d Dev elop m en t Su r v eillan ce Pr og r am f or
children under five years ( VNCD) at a Social Securit y
I n st it u t ion in Mex ico, f ocu sin g on t h e n u r sin g car e
pr odu ct ion pr ocess.
THEORETI CAL FOUNDATI ONS
Th i s s t u d y w a s b a s e d o n t h e o r e t i c a l
considerat ions about work in t he Marxist concept ion( 4),
i n co m b i n a t i o n w i t h co n si d er a t i o n s t h a t st u d y i t s
par t icular it ies in healt h( 5) and in nur sing( 6). I t is also
b a se d o n m i cr o - p o l i t i ca l co n ce p t i o n s o f w o r k i n
healt h( 7) and in inst it ut ing and inst it ut ed processes( 8).
Wo r k co n st i t u t es an essen t i al cat eg o r y t o
st udy social pr act ices, including t hose in healt h and
nursing. The com ponent s of t he work process are “ t he
act ivit y t hat is adequat e for a goal, t hat is, work it self;
t he m at t er t he w or k is applied t o, t he w or k obj ect ;
t he w or k m eans, t he w or k inst r um ent s”( 4).
I n h ealt h , in or d er t o ap p r eh en d t h e w or k
obj ect , i. e. m an and his needs, agent s need t o use
w or k inst r um ent s, in t he int ellect ual ( k now ledge for
ex am ple) and m at er ial dim ensions ( t ools, m achines,
d ev ices)( 5 ). Th ey also n eed t o est ab lish in t er act iv e
r elat ions w it h user s, pr oducing subj ect iv it ies( 9).
Th e t h eo r et i ca l co n cep t i o n su st a i n i n g t h e
inst it ut ing pr ocess em er ges fr om t he I nst it ut ionalist
or I n st it u t in g Mov em en t , j oin in g d if f er en t cu r r en t s
d ev elop ed b y Fr en ch an d Lat in - Am er ican au t h or s.
Th r ee m ain b r an ch es ar e f ou n d in Lat in - Am er ican
l i t e r a t u r e : Gé r a r d Me n d e l ’ s so ci o p sy ch o a n a l y si s,
inst it ut ional analysis by Georges Lapassade and René
Lourau, and schizoanalysis by Félix Guat ari and Gilles
D e l e u ze . Th i s st u d y t a k e s so m e co n ce p t s t h e se
cu r r en t s h av e in com m on , su ch as in st it u t in g an d
inst it ut ed pr ocesses and m olar and m olecular( 8).
Al l p r o d u ct i o n p r o ce sse s h a v e a p r o d u ct ,
generat e a result . That is t he inst it ut ed. “ The inst it ut ed
is t he effect of an inst it ut ing act ivit y ( …) t he inst it ut ing
appears as a process, while t he inst it ut ed appears as
a r e s u l t . Th e i n s t i t u t i n g t r a n s m i t s a d y n a m i c
ch ar act er ist ic an d t h e in st it u t ed t r an sm it s a st at ic,
fr ozen char act er ist ic”( 8 ). Th e in st it u t ed is im por t an t ,
in social life. I n t his sense, t he inst it ut ing is not always
g o o d , n o r i s t h e i n st i t u t e d b a d . “ Th e i n st i t u t i n g
appears as a revolut ionary, creat ive and t ransform ing
act iv it y par ex cellence. I n fact , it is not ex act ly lik e
t hat , because t he inst it ut ing would lack all m eaning if
it w er e n ot sh ap ed , if it d id n ot m at er ialize in t h e
inst it ut ed. On t he ot her hand, t he inst it ut ed would not
b e u sef u l , w o u l d n o t b e f u n ct i o n a l i f i t w er e n o t
p e r m a n e n t l y o p e n t o i n st i t u t i n g p o w e r s” ( 8 ). Th e
concept s of m olar and m olecular r efer t o t he m acr o
an d m icr o- sph er es t h at ar e im m an en t . Th u s, social
lif e is a n et w or k in w h ich t h ese ar eas ar e pr esen t .
The sm all, local ( m olecular) connect ions are t he place
of t he inst it ut ing( 8). Hence, it is in t he m icro- polit ics of
w or k t hat pr oduct ion pr ocesses of subj ect iv it y occur.
Th e t er m i n o l o g y u sed i n t h i s t ex t ( h eal t h
product ion, healt h care product ion, product ive act ) is
based on in st it u t ion alism , w h ich def in es pr odu ct ion
as “ w hat pr ocesses ev er y t hing t hat ex ist s nat urally,
t ech n i cal l y, su b j ect i v el y an d soci al l y ”( 8 ). I n h eal t h
p r o d u ct i o n , i t m e a n s p r o d u ci n g g o o d s/ p r o d u ct s,
subj ect ivit ies and relat ions t o at t end t o individual and
collect iv e healt h needs.
Nursing as a social pract ice ( as work) can be
st u d i e d i n t e r m s o f p e r f o r m a n ce , i d e n t i f y i n g i t s
m o m e n t s , c a r e s u b j e c t / o b j e c t , w o r k a g e n t s ,
in st r u m en t s an d pu r pose, f or w h ich t h e con cept of
t ech n olog ical w or k or g an izat ion w as con sid er ed( 6 ).
Technology in t his concept does not only refer t o t he
m e a n i n g t h e se t o f m a t e r i a l i n st r u m e n t s h a s i n
com m on, but is also considered as a set of knowledge
and m eans expressed in service product ion processes,
t h e n et w or k of social r elat ion s in w h ich it s ag en t s
art iculat e t heir pract ice in a social t ot alit y( 5). I n addit ion
t o t his concept , t here is t he “ t ypology of t echnologies”,
including light ( bonding, aut onom izat ion, w elcom ing) ,
light - har d ( w ell- st r uct ur ed know ledge of healt h ar eas
a n d p r o f e s s i o n a l s ) a n d h a r d t e c h n o l o g i e s
( t echnological equipm ent like m achines, st andards and
or g an izat ion al st r u ct u r es)( 7 ). Th e m eet in g b et w een
h ealt h pr of ession als an d u ser s occu r s t h r ou gh ligh t
t ech n olog ies. Th is classif icat ion of t ech n olog ies in
healt h allow s us t o under st and t he m icr o- polit ics of
healt h work, present ing t he discussion about workers’
self- gov er nm ent and liv e w or k in act ion( 7).
Th e h ealt h w or k pr ocess con t ain s bot h liv e
and dead w or k , and one can pr evail ov er t he ot her.
Dead w or k r ef er s t o all pr odu ct s- m ean s pr esen t in
work ( eit her as t ools or raw m at erial) and which result
fr om ear lier hum an w or k . Liv e w or k m eans w or k in
a ct i o n , p r o d u ce d b y “ o ccu r r i n g ” i n t h e a ct o f i t s
r ealizat ion , allow in g f or in st it u t in g p r ocesses. Th e
w o r k e r c a n p o s s e s s a c e r t a i n d e g r e e o f s e l f
-governm ent , which will be charact erized by t he act ion
of his/ her live work on what ( s) he is offered as dead
w o r k a n d t h e g o a l ( s ) h e i s a i m i n g f o r. Th i s i s
im m ediat ely consum ed by user s in t he pr oduct ion of
t h e a c t i o n . Th u s , i n t h e c a s e o f p r o d u c t i o n /
con su m p t ion in h ealt h , a sp ace f or in t er act ion an d
int ervent ion is const ruct ed bet w een t he user and t he
w or k er w h o pr odu ces t h e act ion , in w h ich bot h t h e
u ser an d t h e w or k er in st it u t es n eed s an d w ay s of
capt ur ing t hem , of act ing( 7). I n healt h car e act s, t he
l i v e w o r k d i m en si o n i s ex p ect ed t o p r ev a i l , a s i t
oper at es w it h r elat ion sh ip t ech n ologies, su bj ect iv it y
e n co u n t e r s, sp a ce s f o r w e l co m i n g a n d l i st e n i n g ,
b e y o n d st r u ct u r e d t e ch n o l o g i ca l k n o w l e d g e a n d
eq u i p m en t . Th e d ead w or k r ecor d ed i n m at er i al s,
st andards, rout ines and care prot ocols is undoubt edly
im port ant for t he product ion of healt h act s. However,
t hese inst r um ent s ar e not sufficient t o pr oduce car e
cent er ed in user s’ needs.
We c o n s i d e r c a r e a s t h e s o u l o f h e a l t h
ser v ices, as t h e essen ce of n u r sin g, as it s cen t r al,
dom inant and unify ing char act er ist ic. This is about a
t h er ap eu t ic in t er v en t ion t h at m u st cen t er in u ser s’
needs. I n t he case of EMI visit s, nurses are responsible
f or p r od u cin g a car e n u cleu s, t h at is, a sp ace f or
w or k er - u ser in t er act ion t h at allow s f or list en in g, as
w ell as bonding and confidence, per m it t ing m ot her s
t o express t heir doubt s relat ed t o care for her healt h
and t hat of her children( 7).
METHODOLOGY
Qu a l i t a t i v e m e t h o d o l o g y w a s co n si d e r e d
appr opr iat e for t h is st u dy, as it allow s for a cr it ical
and reflexive analysis of t he EMI work process. St udy
part icipant s, ident ified as healt h personnel, were: four
n u r ses ( EMI ) w h o car r y o u t VNCD v i si t s an d t w o
m ed i cal assi st an t s o f EMI ( AEMI ) , r esp o n si b l e f o r
receiving users, in t his case m ot hers/ children. We also
included 25 m ot hers who at t ended t he visit s wit h t heir
childr en and ident ified t hem selv es as such, since w e
consider t hem as t he subj ect / obj ect of nur sing car e.
D a t a c o l l e c t i o n t e c h n i q u e s w e r e : d i r e c t
s y s t e m a t i c o b s e r v a t i o n o f 8 7 EM I v i s i t s a n d
ob ser v at ion of t h e r ecep t ion ar ea w h er e AEMI ar e
h ealt h st af f ( 6 in t er v iew s) an d in t er v iew s w it h t h e
m ot hers ( 25 int erviews) . The t echniques were applied
u n t i l d a t a sa t u r a t i o n w a s r e a ch e d a n d u n t i l t h e
m ean in g of t h e EMI w or k pr ocess w as u n der st ood.
Befor e t he obser v at ions and int er v iew s, par t icipant s
r eceiv ed ex planat ions about t he r esear ch obj ect iv es
and signed t he fr ee and infor m ed consent t er m .
Aspect s were regist ered in t erm s of how care
i s p r o d u ce d d u r i n g t h e v i si t , i n cl u d i n g d u r a t i o n ,
i n t e r a ct i o n s, d i a l o g u e s b e t w e e n h e a l t h st a f f a n d
m ot her / child user, accom plished pr ocedur es and how
t h ey w er e accom plish ed, in st r u m en t s u sed, as w ell
as gener al aspect s t o char act er ize childr en at t ending
t he visit s ( age, gender, first or subsequent visit ) . Dat a
w ere regist ered on an inst rum ent especially designed
for t his pur pose.
I nt er v iew s w er e audio- t aped. I n t he case of
h e a l t h p r o f e s s i o n a l s , i n t e r v i e w s l o o k e d a t c a r e
product ion aspect s, allowing subj ect s t o freely express
t heir opinions.
Mot hers were approached when t hey left t he
EMI visit . Tw ent y int erview s w ere held in t he wait ing
room , dist anced from t he EMI work area, and five at
p a r t i ci p a n t s’ h o m e s, t o t a l i n g 2 5 i n t e r v i e w s. Th e
t echnique looked at care product ion aspect s, allowing
m ot her s t o fr eely ex pr ess how t hey per ceiv ed car e,
if t hey had t he opport unit y t o m anifest t heir concerns
and needs during t he visit , and how t he AEMI and t he
EMI t reat ed and int eract ed wit h herself and her child.
Dat a were collect ed bet ween February and July 2004.
Dat a w er e an aly zed b y m ean s of t h em at ic
an aly sis. Th e id ea of t h em e is con n ect ed w it h an
affir m at ion r elat ed t o a par t icular subj ect , t r y ing t o
d i s c o v e r t h e u n i t s o f m e a n i n g t h a t i n t e g r a t e a
com m unicat ion, w hose pr esence or fr equency m eans
so m et h i n g f o r t h e p r o p o sed o b j ect i v e( 1 0 ). Fr o m a
qualit at ive perspect ive, t he presence of cert ain t hem es
indicat es t he r efer ence values and behavior al m odels
t hat ar e pr esent .
Th r ee t h em es w er e id en t if ied : in st it u t ion al
configur at ion, EMI car e pr oduct ion and healt hy child
con t r ol. We decided t o discu ss an d an aly ze n u r sin g
car e pr oduct ion because t he nur sing w or k pr ocess in
healt hy child cont rol is t he cent ral obj ect of t his st udy.
I n t er m s of n u r sin g car e p r od u ct ion, w e an aly zed
aspect s relat ed t o t he dynam ics of t he work process,
t h e o b j e ct / su b j e ct o f w o r k , r e sp o n si b l e a g e n t s,
p r ocesses occu r r in g in t h e in t er ior of t h e w or k er /
int er act ion space, liv e w or k / dead w or k , t echnologies
and self- gov er nm ent of healt h per sonnel, pr oduct ion
of a pr ocedu r e- cen t er ed or u ser - cen t er ed ( m ot h er /
ch ild- cen t er ed) car e n u cleu s.
I n t he last phase, we considered t he ident ified
em p ir ical t h em at ic u n it s an d cor r elat ed t h em w it h
t h e o r e t i c a l c o n c e p t i o n s , w h i c h a l l o w e d u s t o
r econ st r u ct t h e m om en t s of t h e EMI w or k p r ocess
and r each conclusions.
This st udy was carried out in line wit h et hical
g u id elin es p r op osed in t h e Gen er al Healt h Law f or
Healt h Research in Mexico and was aut horized by t he
St at e’s Healt h Resear ch Coor din at ion .
RESULTS AND DI SCUSSI ON
I n t he cases we st udied, m ot hers assum e t he
role of caregiver for t heir children, which is why healt h
pr ofessionals consider t hem as t he subj ect / obj ect of
EMI care: Children are t ot ally dependent on t heir m ot hers ( I nt .
EMI 3 ). Th is sit u at ion m ak es h ealt h st af f t h in k , in
gener al, t hat it is alw ay s t he m ot her w ho com es t o
t he v isit . Consequent ly, v er ify ing t he fam ily r elat ion
bet w een t h e ch ild an d t h e per son accom pan y in g is
not a part of rout ine. Dat a like t he com panion’s age,
n u m ber of ch ildr en , edu cat ion lev el, am on g ot h er s,
ar e not v er ified eit her dur ing v isit s.
I n o u r st u d y, m o t h er s’ m ean ag e w as 2 9
years. They had finished high school ( 11 years) , were
housewives ( 76% ) and m arried ( 76% ) . The children’s
m ean age w as 1 2 m ont hs. Av er age w ait ing t im e t o
receive care was 19 m inut es, rising up t o 90 m inut es
in t w o cases. Eight y - four per cent of t he v isit s w er e
su b seq u en t .
B o t h h e a l t h p r o f e s s i o n a l s a n d m o t h e r s
m ent ioned an unfav or able econom ic sit uat ion as one
a sp e ct t h a t m a d e t h e m v i si t t h e se r v i ce . Th i s i s
according t o lit erat ure, which indicat es socioeconom ic
sit u at ion as a d et er m in an t f act or in h ealt h ser v ice
select ion( 1 1 ). Mot h er s r elat ed t h e econ om ic qu est ion
wit h m ilk donat ion, which appeared as an aspect t hat
or ient ed/ disor ient ed car e: Most people ar e int er est ed in
t he m ilk because of t he econom ic sit uat ion, a box of m ilk cost s 60
t o 80 pesos and only last s 3 days ( I nt . AEMI ) , I don’t have m ilk
anym ore, I was buying it , but it cost s 55 pesos and som et im es
you don’t have t hat m oney ( I nt . m ot her 8) .
H e a l t h p r o f e s s i o n a l s a c k n o w l e d g e t h a t
m ot hers’ educat ion level and t he exist ence of groups
w i t h sp e ci a l ca r e n e e d s, su ch a s a d o l e sce n t a n d
working m ot hers, have been increasing. However, t his
int erviewed m ot hers indicat ed t hat power prevails over
academ ic lev el, w hich r aises a st r ong im pedim ent t o
dialogue: Your academ ic level gives you securit y but , over t here,
all of t hem believe t hey have power, t hey dim inish you and believe
t hat everybody who goes t here is illit erat e ( I nt . m ot her 25).
Th e m o t h e r s m e n t i o n e d r e l a t i o n s h i p
t echnologies as an essent ial elem ent in car e deliver y
an d r eq u est ed t h at u ser s b e r ecog n ized as h u m an
beings wit h needs: They should see us as hum an beings, if
you go t here it ’s because you need t o, and nobody should have t o
leave t here and need t o see a shrink, because of what t hey do t o
you ( I nt . m ot her 25) .
An o t h e r i n t e r e st i n g a sp e ct w a s t h a t t h e
m ot her s indist inct ly ident ified t he EMI as phy sicians
or nur ses, indicat ing t hat t he EMI did not lik e t o be
ident ified as physicians. Som e considered t he fact t hat
t h ey ar e n u r ses as adequ at e, h igh ligh t in g t h e n eed
f o r k n o w l e d g e u p d a t i n g . H o w e v e r, t h e m o t h e r s
m ent ioned t hat t he EMI did not like t o be ident ified as
d oct or s, b u t t h e EMI d id n ot p er ceiv e t h at sh e is
reproducing t he m edical m odel, cent ered in anat om
ic-phy siological par am et er s. This sit uat ion has alr eady
been regist ered in ot her st udies of out pat ient as well
as hospit al car e( 12).
The EMI wast e m any opport unit ies t o ident ify
and answ er t he com panions’ concerns and quest ions.
The care delivered in t he VNCD program under analysis
const it ut es a procedure- cent ered healt h pract ice. The
w a y h e a l t h c a r e i s p r o d u c e d d o e s n o t a c h i e v e
i n t e g r a l i t y, w h i c h i s c o n s i d e r e d t o b e t h e
a ck n o w l e d g e m e n t o f t h e co m p l e t e r a n g e o f u se r
healt h- r elat ed needs. This m ak es it m or e difficult t o
est ablish long- t erm relat ions t hat produce EMI - m ot her
b on d in g , w h ich is on e of t h e p r in cip les of p r im ar y
car e( 13).
EMI st aff carried out 12 healt hy child cont rol
v i si t s p er d ay, w h i ch ar e p r o g r am m ed t o t ak e 1 0
m inut es each. We observed 87 visit s and ident ified a
m ean durat ion of 11 m inut es, ranking from four t o 32
m inut es. The m ot hers qualified t he visit s as fast and
added t hat , som et im es, it is not wort h it t o wait a long
t i m e t o b e a t t e n d e d i n a f a st a n d r o u t i n e w a y.
Moreover, EMI st aff ident ified t he issue of program m ed
visit t im e as a lim it ing fact or t o est ablish t he worker/
user int eract ion space. Neit her t he program m ed t im e
of 10 m inut es, nor t he average observed t im e of 11.34
m inut es is sufficient t o allow for t he est ablishm ent of
a m ot her/ child- cent ered care nucleus. These dat a are
sim ilar t o t h e du r at ion of 1 1 . 8 5 m in u t es f or Fam ily
Healt h Pr ogr am v isit s by fem ale phy sicians in Br azil,
in com par ison w it h 9 m inut es for m ale phy sicians in
t he sam e program . Furt herm ore, it should be point ed
out t hat longer visit t im es ar e associat ed w it h bet t er
car e qu alit y : bet t er qu est ion in g, bet t er ex plan at ion
of t he problem and verificat ion by t he physician about
t he pat ient ’s under st anding( 14).
I n or der t o ident ify w het her car e pr oduct ion
w as p r oced u r e or u ser - cen t er ed , w e an aly zed t h e
w or k er / u ser i n t er act i on sp ace, an d i d en t i f i ed t h at
n u r sin g v isit s f ollow ed t h e sam e sy st em izat ion as
prot ocols and were only different iat ed by t he children’s
age, w hich w as under one or bet w een one and four
y ear s old. What char act er ized EMI v isit s t o childr en
of less t han one year old was t hat t hey verified weight ;
m ea su r ed h ei g h t a n d h ea d , ch est a n d a b d o m i n a l
circum ference; com pared weight and height m easures
w it h r ecom m ended lev els on t he inst it ut ion’s t ables;
r ev ised t he v accinat ion car d; gav e a pr escr ipt ion for
m i l k d o n a t i o n ; r eg i st er ed d a t a i n t h e ch i l d ’ s f i l e,
r ef er r ed t h e ch i l d f o r p r ev en t i v e d en t a l ca r e a n d
pr ev en t iv e m edicin e f or v accin at ion , an d ask ed t h e
m ot her t o m ake t he next appoint m ent wit h t he AEMI .
Pr act ically t he sam e pr ocedur es w er e car r ied out in
childr en bet w een one and four y ear s old, ex cept for
ci r cu m f e r e n ce m e a su r e m e n t s, a n d ch i l d r e n w e r e
screened for flan feet . Therefore, t he EMI ’s live w ork
i s c a p t u r e d b y t h e i r d e a d w o r k b e c a u s e o f t h e
in st it u t ion al con f ig u r at ion ex p r essed in t h e ser v ice
p r ot ocols an d r ou t in es. Th e p r ot ocols p r od u ced in
h ealt h car e t o g u ar an t ee m in im al car e asp ect s f or
specific groups or diseases can provoke alienat ed work
w h en t h ey ar e u sed m ech an ically, an d can m ake it
difficult t o list en or ident ify ot her user needs, beyond
t hose cov er ed in t he pr ot ocols( 15).
The m onosyllabic com m unicat ion pat t ern and
r ap i d w ay o f p er f o r m i n g t h e v i si t m ak es m o t h er s
confused about t he indicat ions t hat are given. There is
great concern about obt aining inform at ion from m ot hers
about t he child’s nut rit ion, as w ell as dat a relat ed t o
gr ow t h and dev elopm ent , w it h a v iew t o r egist er ing
t hem in t he child’s file, wit hout t he goal of providing a
space, t hrough t hese quest ions, for m ot hers t o express
t heir doubt s, feelings, difficult ies and needs t o t ak e
car e of t heir childr en. Thus, t he est ablished dialogue
was m uch m ore of a m onologue from t he EMI t owards
t he m ot her. This result is in line wit h ot her st udies t hat
i n d i ca t e t h a t 6 5 % o f p a t i en t s a r e i n t er r u p t ed b y
physicians 15 seconds alt er t hey have st art ed t o explain
t heir pr oblem and t hat pat ient s’ fear s and anx iet ies
Th e EMI p r o v i d e r e d u ce d a n d i n co m p l e t e
inform at ion t o t he AEMI . Therefore, we cannot consider
t his as healt h educat ion, under st anding t he lat t er as
edu cat ion for t r an sfor m at ion , seek in g t o br eak w it h
p ow er - cen t er ed ed u cat ion m et h od s an d p r om ot in g
individual and group part icipat ion in t he ident ificat ion
and cr it ical analy sis of t heir pr oblem s.
Mot h er s ex pr essed t h e n eed for t h e EMI t o
r eaf f ir m t h eir au t on om y in car e f or t h eir ch ildr en ’s
healt h. None of t hem considered t he healt h st aff ( EMI
a n d AEMI ) a s a d v i se r s o r e d u ca t o r s, w h i ch g o e s
against ot her st udies car r ied out in t he USA, w hich
concluded t hat , in general, nurses are m ore act ive in
h e a l t h a d v i ce a n d e d u ca t i o n i n co m p a r i so n w i t h
p hy sician s( 1 ). How ev er, w e cou ld also id en t if y t h at ,
som et im es, t h e EMI w er e capable of pr odu cin g liv e
w o r k , cr ea t i v e w o r k , m a i n l y b a sed o n t h ei r sel f
-gov er n m en t , w h ich allow ed t h em t o get ou t of t h e
inst it ut ional configurat ion and m anage t o pay at t ent ion
t o user s’ needs. This w as facilit at ed by t he bonding
est ablished w hen t he m ot her is at t ended by t he EMI
du r in g pr egn an cy an d su bsequ en t ch ild car e in t h e
VNCD p r og r am .
AEMI work is reduced t o t he cont rol of users
w h o v isit t h e EMI an d dir ect ed at m ak in g f ir st an d
subsequent appoint m ent s. Her act ivit y is r out ine and
t h e in f or m at ion sh e pr ov ides is lim it in g t o sh ow in g
users where som e services are locat ed. We also found
t h at , at d if f er en t t im es an d in d if f er en t sit u at ion s,
ser v ice access is int er cept ed by t hese pr ofessionals.
EMI who are current ly working at t he service
are specialist nurses. Educat ion is not offered t o at t end
t o t h eir t r ain in g n eeds. Th er efor e, m u ch k n ow ledge
i s a c q u i r e d i n d a i l y e x p e r i e n c e . N o a c a d e m i c
preparat ion in healt h is required t o becom e an AEMI .
These pr ofessionals ar e t r ained at t he unit s.
FI NAL CONSI DERATI ONS
The m ot hers considered t hat t he EMI possess
k n ow ledge. EMI w or k w as ident ified as cen t er ed on
har d t echnologies, t hat is, on car e pr ot ocols and t he
inst it ut ional configur at ion. The t im e dest ined for t he
VNCD program is anot her fact or favoring t he product ion
of pr ocedu r e- cen t er ed v isit s, leav in g lit t le r oom f or
i n s t i t u t i n g p r o c e s s e s . H o w e v e r, i t a r e l i g h t a n d
int eract ion t echnologies t hat allow for t he est ablishm ent
of a m ot her / child- cent er car e nucleus, since m ot her s
perceive t hat confidence is est ablished and developed
t hrough int eract ion wit h t he EMI , st art ing wit h prenat al
car e and cover ing subsequent child car e.
I n t he healt h t eam t hat carries out t he VNCD
p r o g r a m , t h e EM I c o u l d c o n t r i b u t e t o g r e a t e r
approxim at ion bet ween healt h st aff and users t hrough
list ening and bonding, as w ell as t o t he achievem ent
of int egral child healt h care. This can happen t hrough
liv e w or k b y EMI , b ased on t h eir self - g ov er n m en t ,
w h i c h a l l o w s t h e m a c t b e y o n d t h e i n s t i t u t i o n a l
con f ig u r at ion . We r ecom m en d t h e f lex ib ilizat ion of
st andards and rout ines and educat ional reflect ion wit h
healt h pr ofessionals, in or der t o r est or e t he r elat ion
bet ween workers and t he goal of t heir work, which is
t he int egr alit y of car e.
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