NURSI NG, ENVI RONMENT AND HEALTH CONCEPTI ONS: AN ECOSYSTEMI C APPROACH OF
THE COLLECTI VE HEALTH PRODUCTI ON I N THE PRI MARY CARE
Mar t a Regin a Cezar - Vaz1 Ana Luiza Muccillo- Baisch2 Jor gana Fer nanda de Souza Soar es3 Alísia Helena Weis4 Valdecir Zav ar ese da Cost a5 Mar ia Cr ist ina Flor es Soar es6
Cezar- Vaz MR, Muccillo- Baisch AL, Soar es JFS, Weis AH, Cost a VZ, Soar es MCF. Nur sing, env ir onm ent and healt h concept ions: an ecosy st em ic appr oach of t he collect iv e healt h pr oduct ion in t he pr im ar y car e. Rev Lat ino- am Enferm agem 2007 m aio- j unho; 15( 3) : 418- 25.
The present st udy aim ed t o underst and t he m eanings of t he concept ual environm ent cat egory, produced by nurses act ing in t he prim ary healt h care. A t ot al of 30 nurses part icipat ed in t he st udy. Dat a were collect ed t hr ough sem i- dir ect ed int er v iew s. The analy sis w as per for m ed t hr ough t he t hem at ic m et hod of t he em pir ical m eanings, based on t he ecosyst em ic approach of work. The st udy showed t he m eanings of environm ent in t he space lim it s of t he hum an relat ions, w het her t hey are produced at w ork, in t he fam ily scope or in t he general com m unit y, in a t ransversal syst em t hat allows relat ionships of m ut ual exchange by t he hum an condit ion it self in t he societ y . Concluding, t he dev elopm ent in t he nur sing ar ea, in an ecosy st em ic appr oach of t he hum an healt h, dem ands t he const r uct ion of m anagem ent st r at egies int egr at ed t o t he env ir onm ent for t he pr om ot ion of healt h. The nur sing science can be an ally in t he const r uct ion of healt hy and sust ainable envir onm ent s.
DESCRI PTORS: public healt h nur sing; env ir onm ent ; pr im ar y healt h car e
CONCEPCI ONES DE ENFERMERÍ A, SALUD Y AMBI ENTE: UN ENFOQUE ECOSI STÉMI CO DE
LA PRODUCCI ÓN COLETI VA DE SALUD EN LA ATENCI ÓN BÁSI CA
El presente estudio buscó com prender los significados de la categoría conceptual am biente establecido por las enferm eras que trabajan en la atención básica. Treinta enferm eras participaron del estudio. Los dados fueron recolectados a través de entrevista sem i-dirigida. El análisis realizado a través del m étodo tem ático de los significados em píricos, fundam entado en el enfoque ecosistém ico del trabajo. El estudio m ostró los significados del am biente dentro del lím ite de espacio para las relaciones hum anas, est ablecidas en el t rabaj o, en la fam ilia y en la com unidad en general; a través de la sistem ática transversal se pudo establecer relaciones de intercam bio m utuo entre los seres hum anos en la sociedad. Se com prende finalm ente que el desarrollo en el cam po de la enferm ería, en un enfoque ecosistém ico, exige la const rucción int egrada de est rat egias de m edio am bient e para la prom oción de la salud. La ciencia de enferm ería puede ser una aliada en la construcción de am bientes saludables y sustentables.
DESCRI PTORES: enfer m er ía en salud pública; am bient e; at ención pr im ar ia de salud
CONCEPÇÕES DE ENFERMAGEM, SAÚDE E AMBI ENTE: ABORDAGEM ECOSSI STÊMI CA DA
PRODUÇÃO COLETI VA DE SAÚDE NA ATENÇÃO BÁSI CA
O pr esent e est udo pr ocur ou com pr eender os significados da cat egor ia conceit ual am bient e, pr oduzidos pelas en fer m eir as at u an t es em at en ção básica. Tr in t a en fer m eir as par t icipar am do est u do. Os dados for am obt idos por ent r ev ist a sem idir igida. A análise foi r ealizada pelo m ét odo t em át ico dos significados em pír icos, ancorado na abordagem ecossist êm ica do t rabalho. O est udo m ost rou os significados de am bient e nos lim it es do espaço das r elações hum anas, sej am essas pr oduzidas no t r abalho, na abr angência fam iliar e da com unidade em geral, em um a sist em át ica t ransversal que viabiliza relações de t roca m út ua pela própria condição hum ana n a sociedade. A com pr een são f in al é qu e o desen v olv im en t o n o cam po da en f er m agem , n u m a abor dagem ecossist êm ica da saúde hum ana, exige a const rução de est rat égicas int egradas do m eio am bient e para a prom oção da saúde. A ciência da enferm agem pode ser um aliado na const rução de am bient es saudáveis e sust ent áveis.
DESCRI TORES: enfer m agem em saúde pública; m eio am bient e; at enção pr im ár ia à saúde
1 RN, PhD in Nursing Philosophy, Adj unct Professor, St udy linked t o t he Laborat ory of socio- environm ent al st udies and processes and collect ive product ion of
health, e- m ail: cezarvaz@vetorial.net; 2 RN, PhD in Health Sciences, Adj unct Professor; 3 RN, CAPES grant holder, Master Student in Nursing. Foundation
Federal University of Rio Grande, Brazil; 4 RN, M. Sc. I n Nursing; 5 RN, Hospital Santa Casa of Rio Grande. Master Student; 6 Physiot erapist , PhD in Hum an
Physiology, Adj unct Professor. Foundation Federal University of Rio Grande
I NTRODUCTI ON
P
rivileging nursing work as an action area in the ecosystem ic dom ain, in which the conceptual nuclei health, work and environm ent are im plied in a dialectic sy l l o g i sm , w i t h w o r k a s t h e ce n t r a l t e r m , t h i s in t er p r et iv e ex p lan at ion st u d y of t h e h e a l t h a n d nursing phenom enon was based on the guiding inquiry a b o u t w h i ch a r e t h e m a i n m e a n i n g d e si g n s o f en v ir on m en t ex pr essed in r elat ion t o t h e w or k of nurses in the basic health care network, based on the ecosyst em ic approach( 1) in healt h product ion( 2- 3).Th i s a p p r o a ch a d o p t s t h e p r e m i se o f decom posing t he elem ent s of w ork ( purpose, need, o b j e ct / su b j e ct , i n st r u m e n t a n d p r o d u ct ) a s com ponents that structure, in a system ic way in action, health production in collective work organization, from a n u r sin g f ocu s. I n t h is sen se, t h e elem en t s t h at possess ecosyst em ic charact erist ics before act ion in w or k , acqu ir e a con cr et e m ean in g w h en t h ey ar e assu m ed an d t r an sf or m ed i n t h e p r ocess. I n i t s i n t e r i o r, w o r k i s m a d e co n cr e t e t h r o u g h t h e ecosyst em ic approach of it s elem ent s, ext ernalizing its system ic com ponents, in the attem pt to overcom e t he predom inant “ bioclinical” prem ise in healt h care. Thus, in t his st udy, t he not ion of w or k as a social ecosyst em is being applied as an analyt ic unit of t he phenom enon and not as a biological ent it y( 1).
I n the content of the text, presupposing that k now ledge about sociohist or ical and env ir onm ent al phenom ena const it ut es a t echnological inst rum ent t o 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 (3rd CRS), in
the South of the State of Rio Grande do Sul.
Assu m i n g h e a l t h w o r k a s a b r o a d en v i r o n m en t a l f i el d , h ea l t h p r o d u ct i o n i n i t sel f, t h er ef o r e, ex h i b i t s g ap s t o u n d er st an d t h e v i t al r e l a t i o n s o f t h e h u m a n b e i n g / e co sy st e m i c en v ir on m en t com plex an d con st it u t es a ben ef icial space for nursing and ot her professions int erest ed in i ssu e s r e l a t e d t o t h e h e a l t h o f h u m a n i t i e s, i n k n o w l e d g e p r o d u ct i o n a n d i n t h e a d a p t a t i o n o f differ ent pr act ices, based on br oad st r at egies( 1) t o
im prove t he qualit y of life of hum an beings and t he sust ainabilit y of nat ur al and social biot a. Thus, all efforts in this study privilege the insertion of collective health nursing work( 5) into the m odel structure of health
production ( as m ateriality present in the Public Health System , in the particularity of the basic care network) , wit hin t he ecosyst em ic focus( 1), in which healt h and
environm ent are intrinsic categories of hum an beings’ sur v iv al and ar e r elat ed in t he concr et e spaces of hum an act ions, like in t he space of healt h work.
I n t he analysis process, t raffic exposes t hat different system ic, historical, social and environm ental healt h product ion and reproduct ion processes, in t he coordinated set of their actions at work( 3- 4), only appear
a n d a r e p o ssi b l e i n t h e p h y si ca l e n v i r o n m e n t s ( physical ecosyst em s) and in hum an relat ions based o n i n d i v i d u a l a n d co l l e ct i v e st r u ct u r e ( so ci a l ecosyst em s) . This m eans affirm ing t hat work is seen a s a co m p l e x e co sy st e m( 6 ) t h a t p r o d u ce s a n d
r ep r o d u ces h ea l t h( 3 ), w h i ch r ev ea l s i t sel f, i n i t s
concrete abstract concept( 3), as a phenom enon whose
m ateriality is apprehended in the biophysical and social environm ents, in the individual subj ect and in different social st ruct ures and groups.
I n the result presentation and discussion, the system of m eanings is privileged in the understanding of the phenom ena based on the nurses’ work, that is, i n t h e o b j e ct / a g e n t o f w o r k , a p p r o a ch i n g t h e conceptual nuclei of the syllogism that involves health and t he environm ent , developed in t he relat ion wit h the product of work, m aterialized as health production. I n t h e f in al con sider at ion s, a r ef lect ion is present ed on t he relat ion bet ween knowledge of t he env ir onm ent , in a socioenv ir onm ent al appr oach, as instrum ental knowledge in the field of nursing science and its applicability at work. I t is highlighted that the analy sis of specific k now ledge about act ing in t he environm ent as a broad obj ect and about t he w ork pr ocess is discussed in anot her publicat ion, as t he nat ure of t he t hem e, t he int roduct ory charact erist ic of t his t ext and t he rest rict ed num ber of pages lim it this text.
METHODOLOGI CAL DESI GN
We car r ied ou t an ex plor at or y, descr ipt iv e and analogical st udy, adopt ing a dialect ic appr oach of t h e socioh ist or ical p h en om en on . Th e d ialect ic a p p r o a ch( 7 ) t o t h e st u d y o b j e ct d e m a n d s a n
an d m u t u ally opposed, as a n eed of t h e r esear ch process itself. I n this sense, the obj ect is constructed so as t o belong t o t hat m ut ual developm ent process between the obj ect and the world, in which the subj ect itself starts to be a part( 7). What we intend to say is
t h a t t h e a n a l y si s r e p r e se n t s a t h e o r e t i ca l a n d philosophical cont ext t hat draws t he research obj ect in a spat ialized and, t her efor e, socially const it ut ed and t ransform ed t im e.
The r esear ch w as developed in t he nur sing work environm ent in t he Basic Public Healt h Service Net w or k of t he Thir d Regional Healt h Coor dinat ion Of f i ce ( 3r d CRS) i n Ri o Gr a n d e d o Su l – w h o se
h ead q u ar t er s ar e locat ed in Pelot as an d , on t h e occasion, consist ed of t went y- t wo ( 22) cit ies, locat ed on the South coastal plain of the State, at the m argins of t he Lagoa dos Pat os and Lagoa Mir im est uar ies. During the field research, in the first sem ester of 2003, t h e 3r d CRS in clu ded a basic h ealt h car e n et w or k
structured in one hundred forty- six ( 146) Basic Health Unit s ( BHU) , w her e one hundr ed for t y - t hr ee ( 143) nurses were act ive.
I n order to select the subj ect/ agent group to part icipat e in t he st udy, we considered crit eria like: t h eor et ical an d m et h od olog ical d esig n , n u m er ical r epr esent at iveness ( per cent age) of each cit y in t he t ot al num ber of nur sing pr ofessionals act iv e in t he b a si c n e t w o r k , t i m e t a b l e t o ca r r y o u t t h e f i e l d research, financial resources available for t ransport , as well as access t o som e locat ions. The size of t he st u d y g r ou p w as d ef in ed as 3 0 su b j ect s/ ag en t s, corresponding to 21% of the total population. According t o t he cit ies’ represent at iveness, init ially, we included nine (9) nurses from Pelotas, nine (9) from Rio Grande and two (2) from Santa Vitória do Palm ar. As the other ninet een ( 19) cit ies in t he regional office each cover about 1% of t he sam ple, t his im paired t he opt ion t o se l e ct p a r t i ci p a n t s a cco r d i n g t o t h e n u m e r i ca l representativeness criterion. A com plem entary criterion was chosen, that is, we selected those cities that were m ost dist ant from t he referral cent er of t he 3rd CRS,
located in Pelotas, which are: Am aral Ferrador, Arroio Grande, Chuí, Cristal, Herval, Jaguarão, Pedras Altas, Pinheiro Machado, Pirat ini and Sant ana da Boa Vist a. Aft er delim it ing t he cit ies, t he subj ect s/ agent s were select ed t hr ough a sim ple dr aw am ong t he nur ses, who were identified and coded by num bers. Thus, we constituted a representative sam ple of the population in the study focus, as this assum es the object as being hist orical- social( 7- 8).
Tape- r ecor ded sem ist r u ct u r ed in t er v iew s( 9 )
w er e used t o obt ain em pir ical dat a. The pr ev iously elaborated and tested procedure, based on a protocol w it h guiding quest ions, allow ed t he w orkers t o t alk about t he st ruct ure of t he work t hey were included in, evidencing t he act ions and m ovem ent s relat ed t o t h e en v ir on m en t cat egor y, seek in g sit u at ion s t h at w o u l d f av o r an sw er s, i n w h i ch t h e co n cep t i o n s, const ruct ed in t he nurses’ w ork, w ould be revealed inside t he t est im onies, t hat is, w it h r espect t o t he ap p r eh en sion of t h e m ean in g s of t h e con cep t u al cat egor y of envir onm ent .
The field research was m apped and delim ited b y e t h i ca l p r i n ci p l e s a n d ca r r i e d o u t t h r o u g h a t im et ab le f or h old in g t h e t h ir t y ( 3 0 ) in t er v iew s, bet ween t he second sem est er of 2003 and t he st art of the first sem ester of 2004. We requested perm ission f r o m t h e Bo a r d o f t h e Th i r d Re g i o n a l He a l t h Co o r d i n a t i o n Of f i ce ( 3r d CRS) a n d , i n l i n e w i t h
guidelines and standards for research involving hum an beings, est ablished by t he Brazilian Nat ional Healt h Council’s Resolution No 196/ 96( 10), a free and inform ed
consent t er m w as elabor at ed for t he nur ses, w hich included the study obj ect, the research obj ective, the im plem ent at ion st r at egy and t he w ay t he subj ect / agent would be inserted in the research. The fact that t h is st u d y d id n ot in v olv e an y d ir ect r isk t o t h e subj ect s’ physical int egr it y w as also explained. The subj ect s’ anonym it y was guarant eed, as well as t heir right to leave the research group at any tim e if they wanted to. The thirty ( 30) nurses who participated in t his st udy expressed t heir post - inform ed consent in writ ing.
The testim onies were transcribed and extracts of int erest w ere select ed, w hich illust rat ed t he t ext and m ot ivat e t he analysis below. The ext ract s were select ed t hrough sequent ial st eps in accordance wit h them atic analysis( 8), in which the m eanings expressed
i n t h e e x a m p l e s r e p r e se n t t h e p o ssi b l e se t o f m eanings in t he analysis t hat was carried out . Thus, the group of data obtained in the field research is the research’s prim ary source and supports the analyses, based on the concept of health( 2- 4) as a sociohistorical
and environm ent al syst em of healt h product ion and r epr oduct ion( 2- 3) t hr ough w or k , and t he concept of
en v ir on m en t / ecosy st em , b ased on t h e con t en t of environm ent al knowledge( 11- 13). The use of exam ples
broadest way, also considering t he lim it ed possibilit y of presenting the statem ents in the space of this text. At t he end of each quot at ion, wit hout ident ifying t he int erviewed subj ect / agent , t he order of t he int erview is indicat ed bet ween bracket s ( N. No) .
RESULTS PRESENTATI ON AND ANALYSI S
The ecosyst em ic approach of hum an healt h im poses “ a process of developing specific knowledge and int egrat ing act ors and approaches, subj ect s and sect ors, scient ist s, regulat ory aut horit ies, polit icians and m anager s; and all of t hese w it h t he public in general and with the organized civil society”( 1). I n this
sense, t he pr oposal pr esent ed her e const it ut es an int roduct ion t o t his approach, addressing t he healt h, environm ent and condit ions, sit uat ions and lifest yles of specific social groups( 1) as apprehended elem ent s
of m eaning by t he unit ar y st udy elem ent – healt h w or k. For t his t ext ual pr esent at ion, t hese elem ent s ar e ex t ended int o h ealt h, m at er ialized by t he w or k developed by t he st udy agent s – t he nurses in t he basic car e net w or k ; int o en v ir on m en t , ident ified in t h e w o r k a s d e t e r m i n i n g a n d co n d i t i o n i n g env ir onm ent s of t he w or k er s t hem selv es and ot her subj ects of work, exposed as the obj ect/ agent of work, which entail different actual characteristics that appear in the possible product of the work that is developed. I n t h e i r v i t a l p r o ce sse s, h u m a n b e i n g s dev elop social r elat ions, based on spaces t hat ar e ecosyst em ic cont ext s( 1,6), so as t o provoke, direct ly
or indirect ly, st at es t hat are adequat e or inadequat e to life in and of the ecosystem itself, as an interaction sy st em bet w een liv in g an d n on - liv in g bein gs t h at const it ut e com m unit ies, int er act ing w it h a v iew t o pr oducing and r epr oducing fav or able sit uat ions for t he const r uct ion of t he env ir onm ent , based on t he sust ainabilit y of vit al com ponent s.
The t est im onies cont ain relevant references to the m eaning of environm ent, as a space for hum an relations, in which the conditions, situations or lifestyles appear as it s predicat es. Thus, t he environm ent , as highlight ed by t he st at em ent below, has a m eaning
in t h e lim it s of t h e sp a ce of h u m a n r e la t ion s,
w het her t hese ar e pr oduced at w or k , in t he fam ily r ange or ev en in t he cont ex t of t he com m unit y in gener al, w it h a v iew t o pr oducing and r epr oducing fav or able sit uat ions for t he const r uct ion of healt hy int eract ions wit h t he obj ect / subj ect of work.
Work is the place, it is the site [ ...] the work environm ent
is everyt hing where we are insert ed in... We are t he m aj orit y
here, we are wom en! The cit y is also a hospit able cit y, t he people
here are very hospit able [ ...] t hey t ry t o be m ore pleasant [ ...] it ’s
everyt hing, but here in t he work place t here are disagreem ent s,
it ’s like t hat wit hin norm al st andards, if it has t o be done it has
t o be done... ( N. 23) .
I n t he st at em ent s, t he environm ent reveals t h e m ean in g of r elat ion s b et w een h u m an b ein g s, whet her in harm ony or not , in view of t heir possible dist an cin g fr om differ en t ph en om en al sen ses. Th e under st anding of t he env ir onm ent appr oaches it t o t he m eaning of ecosyst em , and can be perceived as “ a syst em of int eract ions bet ween populat ions from d if f er en t sp ecies t h at liv e in t h e sam e sit e, an d b e t w e e n t h e se p o p u l a t i o n s a n d t h e p h y si ca l environm ent [ ...] ecosyst em s are st ruct ured in space and tim e...”( 6). I n this sense, the environm ent has the
m eaning of social space – a social ecosy st em( 1), in
t h e r e l a t i o n sh i p st r u ct u r e est ab lish ed b et w een living beings and physical- social environm ent s, wit h nat ural charact erist ics const ruct ed by hum an act ions, as the space of work itself. The latter is part of hum an beings’ creative process and, thus, work can result in healt hy or unhealt hy effect s for t he vit al process, in t his par t icular case for t he w or k er s and t he ot her subj ect s inv olv ed ( “ t he client s” ) in t he com m unit y healt h care process.
The st ruct ures are com posed of com ponent s and relations that are produced in the ecosystem and concret ely const it ut e a singular unit in space and in t im e, which put s t he organizat ion of work in act ion f or t h e con st r u ct ion of t h e h ealt h u n iv er sal( 2 - 4 ); a
con t en t t h at is ex pr essed in cou n t less f or m s, bu t a l w a y s m a i n t a i n i n g i t s i d e n t i t y a n d u n i t y, a l so d et er m i n i n g t h e d ev el o p m en t l o g i c i t s d i f f er en t hist orical form s will assum e up t o it s m axim um lim it a n d i t s se l f - o r g a n i za t i o n( 4 ), g i v e n t h e
socioenvironm ent al and hist orical condit ions. I n t his r el at i o n , t h e en v i r o n m en t ap p ear s as a si n g u l ar elem ent t o nurses, t hat is, t he environm ent it self is t he spat ializat ion( 4) expressed in t he relat ions of t he
pract ical work act ion.
( healt h work) . Thus, t h e e n vir on m e n t lie s in t h e m e a n in g o f t h e co n d it io n s t h e a g e n t s/ clie n t s
live in and t he nurses “ should” know t his realit y in
order to be able to com m unicate with the individuals. Th e e x t r a ct b e l o w cl a r i f i e s t h e i m p o r t a n ce o f approaching t he client s by “ arriving at t he hom e” of each particular client. This relation is directly contained in t he w ay of appr ehending t he w or k obj ect , as a cult ural agent and in t he validat ion of t his approach action, as well as through the doubt expressed in the extract about the possible value it can acquire for the obj ect / agent ( agent / client ) of t he work.
I kept on visit ing t he pat ient s at t heir hom es. At first
I didn’t know t hat I had t o do t hat , t hey hadn’t warned m e [ ...]
t hese people, t o achieve t his com m unicat ion wit h m e, at first it
w as d if f icu lt , also b ecau se t h ey t h ou g h t it w as silly , t h ey
ironically said t hat I was going t o ‘ask som e quest ions’. So t hen
I went t o do t he research, not only t o advise t he pat ient , but t o
see his condit ions, how he was doing? Now t here is com m unicat ion
[ ...] if it is like I t old you, t here, in t he work environm ent , in m y
com m unicat ion wit h t he pat ient , I t hink it is t he result of work. I
t hink t hat each place, each sit e, t he people are different , one
place’s cult ure is different from t he ot her, if t hey didn’t consider
som et hing im port ant here, t hey could at t ribut e a different value
in anot her place and it would already be easier t o work ( N. 24) .
The approach of t he sit uat ional environm ent of t h e w or k ob j ect / ag en t is r elat ed w it h an ot h er d i m en si o n o f t h e w o r k act i o n , w h i ch co v er s t h e productive possibility of the set of health care actions. Product ive in t he sense t hat t he reason j ust ifies t he fact through the satisfaction of the agent/ client’s needs inst ead of t he worker agent ’s. Thus, t he act ion can work in the sam e sense as the goal of work, wanting t o ap p r o ach i n t h e si t u at i o n , t h r o u g h l an g u ag e, possibilit ies of dialogues bet ween different agent s in one and the sam e situation, som eone with care needs wit h his/ her condit ions of m anifest at ion and organic feeling.
Action, however, does not withdraw from this construct – care in the individual’s cultural environm ent – it s m axim um value of exchange in t he relat ion, in w hich t he inst igat ion lies in t he r each pr ov ok ed by t he nursing act ion, as a healt h agent included in t he sick individual’s private environm ent, appearing in this a g e n t / o b j e ct ’ s cu l t u r a l sce n a r i o , w h i ch i s acknowledged as being of com m on language.
To develop t he int ended work, t he aspect in t h e r e f e r e n ce o f t h e n e ce ssa r y co m m u n i ca t i o n p r e su p p o se s t h e co n ce p t i o n t h a t “ t h e r e l a t i o n s b e t w e e n t h e h u m a n b e i n g a n d t h e su r r o u n d i n g
en v ir on m en t h av e a com m on ch ar act er ist ic: w h ile h u m an bein gs can com m u n icat e dir ect ly w it h on e another, through language, they cannot do this directly w it h n on - h u m an en v ir on m en t s”( 1 4 ). Th er ef or e, t h e
en v ir on m en t s ap p ear w it h t h e m ean in g of social sp a ce s ( so ci a l e co sy st e m s) i n w h i ch t h e com m unicat ion needed for car e is put in pr act ice, assu m in g an in dir ect f or m of basic in st r u m en t of pr odu ct iv e act iv it y. Th is m ean s af f ir m in g t h at t h e env ir onm ent “ is neit her t he ‘out side’ w or ld nor t he hum an being’s pure subj ectivity and interiority [ ...] it i s t h e e x t e r i o r i ze d n a t u r e , t h e d e t e r r i t o r i a l i ze d ident it ies [ ...]( 13), t hat is, t her e ex ist s an appar ent
disfigurat ion of individuals’ part icular charact erist ics d u e t o t h e l a ck o f k n o w l e d g e i t se l f o f t h e se char act er ist ics.
Th e clien t ’s cu lt u r al dim en sion appear s in m o st p a r t i ci p a t i n g n u r ses’ st a t em en t s, w i t h t h e ch ar act er ist ic of n ot n ecessar ily adh er in g t o t h eir acknowledgem ent as cultural agents. Nurses integrate t his dim ension int o t he set of t ransform at ions of t he sociohistorical environm ent ( work in basic care) which, due t o it s consequent indefinit ions and ev en gaps, cont ribut e t o negat ive evidences wit h respect t o t he underst anding of t he goal of t he work process and, why not, of the problem - solving capacit y of the health care int ended by nursing.
I n t he r ealit y analy zed in t his st udy, in it s const it ut ion as st ruct ured social act ion t o respond t o h i st o r i ca l l a ck s, t h e m e a n i n g o f c u l t u r a l
e n v ir o n m e n t, as a con cr et e cat egor y, is lik e t h e
part icular exam ple present ed below, in t he cor e of t h e r e la t io n w it h n a t u r e. Th e ob j ect / su b j ect is apprehended through the knowledge transform ed into act ion, in t his case wit h t he m eaning of knowing in t h e sen se b ef or e t h e w or k , t h at is, as a cer t ain charact erist ic present in Professional knowledge, but n o t t o t h e e x t e n t o f t u r n i n g i n t o t e ch n o l o g i ca l knowledge, given t hat collect ive work it self does not r equir e t his t r ansfor m at ion, unless w hen it has t he m eaning of dir ect ion in t he sit uat ional envir onm ent of t he hum an condit ion. Consequent ly, w or k , as a hum an pr oduct iv e act iv it y, “ r efer s t o nat ur e t o t he extent that m an does not give up being natural when he posit ions him self as a subj ect t owards t he nat ure out side him , now obj ect ified in t he condit ion of work obj ect and/ or m eans”( 15).
[ ...] I alw ays use t he environm ent , according t o how
pat ient s relat e. How could t heir life be? Giving im port ance t o
pat ient s t owards int egrat ion, t he relat ion bet ween t hem , t hey do
not have t his cust om , I work on t hat a lot , I develop t he relat ions
am ong people. I live alone, but t here’s a t ree t here, I work a lot
wit h t he part of nat ure. Pat ient s have quit e a lot of room t o look at
nat ure here, t hat is harder in a neighborhood full of houses! I
work a lot wit h t hat part ; suddenly going out for a walk, paying
at t ent ion t o t he t ries, t he birds, t hat part I m ent ioned about
nat ure, t hat ´ s included t oo. Besides t he fam ily environm ent ,
when t hings are not working out in t he fam ily, who knows t alking
t o anot her person who is not part of t he fam ily. The fam ily m akes
t he person ill, so ( s) he has t o look for ot her t hings t o get a bit
bet t er; we oft en know t hat t hat person wit h a m ent al problem ,
his fam ily is sicker t han him self [ ...] ( N. 8) .
This st at em ent ev idences nur sing pr act ice, in linking aspect s relat ed wit h t he cult ure of hum an beings and t he privilege of nat ural quest ions, in an attem pt to naturalize cultural custom s through hum an relat ions wit h nat ure. This represent s subsum ing t he hum an m eaning of nat ure, which only exist s for t he
social hum an being, “ because it is only in t his case t h at n at u r e em er g es as a l i n k w i t h m a n, a s a n ex ist ence fr om oneself t o t he ot her s and fr om t he others to oneself, and also as a vital elem ent of hum an reality: it is only here that nature reveals itself as the f ou n dat ion of h u m an exper ience it self. I t is only in this case that m an’s nat ural existence turned into his hum an exist ence and t hat nat ure becam e hum an t o him [ . . . ] . Alt hough m an t hus r ev eals him self as a part icular individual, it is exactly this particularity that m a k es h i m i n t o a n i n d i v i d u a l a n d a n i n d i v i d u a l com m u n al bein g [ . . . ] . He also ex ist s in r ealit y as intuition, as the actual spirit of social existence, as a totality of the hum an m anifestation of life”( 16).
Nu r sin g adopt s t h e r elat ion al en v ir on m en t quest ions t o act on t he agent s/ client s of t heir work. I n this naturalization process, there exists an intention that is strongly m arked by the need for com m unication am ong hum an beings, that is, aim ed at unifying nature and cult ure int o a cross- sect ional syst em at ic, which nat urally m akes possible m ut ual exchange relat ions, due t o t he hum an condit ion it self in societ y. Societ y h as a h ist or y an d t h e p ot en t ial t o allow f or t h e obj ectification of different subj ectivities in “ the perfect union of m an and nat ur e, t he t r ue r esur r ect ion of nature, the integral naturalism of m an and the integral hum anism of nat ure”( 16).
The const ruct ion of t he subj ect ivit y int rinsic to social processes is developed within the system of
health production and reproduction itself, in the interior of this construction of actions ( basic care work) which, in t urn, affect s t he subj ect ivit y of t he individual and t h e o ccu p i e d sp a ce s. He n ce , t h e p r o ce ss o f const r uct ing t his subj ect iv it y is under st ood her e as t h e si m u l t a n e o u s co n st r u ct i o n o f p o ssi b l e intersubj ectivities that occur in collective activities, in w h ich in div idu als con st r u ct , based on sy n cr et ism s through relational life, their own living spaces, in the social ecosyst em s. And it is in t hese spaces t hat t he collect ive and t he social are obj ect ified. I t should be highlight ed t hat t he individual is a social being and that “ the m anifestation of his life – even if it does not a p p e a r d i r e ct l y i n t h e f o r m o f a co m m u n i t y m an if est at ion , r ealized j oin t ly w it h ot h er m en – const it ut es, t hen, an expression and a confirm at ion of social life. Man’s individual and generic lives are not different, no m atter whether – and this is necessary – indiv idual life is a m or e specific or m or e gener al way of existence of generic life, or no m atter whether generic life constitutes a m ore specific or m ore general individual life”( 16).
Thus, t he m eaning of environm ent , assum ed i n t h e r e l a t i o n w i t h t h e h e a l t h a n d d i se a se phenom enon, is clear ly under st ood as collect iv e in it s sociobiological dim ension and t he challenge is t o apprehend it in an expanded ecological dim ension of h u m a n h e a l t h p r o m o t i o n * i n r e l a t i o n w i t h h i s co n st r u ct e d ( so ci a l e co sy st e m ) a n d n a t u r a l en v ir on m en t . Th is ch allen g e af f ect s a “ collect iv e process of knowing, in which each person learns from his ‘nat urally’ different part icular [ ...] perspect ive, t o resignify and recodify t he environm ent al know ledge t o im print it wit h his personal m ark, t o inscribe his cultural style and to reconfigure collective identities”( 13).
The incor por at ion of hum an beings in t heir environm ent s int o nursing act ions, as obj ect s/ agent s of w or k, per m anent ly needs adequat e t echnological inst rum ent s ( knowledge t ransform ed int o act ion) for observation and intervention, so as to produce power-act ion in different social and hist orical environm ent s. I n t he daily work space, looking at t he environm ent w it h a v iew t o sat isfact ion, t hat is, t o achiev e t he product ’s goal, refers t o t he range of t he obj ect t hat nursing will t ransform t o produce it s product . I f t he d esir ed p r od u ct con t ain s t h e socioen v ir on m en t al ( ecosystem ic) dim ension, even if incipiently, the work pr ocess w ill get or ganized accor ding t o t he set of
* This t hem e is current ly developed by t he St udy Lab on Socioenvironm ent al Processes and Collect ive Healt h Product ion - LAMSA, “Healt h Product ion and
actions that allow for the m aterialization of the desire, of t he idealized act ion ( t he proj ect ) , of t he concret e act t urned int o product . And t herefore, achieving t he satisfaction for its transform ation into product requires interdisciplinary instrum ents for this desire, collectively t r ansfor m ed int o a pr oduct of w or k , as a com plex pr oduct , w hich needs m ult iple ex change r elat ions. Exchanges in the sense of m aking possible conditions produced by t he different agent s of t he act ion, i.e. the worker agent and the client agent, in their different so ci al p o si t i o n s t h at ap p r o x i m at e t h e p r esen t ed hist or ical r equir em ent s.
As t his required product is com plex and t he produced subst ance is som et hing const ruct ed in t he w or k pr ocess it self, but not only at t his par t icular m om ent in life in general, t he charact erist ics of t he t r ansfor m at ion pr ocess of t he agent / client dem and at least an int erdisciplinary cont ent , whet her in t he r e l a t i o n w i t h t h e p r o j e ct e d e l a b o r a t i o n o f t h e t r ansfor m at ion obj ect , or in t he elabor at ion of t his t r a n sf o r m e d o b j e ct ’ s i n st r u m e n t a l k n o w l e d g e . Therefore, t he com plexit y of t he work obj ect and it s t r a n sf o r m a t i o n r e q u i r e “ k n o w l e d g e a b o u t t h e e n v i r o n m e n t a l co m p l e x i t y, w h o se co n st r u ct i o n r eq u i r es a d i a l o g i c p r o cess, i n t h e ex ch a n g e o f knowledge, in the hybridization of science, technology and popular knowledge”( 13).
FI NAL CONSI DERATI ONS
Th e h u m an b ein g , in clu d in g h is d if f er en t relat ional environm ent s, const it ut es t he m ain obj ect / subj ect of nur sing act ion and it s k now ledge, w hich are part of t he work relat ed t o t he healt h and well-being of individuals and environm ents( 11- 13). Thus, the
t heor et ical and oper at iv e const r uct s of t his science should conj unct urally address general environm ent al quest ions as com ponent s of t heir knowledge.
Hence, if t he proposal is for nursing science t o be t h e f ir st qu est ion t o discu ss t h e con cept of e n v i r o n m e n t a n d i t s e x p a n si o n i n t o a se t o f coor dinat ed act ions – nuclear and collect ive w or k -which represents a challenge to the scientific research area, the look has to be prepared for the com plex set of init ial observat ions wit h a view t o t he form ulat ion and construction of research obj ects that include these quest ions.
Wit h r espect t o t he com plex it y inher ent in scient ific research processes, we inquire whet her t he
pr edom inant pr ofile in science has one appear ance relat ed t o scient ific discoveries, t hat is, I F t hese are r eflex es of t he pur e phy sical r ealit y of t he nat ur al w or ld and, also, if in a r elat iv ely dir ect way. I t is observed that, if this is the case, “ thus, science would seem to be an investigation of the truth, in which the global obj ective is to obtain a clear reflection of nature, as detached as possible from any social and subj ective influences t hat could dist or t t he fact s”( 17). And t his
am biguit y st im ulat es t he count er - act ion of lear ning t he env ir onm ent , as a w or k obj ect , based on “ t he ecologic potential of nature and the cultural m eanings t hat m obilize t he social const ruct ion of hist ory”( 13).
I t is on t he basis of t he m icr osit uat ions of life, as sociohist or ical and social phenom ena, t hat n u r sin g st r u ct u r es an d pr odu ces it s r esear ch an d i n t er v en t i o n a ct i o n s, i n w h i ch t h e p h en o m en a ’ s r epr oduct ion and int er act iv e nat ur e ar e ex pr essed. These repet it ions/ reproduct ions possess, at t he sam e t im e, differ ences in m eanings, w hich ar e giv en by t h e r ef l ex i v e co n t ex t i n cl u d ed i n t h e el u ci d a t ed phenom ena, in w hich t he social differences int eract wit h different worlds in one and t he sam e hist orical t i m e . Th e p h e n o m e n a a ssu m e d e t e r m i n a n t a n d com plex charact erist ics, discovering know ledge t hat adv ances in t he for m and funct ion of t he elem ent s and pr ocesses t hat const it ut e t he r esear ch obj ect , seeking for expansion in the sense of knowledge about t he socioenvironm ent al cont ext t he knowledge obj ect is integrated in ( natural and social)( 18- 19).
Th u s, lik e in ot h er fields of h ealt h act ion , n u r si n g k n o w l e d g e a n d p r a ct i ce s e x p r e ss a n d ext eriorize t he hum an world and are included in t he i n t e r d i sci p l i n a r i t y n e e d e d t o p r o d u ce / co n st r u ct adequate sciences for the well- being of hum an beings and t he sust ainabilit y of social ecosyst em s( 10). Thus,
it s knowledge and pract ices are not rest rict ed t o one sin gle ph en om en on ( h ealt h discon n ect ed fr om t h e p h y si ca l a n d / o r so ci a l e n v i r o n m e n t ) . Th e y a r e const ruct s t hat , in t his t im e/ space, are pot ent ialized for hum an health and the environm ents ( a sustainable society as part of a vital ecosystem that is larger than itself ) and in them selves reveal to be coherent or not with the return to the spaces they were produced in. Phenom ena and processes t hat require “ learning t he environm ental com plexity by knowing how to be with the otherness, which goes beyond ‘know yourself’, as the art of life ( ...) integrates the knowledge about the lim it and the m eaning of existence”( 13), that is, about
Finally, we em phasize t hat t he developm ent of know ledge in t he healt h ar ea and par t icular ly in nur sing, w it hin an ecosy st em ic appr oach of hum an h ea l t h , d em a n d s t h e co n st r u ct i o n o f i n t eg r a t ed en v i r o n m en t al m an ag em en t st r at eg i es i n h eal t h pr om ot ion . Appr eh en din g h ealt h pr om ot ion in t h e pr ocess sense, at bot t om , pr act ices and know ledge a r e co n st i t u t e d b y t h e r e q u i r e m e n t t o p r o d u ce i n t e r d i sci p l i n a r y a ct i o n , i n w h i ch p r o m o t i o n i s
r ep r esen t in g n ot on ly act ion p ow er f or b iosocial p r o b l e m s, b u t so ci a l t r a n sf o r m a t i o n p o w e r. Consequent ly, t his provokes social m at erialit y, which in clu d es t h e m in im izat ion of d if f er en ces b et w een d if f er en t social g r ou p s. I n t h is p r ocess, h ealt h is underst ood as a condit ion and condit ioning fact or of concret e life realit ies, for which nursing science can b e a n a l l y i n t h e co n st r u ct i o n o f h e a l t h y a n d sust ainable env ir onm ent s.
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