Disponible en castellano/ Disponível em língua portuguesa SciELO Brasil w w w .scielo.br/ rlae 1
RN, Doct oral St udent in Public Healt h at t he Universit y of Mont real, Professor at t he Federal Universit y of Ot t awa, College of Nursing, Canada, e- m ail: hlaperri@uot t awa.ca
COMMUNI TY HEALTH NURSI NG PRACTI CES I N CONTEXTS OF POVERTY, UNCERTAI NTY
AND UNPREDI CTABI LI TY: A SYSTEMATI ZATI ON OF PERSONAL EXPERI ENCES
Hélèn e Laper r ièr e1
Laperrière H. Com m unity health nursing practices in contexts of poverty, uncertainty and unpredictability: a system atization of personal experiences. Rev Latino- am Enferm agem 2007 setem bro- outubro; 15( núm ero especial) : 7 2 1 - 8 .
Sev er al y ear s of p r of ession al n u r sin g p r act ices, w h ile liv in g in t h e p oor est n eig h b ou r h ood s in t h e out lying areas of Brazil’s Am azon region, have led t he aut hor t o develop a bet t er underst anding of m arginalized populat ions. Providing care t o people wit h leprosy and sex workers in riverside com m unit ies has t aken place in condit ions of uncer t aint y , insecur it y , unpr edict abilit y and inst it ut ional v iolence. The quest ion r aised is how w e can dev elop com m u n it y h ealt h n u r sin g pr act ices in t h is con t ex t . A sy st em at izat ion of per son al ex per ien ces b ased on p op u lar ed u cat ion is u sed an d an aly zed as a w ay of lear n in g b y ob t ain in g scien t if ic k n ow led g e t hr ough cr it ical analy sis of field pr act ices. Ties of solidar it y and belonging dev eloped in infor m al, m ut ual- help act ion gr ou ps ar e pr om isin g av en u es f or r esear ch an d t h e dev elopm en t of k n ow ledge in h ealt h pr om ot ion , pr ev ent ion and com m unit y car e and a necessar y cont r ibut ion t o nat ional public healt h pr ogr am m er s.
DESCRI PTORS: com m unity health nursing; professional practice; problem -based learning; com m unity networks; poverty
PRÁCTI CAS DE ENFERMERÍ A EN SALUD COMUNI TARI A EN CONTEXTOS DE POBREZA,
I NCERTI DUMBRE Y I MPREVI SI BI LI DAD? SI STEMATI ZACI ÓN DE EXPERI ENCI AS PERSONALES
Var ios añ os d e p r áct icas p r of esion ales d e en f er m er ía, v iv ien d o en los d ist r it os m ás p ob r es d e las ár eas per ifér icas de la r egión am azónica de Br asil, llev ar on o aut or a desar r ollar una m ej or com pr ensión de p o b l aci o n es m ar g i n al i zad as. La p r o v i si ó n d e cu i d ad o s a p er so n as co n l ep r a y t r ab aj ad o r es d el sex o en com unidades r iber eñas ha sido llev ado a cabo en condiciones de incer t idum br e, insegur idad, im pr ev isibilidad y v iolencia inst it ucional. Se pr egunt a com o podem os desar r ollar pr áct icas de enfer m er ía en salud com unit ar ia en est e con t ex t o. Un a sist em at ización de ex per ien cias per son ales basada en edu cación popu lar es u sada y analizada com o un m ét odo de saber, obt eniendo conocim ient o cient ífico m ediant e un análisis crít ico de práct icas en el cam p o. Lazos d e solid ar id ad y p er t en en cia d esar r ollad os en g r u p os d e acción in f or m ales, d e ay u d a m ut ua son cam inos pr om et edor es par a la inv est igación y el desar r ollo de conocim ient o en la pr om oción de la salud, prevención y at ención com unit aria y una cont ribución necesaria a program as nacionales de salud pública.
DESCRI PTORES: en f er m er ía en salu d com u n it ar ia; pr áct ica pr of esion al; apr en dizaj e basado en pr oblem as; r edes; com u n it ar ia; pobr eza
PRÁTI CAS DE ENFERMAGEM EM SAÚDE COLETI VA NOS CONTEXTOS DE POBREZA, I NCERTEZA
E I MPREVI SI BI LI DADE: UMA SI STEMATI ZAÇÃO DE EXPERI ÊNCI AS PESSOAI S NA AMAZÔNI A
Muit os anos de pr át ica pr ofissional em enfer m agem , v iv endo nas v izinhanças m ais pobr es de ár eas d ist an t es d a r eg ião Am azôn ica b r asileir a lev ar am a au t or a a d esen v olv er u m a m elh or com p r een são d as populações m arginalizadas. O cuidado às pessoas com lepra e t rabalhadores do sexo de com unidades ribeirinhas t em sido realizado em condições de incert eza, insegurança, im previsibilidade e violência inst it ucional. A quest ão lev ant ada é com o podem os desenv olv er pr át icas de enfer m agem na saúde da com unidade nest e cont ex t o. A sist em at ização de experiências pessoais baseadas na educação popular é usada e analisada com o um a m aneira de conhecer e obt er conhecim ent o cient ífico at ravés da análise crít ica das prát icas da área. Laços de solidariedade e per t encim ent o desenvolvidos em ações de gr upos infor m ais de aj uda m út ua são cam inhos pr om issor es par a pesqu isa e desen v olv im en t o do con h ecim en t o em pr om oção a saú de, pr ev en ção e cu idado à com u n idade e um a cont r ibuição necessár ia par a os pr ogr am as de saúde pública nacional.
THE PROBLEMATI ZATI ON
T
h e p r om ot ion of h ealt h car e’s in eq u alit ies am ong populat ions in special sit uat ions, such as black,r u r al an d r ain f or est p eop le ar e of in t er est f or t h e
Br azilian Nat ional Policies of Healt h. Sever al year s of
com m unit y healt h nursing, including six in lower class
neighborhoods in t he out lying areas of Brazil’s Am azon
region have led t he aut hor t o becom e acquaint ed wit h
gr oups and collect iv it ies w hich ar e m ar ginalized w it h
r espect t o h ealt h ser v ices. Be it pr ov idin g car e f or
p eo p l e w i t h l ep r o sy b y t r av el i n g ar o u n d r i v er si d e
com m unit y on wooden boat s or doing prevent ion work
wit h sex workers in prost it ut ion urban areas, t he care
w or k ex per ien ces h av e t ak en place in con dit ion s of
uncert aint y, insecurit y and inst it ut ional violence. Being
close t o t he com m unit y in her int ervent ions gives rise
t o com m it m ent and solidarit y in socio- polit ical act ions
i n ci v i l so ci et y o r g an i zat i o n s ( co m m u n i t y g r o u p s,
associat ion of w om en, coalit ion for t he fight against
Aids or pov er t y ) .
I n t h e s e c o n d i t i o n s , d e f e n d i n g t h e c a r e
provided t o t hese populat ions oft en becom es a polit ical
act . Her e, Dem o’s “ k now ing how t o car e”( 1) inv olv es
br oaden in g t h e t ech n ical r ole of clin ical assist an ce,
p r e v e n t i o n a n d h e a t h p r o m o t i o n —w h i c h i s a n
i m p o r t an t p ar t o f car e w o r k—t o i n cl u d e a cr i t i cal
ex am inat ion of t he socio- polit ical and socioeconom ic
r e a l i t y o f c o m m u n i t y h e a l t h p r a c t i c e s . Th e s e
e x p e r i e n c e s h a v e d r a w n o u t t h e r e l e v a n c e o f
dev eloping a bet t er under st anding of t he social and
p olit ical r ole p lay ed b y n u r ses. Com m u n it y h ealt h
n u r si n g i n v o l v es a p r act i ce i n m an y ar eas o f t h e
com m u n it y in clu din g at t h e popu lat ion h ealt h lev el,
but also uses div er se appr oaches t o car e and healt h
i m p r o v e m e n t f o r i n d i v i d u a l , f a m i l i e s , g r o u p s ,
com m unit ies or populat ions.
Using t he pr inciples of liber at ion t heology in
m edical pract ice, Far m er ex plains how pr im ar y car e
a n d p r e v e n t i v e se r v i ce s m i g h t b e m a d e i n l o ca l
com m u n it y w it h a « pr agm at ic solidar it y » in car in g
wit h biological suffering of HI V/ AI DS pat ient s in Lat in
Am er ica( 2 ). Pr ev en t ion r equ ir es dy n am ic ev alu at ion s
an d a gr ou n din g in local cu lt u r es t h at r espect s t h e
dy nam ics of local pr ev ent iv e pr act ices, especially in
set t in g s in w h ich t h e r elev an t v ar iab les can n ot b e
pr edet er m in ed. Wh er e cr u cial v ar iables of con cr et e
polit ical power, obscure relat ionships of illicit act ivit ies
and cat ast r ophic nat ur al disast er s define a w or ld far
aw ay fr om t he ex pect ancies of r esear cher s( 3). Ther e
ar e sev er al ch al l en g es t h at can i n cr ease ex t er n al
v alidit y aw ar eness. Ther e is also t he polit ical defy of
lear n in g f r om ou r ex per ien ces( 4 ). How can w e t ak e
in t o accou n t u n com f or t ab ly con t ex t u al d et ails f r om
n u r sin g p r act ices w it h t h ese p op u lat ion s, m an y of
which are st ories t hat rem ains unt old because of t heir
pot ent ial dangerousness and t he difficult ies of m aking
t hem public in an “ evidence- based pr act ice” t hat can
be published?
OBJECTI VE
Th e r a t i o n a l o f t h i s a r t i cl e i s t o p r o v i d e
st rat egies t o bet t er know how t o build up com m unit y
healt h pr act ices based on ex per ient ial lear ning w it h
m arginalized populat ions ( per exam ple, persons living
w it h Aids, sex w or k er s, r u r al an d isolat ed r iv er side
populat ions, st r eet gangs, popular liv ing zones w it h
lim it ed econom ic r esour ces) by using t he hist or y of
cu m u lat iv e ex p er ien ces as p er t in en t in f or m at ion t o
con st r u ct k n ow ledge w h ich con f r on t s u n con t r ollable
co n t e x t u a l v a r i a b l e s ( i n e r t i a s, r o u t i n e s, p h y si ca l
dan ger s, polit ical st r u ct u r es of oppr ession , elect ion
cam p aig n ) .
The sy st em at izat ion of per sonal ex per iences
is her e use as a m et hod of cr it ical r ev iew . What do
we know from experience t o be share t o ot hers? This
is a t ent at iv e t o find w hat Dem o called “ equilibr ium
in- bet ween form and cont ent ”( 5) t o surpass silence t o
f o r m a l i z e d a n a n sw e r. Ba se d o n La t i n - Am e r i ca n
popular educat ion, t his m et hod is a form of savoir by
obt aining scient ific knowledge t hrough crit ical analysis
of field pr act ices. I t r aises her e t he quest ion of how
can w e dev elop com m unit y healt h nur sing pr act ices,
in clu d in g h ealt h p r om ot ion , p r ev en t ion an d car e in
cont ex t s of pov er t y, uncer t aint y and unpr edict abilit y.
Also based on Schön “ reflexive pract it ioner concept ”( 6),
t his paper aim s at explaining t he process of reflexive
con st r u ct ion an d in t er su b j ect iv it y of t h e au t h or t o
discov er a w ay t o com m unicat e ex per iences lear ning
w it h colleagues and st udent s.
LATI N- AMERI CAN SYSTEMATI ZATI ON OF
EXPERI EN CES AS A M ETH ODOLOGY OF
CRI TI CAL REVI EW
Th e sy st em at i zat i o n o f ex p er i en ces w o r k s
t o agree in t he descript ion of a problem sit uat ion and
t he goal of t he act ion t oward change; t he progress of
t h e ch a n g e p r o ce ss a r e u n d e r st o o d i n t e r m s o f
s i t u a t i o n a l f a c t o r s t h a t h e l p o r h i n d e r t h e g o a l
at t ainm ent , and t he group’s rat ing of t heir own act ions
as successes or failur es in adv ancing t heir act ion( 7 ).
For Morgan & Monreal, t his m et hod int egrat es t heory
an d pr act ice, w it h t h e goal of pr odu cin g k n ow ledge
from experience in order t o offer orient at ion for sim ilar
e x p e r i e n c e s( 8 ). S y s t e m a t i z a t i o n i s a f o r m o f
invest igat ion t o obt ain scient ific knowledge from realit y,
t hrough t heoret ical reflect ion and crit ical analysis from
pract ices. I t perm it s a ret rospect ive regard of t he past
and, fr om t he lear ning der iv ed, t o or ient t he fut ur e.
Th e se a u t h o r s e x p l a i n e d t h e d i st i n ct i o n b e t w e e n
sy st e m a t i z a t i o n f r o m o t h e r f o r m s o f k n o w l e d g e
pr odu ct ion . I t h elps t o u n der st an d “ scien t if ically ” a
pract ice, an experience in which one has part icipat ed,
and fr om t hose, elabor at e k new sav oir t hat per m it s
not only it s com prehension, but also it cont ribut ion as
a t o o l o f so ci a l t r a n sf o r m a t i o n( 8 ). To sy st e m a t i ze
m ean s t o h av e som e q u est ion s in on e’s h ead t h at
guide t he analy sis of an ex per ience so as t o ident ify
som e perspect ives and act ions t hat m ight m odify t he
problem in a m ovem ent for a bet t er societ y( 9). Som e
rout e quest ions help for t he crit ical revision: How can
I describe what I do, explain how t o I do it , j ust ify m y
act ions, and so t o be able t o defend w hat I do and
how I do it , and t his in order t o vindicat e what will be
necessary t o be able t o do in order t o at t ain t he agreed
ai m s?
A recollect ion of inform at ion w as first ly done
from m y hist ory of experiences from diverse pract ices
of popular educat ion and com m unit y healt h pr act ices
w i t h r i v er si d e p o p u l at i o n s o f Br azi l i an Am azo n i an
region. The m ain ideas of t his paper w ere previously
debat ed w it h colleagues in t he 2 0 0 6 CASN Nat ional
Resea r ch Co n f er en ce i n Vi ct o r i a BC ( Ca n a d a ) . I n
ad d it ion t o collab or at ion w it h f or m al p u b lic h ealt h
pr ogram s as a com m unit y healt h nur sing v olunt eer,
t h e r e w a s t h e l i v i n g e x p e r i e n ce a s a co m m u n i t y
anim at or and r esident am ong r ur al com m unit ies for
m ore t han six years in t he field ( 1994- 2000; 2004) . A
reconst ruct ion of t he m ost significant elem ent s of t he
p r of ession al act iv it ies w as p r ev iou sly r ealized as a
r ecuper at ion of t he per sonal pr ofessional hist or y.
Th e f ir st in t eg r at ion w or k w as com m u n it y
anim at ion in neighborhood com m it t ees of t he Wom en’s
associat ion ( from 1994 t o 1997) . Several educat ional
docu m en t s an d m an u als w er e pr odu ced or adapt ed
t o t h e Am azo n i an cu l t u r e i n co o p er at i o n w i t h t h e
Wom en’ Associat ion. Those popular educat ion act ivit ies
dealt w it h t opics dir ect ly per t in en t t o t h e ev er y day
life of w om en such as conj ugal v iolence, t he use of
t h e “ See - Ju dge - Act ” m et h od, polit ical edu cat ion ,
car e f o r w o m en , t h e u se o f m ed i ci n al p l an t s, t h e
organizat ion of neighborhood com m it t ees and t raining
for act ive part icipat ion in dem ocrat ic elect ions. Furt her,
t here was t he t raining of com m unit y healt h agent s in
bot h inst it ut ional and non- inst it ut ional areas [ Past oral
da saúde] ( fr om 1996 t o1999) . This act iv it y im plied
conduct ing com m unit y act ions t o ident ify needs and
t o or g an ize t h e t r ain in g of com m u n it y m em b er s in
com m unit y healt h pract ices; t o underline and develop
p o p u l a r k n o w l ed g e o f t r a d i t i o n a l h ea l t h p r a ct i ces
p r esen t i n t h e l o cal p o p u l at i o n , an d t o su p er v i se
per son s en r olled in pr act icu m act iv it ies for Can ada,
Lat in Am er ica and t he Br azilian capit al.
Aft er t hree years, t he social engagem ent was
t r an sf o r m ed i n a p u b l i c h eal t h n u r si n g as a j o i n t
coor dinat ion of m unicipal Lepr osy pr ogr am s of r ur al
ex t en sion for a r efer en ce cen t er for t h e Am azon ian
r e g i o n . I t w a s cr e a t e d w i t h t h e a i m o f o f f e r i n g
t r eat m ent for sk in and sex ually t r ansm it t ed diseases
as w el l as t o d ev el o p t ech n o l o g i cal an d sci en t i f i c
act iv it ies in t he field of r esear ch, educat ion, t r aining
and ext ension. Part of t he collaborat ion wit h t he rural
e x t e n si o n o f t h e i r i n st i t u t i o n a l r e g i o n a l Le p r o sy
pr ogr am w as t o car r y out t he t r aining of com m unit y
healt h agent s, healt h- workers of t he hospit al and t he
m unicipal secr et ar y office and under t ak ing a num ber
of pr olonged t r ips int o t he r iv er side com m unit ies, in
or der t o or ganize a cam paign on lepr osy, w hich w as
bot h educat ional and clinical.
Lat er one, t here was a gradual int egrat ion t o
t h e j oin t coor d in at ion of DST/ AI DS p eer - ed u cat ion
act ivit ies wit h sex workers ( from 1999 t o 2000) . The
pr oj ect sou gh t t o im pr ov e cit izen sh ip r igh t s an d t o
encourage safer sexual pract ices as well as t o provide
specialized m edical and nursing care for free diagnosis
an d t r eat m en t of STDs. Based on a peer - edu cat ion
m et h od , com m u n it y p eer - ed u cat or s w er e select ed ,
e m p l o y e d a n d t r a i n e d t o c a r r y o u t e d u c a t i o n a l
a c t i v i t i e s a b o u t s y s t e m a t i c c o n d o m u s e . Th e s e
act iv it ies w er e conduct ed in differ ent m eet ing places
( f l o at i n g p o r t , b ar s, h o t el s, p u b l i c p ar k s, st r eet s,
sch ools, et c. ) . Th e r et u r n in t h is r egion af t er t h r ee
y ea r s w a s t o d o a n ev a l u a t i o n i n t h i s co n t ex t o f
unpr edict abilit y w it h peer - educat ion pr oj ect s for sex
f r om p op u lar b ar r ios or “ in v asão” [ in v asion ] ar eas
( from January t o June 2004) . The evaluat ion sit uat ion
was im m ersed in socio- polit ical danger, which affect ed
socio- polit ical r elat ion s am on g all act or s — san it ar y,
police, legal, gov er n m en t al, cu lt u r al ( edu cat or s an d
t he cler gy ) , and cr im inal. Giv en it s pr ox im it y t o t he
border, t he region had problem s relat ed t o sm uggling
and dr ug t r affick ing, t he flux of clandest ine people,
a n d l a n d i n v a s i o n i s s u e s , w i t h t h e i r v i o l e n t
con seq u en ces.
Th e p h i l o s o p h y o f d a t a q u a l i t y c o n t r o l
ex p lain ed b y Nar r oll p oin t ed ou t t h e con d it ion s of
o b s e r v a t i o n w h i c h c a n b e l i n k e d t o t h o s e f i e l d
e x p e r i e n c e s a s a c o m m u n i t y a n i m a t o r, n u r s e ,
r e s e a r c h e r - e t h n o g r a p h e r a n d i n h a b i t a n t o f t h e
region( 10). To live and pract ice in anot her cult ure oblige
t h e d ev elop m en t of an et h n og r ap h er n u r se r ole t o
em pat hize w it h t he com m unit y t o ser v e. Am ong t he
m ain cont r ol fact or s t hat incr ease t he qualit y of t his
syst em at izat ion of experiences’ dat a are: ( a) t he “ use
b y t h e e t h n o g r a p h e r o f d i r e c t o b s e r v a t i o n a n d
personal part icipat ion in an ongoing cult ure as a m aj or
sou r ce of f ield dat a” ; ( b) t h e len gt h of st ay of t h e
researcher in t he field am ong t he people st udied; ( c)
t he fam iliar it y w it h t he language of t he people; ( d)
t he role of t he et hnographer am ong t he people st udied
( social scient ist , m issionar y, gov er nm ent official) and
t he ex plicit ness and gener alit y of t he r epor t s on t he
t rait in quest ion( 10).
A LECTURE OF PERSON AL EXPERI EN CE
I NTERLI NKED W I TH LI TERATURE
Fr o m t h i s r e cu p e r a t i o n o f t h e h i st o r y o f
aut hor’s personal experiences, cat egories were define
accor ding t o gener al r ecognized funct ions in nur sing
such as m ediat ion, educat ion, pr act ice/ r esear ch and
et hic. Those cat egor ies w er e analy sed w it h lit er at ur e
in or der t o r ealize a cr it ic int er pr et at ion of per sonal
and pr ofessional ex per iences and ex t r act lear ning t o
be shar ed and used in public and com m unit y healt h
nur sing pract ices facing pov er t y.
Being a m ediat or bet ween com m unit y, healt h net work
an d acad em ia
The nat ional and int er nat ional cult ur es of a
f o r ei g n m an ag er i al sect o r ar e n o t al w ay s ab l e t o
decode t he local cont ingent fact or s of v ar iabilit y and
v i e w t h e m a s o b s t a c l e s r a t h e r t h a n a s h e a l t h y
r equest s for adj ust m ent . To bet t er t ake int o account
local act or s dir ect ly inv olv ed in change, t he st ar t ing
p o i n t co n si st s i n a m e d i a t i n g f u n ct i o n b a se d o n
pract ices, which are int roduced in t he com m unit y. This
m ed iat in g f u n ct ion in v olv es coach in g as a st r at eg y
for m obilizing nur ses in t he com m unit y net w or k . As
com m u n it y an d p u b lic h ealt h n u r ses, w e ar e in a
posit ion t o ex per ien ce u n com for t able defin in g t r ait s
of t he local cont ex t —such as v iolence, t r affic dr ugs
t raffic, prost it ut ion and socio- polit ical rest raint s, which
higher - lev el agencies pr efer t o ignor e( 11).
Working in close proxim it y t o t he com m unit y
b r i n g s o u t t h e e x i st e n ce o f i n e q u a l i t i e s t h a t ca n
i n v a l i d a t e m a n y e m p o w e r m e n t a n d h e a l t h p o l i cy
par t icipat or y appr oaches as conceiv ed by t he upper
lev els of t he net w or k . While one can dr aw at t ent ion
t o t heoret ical inequalit ies, on t he local level, t he ot hers
on t he field hav e t o deal w it h concr et e inequalit ies,
which det erm ine t he healt h of vulnerable populat ions.
This fact engender s t he necessit y of basing nur sing
on discussions w it h ot her sect or s, com m unit y gr oups
and disciplines about t he k inds of desir ed societ ies,
econom ies, and polit ical syst em s and t he reasons for
w ant ing t hem .
N u r s e s b e c o m e m e d i a t o r s b e t w e e n t h e
c o m m u n i t y a n d a c a d e m i a , w i t h a v i e w t o t h e
s t r e n g t h e n i n g o f t h e c o l l e c t i v e c o n s t r u c t i o n o f
k n o w l ed g e g o i n g f r o m t h e b ase ( l o cal co m m u n i t y
act or s and pr ofessionals in com m unit y net w or k s) up,
such so t hat r esear ch act iv it ies t ak e t his k now ledge
i n t o c o n s i d e r a t i o n a n d g i v e i t v i s i b i l i t y i n a
“ k n ow ledgeable v ocabu lar y.” I n an ot h er pu blicat ion ,
I t alked about “ int er m ediar ies”, but her e I w ould like
t o f o l l o w L a t o u r i n h i s d i s t i n c t i o n b e t w e e n
i n t e r m e d i a r i e s a n d “ m e d i a t o r s ”( 1 2 ). Fo r h i m ,
in t er m ediar ies “ is w h at t r an spor t s m ean in g w it h ou t
t r a n s f o r m a t i o n ” ; w h i l e m e d i a t o r s “ t r a n s f o r m ,
t r an slat e, d ist or t , an d m od if y t h e m ean in g or t h e
elem en t s t h ey ar e su pposed t o car r y ”. “ Th eir in pu t
i s n e v e r a g o o d p r e d i ct o r o f t h e i r o u t p u t ; t h e i r
s p e c i f i c i t y h a s t o b e t a k e n i n t o a c c o u n t e v e r y
t im e”( 12). Accor ding t o t his dist inct ion, nur ses ar e not
m e r e i n t e r m e d i a r i e s ( p a s s i v e t r a n s m i t t e r s ) o f
k n ow led g e con n ect in g acad em ia an d p u b lic h ealt h
n et w or k s t o com m u n it y, bu t possess t h e au t on om y
t o adapt t he com m unicat ion accor ding t o cont ex t and
sit uat ions. Dubet also t alk s about “ m ediat or s”( 13). For
h im , m ed iat or s h av e a cu lt u r al p r ox im it y w it h t h e
t heir “ being”, for “ w hat t hey ar e” and t heir “ per sonal
ch a r a ct e r i st i cs” , ca p a b l e o f e n g a g i n g w i t h o t h e r
t hr ough t heir nat ur al sk ills. This connect s t o t he r esult
of an et h n og r ap h ic st u d y in Br azilian sh an t y t ow n :
co m m u n i t y h e a l t h a g e n t s co n f r o n t p e r so n a l a n d
p r o f essi o n a l i d en t i t i es i n si t u a t i o n s i n f l u en ced b y
p o w e r a n d p e r so n a l p r e st i g e , f i d e l i t y a n d m o r a l
en g ag em en t w it h t h eir com m u n it y w it h in a f or m al
w or k com m it m en t( 1 4 ).
One im por t ant com pet ency t o develop is t he
way t o m ake care accessible t o a local group living in
a so ci o eco n o m i ca l l y ( p r eca r i o u sn ess) a n d so ci o
-polit ically ( inequalit ies wit h regard t o being heard and
co n si d e r e d ) v u l n e r a b l e co n t e x t . W h i l e r e m a i n i n g
cr it ical w it h r eg ar d t o t h e p olit ical im p licat ion s of
p a r t n e r s h i p s , n u r s e s c a n c a t a l y z e c o l l a b o r a t i v e
p r o j e ct s b e t w e e n t h e l o ca l co m m u n i t y, f r o n t - l i n e
int er vent ion or ganizat ions, t he adm inist r at ive level of
healt h car e for t he populat ion, and t he t eaching and
research com m unit ies. The engagem ent in t he set t ings
of or ganized collect ives of people living in vulner able
cont ext s can also be viewed as a professional pract ice
( e.g., wit h com m unit y groups in t he fight against AI DS,
co l l e ct i v e k i t ch e n s, r e f u g e e r i g h t s g r o u p s, y o u t h
sh elt er s, et c) . I n t h is con n ect ion , t h eir pr of ession al
f u n ct ion s in v olv e h ealt h pr om ot ion , pr ev en t ion an d
social act ion relat ed t o individuals, groups, organized
collect iv es or local com m unit ies.
Educat ing people t o see and act t oget her in condit ions
of pr ecar iousness and insecur it y
I t i s i m p o r t a n t t o p a y a t t e n t i o n t o t h e
ev olu t ion ar y pr ocess w it h in pr oj ect s, pr ogr am s an d
h ea l t h ca r e ser v i ces. To b e i m m er sed i n t h e l o ca l
act iv it ies h elp t o get a bet t er gr asp of t h e r ealism
t h a t “ d e v i a t i o n s ” o r “ g a p s ” m i g h t a c t u a l l y b e
adj u st m en t s an d safegu ar ds dev eloped by t h e local
healt h professional, despit e apparent “ deviat ions from
t he ends” of t he pre- est ablished public healt h program
o b j ect i v es. D u r i n g t h e n u r si n g r esear ch act i v i t i es
per for m ed in 2004, t he per cept ion of t he dy nam ism
of t he process would not have been possible if it had
b een b ased on ly at a m om en t in t im e. I t w as an
et hnogr aphic appr oach and pr ev ious pr act ices in t he
co m m u n i t y o v e r t i m e ( 1 9 9 4 - 2 0 0 0 ) t h a t m a d e i t
possible t o obser v e t hese changes.
There is a “ nursing pot ent ial” in draw ing out
a n d g i v i n g v i si b i l i t y t o k n o w l e d g e g e n e r a t e d b y
fieldw or k . How ev er, t her e is a lack of r ecognit ion of
n u r ses’ con t r i b u t i on t o d ev el op i n g t h e com m u n i t y
a p p r o a ch i n p u b l i c p o l i ci e s. Nu r se s t a k e a l o ca l
a p p r o a ch b a se d o n cl o se n e ss t o t h e co m m u n i t y,
enabling t he const r uct ion of know ledge based on t he
ex per iences of local act or s. This appr oach act s as a
cat aly zer f or ex ch an gin g k n ow ledge am on g n u r ses,
t h e o r g a n i ze d co l l e ct i v e , a n d t h e l o ca l , r e g i o n a l ,
n at ion al an d in t er n at ion al academ ic com m u n it y. For
ex am ple, t h e collect iv e pr odu ct ion of an ev alu at ion
g u i d e i n v o l v i n g a c o a l i t i o n o f c o m m u n i t y A I D S
or g an izat ion s led t o t h e d ev elop m en t of p r om isin g
pr act ical ev aluat ion t ools for im pr ov ing t he v isibilit y
of local k n ow led g e g en er at ed b y local in t er v en er s,
including nur ses specializing in AI DS( 9).
Th er e i s an i m p o r t an t l i t er at u r e i n h eal t h
p r om ot ion t h at f av or s t h e em p ow er m en t of p eop le
liv ing in cont ex t s of v ulnerabilit y. I t im plicit ly m eans
t h a t t h e s e m a r g i n a l i z e d s e c t o r s s h o u l d a c q u i r e
capacit ies t o t ake t hem selves in hand and t o advance
t h e i r ca u se . On t h e o t h e r h a n d , Fr e i r e se e s t h e
e m a n ci p a t i o n o f co m m u n i t y n o t a s t h e r e su l t o f
adapt ing t o a realit y, but , rat her, as t he capacit y of it s
m e m b e r s t o b r e a k w i t h cr y st a l l i ze d i d e a s a b o u t
a cco m m o d a t i o n a n d t o o p t f o r t r a n sf o r m i n g a n d
int ervening in t he world( 15). He believes in t he possibilit y
people have for becom ing act ive and fully part icipat ing
people able t o t ak e chances and becom e car r ier s of
social change. This radical way of seeing people st ands
apar t fr om t he concept ion of healt h educat ion aim ed
at k now ledge t ransfer t o t he com m unit y.
What is inv olv ed her e is a shar ing dim ension
in our under st anding of k now ledge concept ualizat ion
and diffusion, w hich goes bey ond t he sim ple not ion
of u n ilat er al k n ow led g e t r an sf er f r om ex p er t s t o a
lay public. I t calls for an ex change of k now ledge in
w hich ex per t s also place t hem selv es in t he r ole of a
lay public, r ealizing t hat bot h int er act iv e sect or s hav e
s o m e t h i n g t o l e a r n f r o m t h e o t h e r. T h e
s y s t e m a t i z a t i o n o f h e a l t h p o p u l a r e d u c a t i o n
ex per iences br ought a Per uv ian int er disciplinar y t eam
t o analy ze t he spont aneous pr act ice fr om com m unit y
t o r esolv e t h eir h ealt h an d ot h er p r ob lem s( 1 6 ). Th e
em pow er m en t an d par t icipat ion ’ s ph ilosoph y m u st
be r ealist ic w it h r egar d t o r aising t he consciousness
of people w ho hav e long been im m er sed in collect iv e
an d in d iv id u al p ow er lessn ess. Th ese p eop le d o n ot
n e e d t o b e “ e n l i g h t e n e d ” o r h a v e t h e i r
“ consciousness raised.” Rat her, t hey need t o acquir e
concr et e st r at egies for incr easing t heir r esour ces and
D e v e l o p i n g a t h e o r e t i c a l - p r a c t i c a l m e d i a t i o n o f
r esear ch in act ion
The m ax im izat ion of gr oup par t icipat ion and
a u t o n o m y h a s a d i r e ct e f f e ct o n t h e ch o i ce o f a
t h e o r e t i ca l f r a m e w o r k f o r d e v e l o p i n g co m m u n i t y
h eal t h k n o w l ed g e. I n g r ad u at e st u d i es p r o g r am s,
p r of ession al n u r ses t r y t o in cor p or at e p r act ice an d
r esear ch in a sin g le car eer sp ace. Th is m er g in g of
t he concept ion of research and pract ice can pot ent ially
sh i f t k n o w l e d g e d e v e l o p m e n t i n t h e d i r e ct i o n o f
com m u n it y pr act ice set t in gs. I t open s t h e door n ot
o n l y t o i n t e r d i sci p l i n a r y a p p r o a ch e s, b u t a l so t o
d i v e r si t y i n t h e p r o d u ct i o n o f co m m u n i t y h e a l t h
knowledge. “ Research in act ion” is a pot ent ial t ool for
dev eloping t his t heor et ical- pr act ical m ediat ing r ole in
gr oups and collect iv it ies.
Act i o n - r esear ch st r esses t h e r eso l u t i o n o f
r eal, con cr et e pr oblem s det er m in ed by par t icipan t s
w h o f e e l t h e y a r e i m p o r t a n t i n t h e i r d a i l y l i v e s.
D r ev d ah l p r o p o ses an act i o n - r esear ch m o d el t h at
t ak es t h is r eq u ir em en t in t o accou n t an d ad v ocat es
t he sear ch for act ions t o help t he com m unit y aim at
changing it s condit ions of social precariousness rat her
t h an m er ely ad ap t in g t o t h em( 1 7 ). Sh e ar g u es t h at
p a r t i c i p a t o r y r e s e a r c h i s b o t h i n t e r v e n t i o n a n d
knowledge product ion, inasm uch as t he lat t er is used
t o bet t er under st and and change sit uat ions of social
oppr ession w it hin t he com m unit y.
I n addit ion, “ research in act ion” is also viewed
her e as a for m of lear ning in w hich par t icipant s and
r esear ch er s co- gen er at e k n ow ledge v ia a dialect ical
p r o c e s s t h a t a l s o d r a w s o n t h e d i v e r s i t y o f
e x p e r i e n ce s. Ph y si ci a n s, n u r se s a n d co m m u n i t y
w o r k er s h a v e t o co m e t o t er m s w i t h a t a sk t h a t
requires const ant availabilit y t o provide t he em ergency
ser v ices ch ar act er ist ic of t h e social ser v ices, h ealt h
and com m unit y net w or k . As such, r esear ch act iv it ies
are added ont o professional responsibilit ies wit h users,
who rem ain t heir priorit y. Meet ings wit h t he com m unit y
an d v ar iou s cu lt u r al ev en t s ( f est iv als, celebr at ion s,
and t raining sessions) are im port ant opport unit ies for
r esear ch , lead in g t o t h e id en t if icat ion of issu es f or
discussion, t o giving m eaning t o collect ively generat ed
inform at ion and t o t hinking about t he progress m ade
b y com m u n it y h ealt h n u r sin g act ion s. Walk in g f iv e
m in u t es fr om h om e t o j oin a w eek ly m eet in g in an
“ inv asão” [ land inv asion] dur ing a y ear w as for t he
aut hor a v er y r ich oppor t unit y t o bet t er under st and
t h e liv in g con d it ion s an d r eal n eed s of a g r ou p of
people living in a m arginalized sit uat ion wit h precarious
m ean s for su bsist en ce.
Par t icip at ion also p r esu p p oses in t er cu lt u r al
negot iat ion in every sense of t he t erm : et hnic cult ures,
nat ions, regions and unequal power relat ionships. The
open ex pr ession of t h e par t icipan t s’ t h in k in g is t h e
f ou n dat ion of t h is agr eem en t . I t is a dialogu e t h at
begins wit h an explanat ion of research in act ion, t hat
is, in sit u at ion s t h at r equ ir e dir ect act ion . Abst r act ,
t heor et ical ex planat ions of par t icipat or y per spect iv es
are incom prehensible t o part icipant s. They grasp t heir
pr act ices on t he basis of a palpable r ealit y and t he
em erging problem s encount ered in day- t o- day life and
survival. During t he group discussions wit h part icipant s
of t he peer- educat ion evaluat ion’ experience wit h sex
workers, inform at ion was produced t hrough analogies
w i t h en v i r o n m en t , n at u r e, w i t h co m p ar i so n s w i t h
si m i l a r si t u a t i o n s, a n d b y i n d i v i d u a l o r co l l ect i v e
ex per iences of t he Am azonian por t r ait .
By becom ing inv olv ed in local act iv it ies w it h
com m unit y gr oups, t her e ar e pot ent ial oppor t unit ies
t o cr eat e spaces for gr oups and collect iv es liv ing in
cont ext s of vulnerabilit y t o express t hem selves. These
e x p l o r a t i o n s o f co n cr e t e p a t h w a y s f o r p r o d u ci n g
ch an g es in t h eir liv es ev en t u ally b ecom e t h e r eal
“ ar gum ent s” for t heir em pow er m ent . The pr em ise of
p ar t i ci p at or y act i on - r esear ch i s t h e i m p or t an ce of
est ablishing a dialogue wit h part icipant s t o ensure an
underst anding of t heir sit uat ion and t heir possibilit ies
for m ak ing suggest ions lik ely t o be incor por at ed int o
a r e se a r ch p r o t o co l a n d t h e p a r t i ci p a t i o n o f t h e
r esear cher as volunt eer s am ong t he par t icipant DST/
AI DS com m unit y groups. As an int ernat ional volunt eer
a n d i n h a b i t a n t , t h i s si t u a t i o n m ea n t t o d ea l w i t h
m ult iple languages t o com m unicat e such as Port uguese
an d Span ish w it h local colleagu es, En glish w it h t h e
f u n d i n g i n st i t u t i o n a n d Fr e n ch w i t h f a m i l y w h i ch
en cou r ag e “ m u lt i- lan g u ag e com p r eh en sion ”( 1 8 ) an d
m in u s et h n ocen t r icit y. Par t icipat ion pr esu pposes t h e
in clu sion of t h e v ar iet y of in d iv id u als or or g an ized
co l l e ct i v e s u p o n w h o m t h e su cce ss o r f a i l u r e o f
im plem ent ing com m unit y car e par t ly depends.
As a st art ing point for incorporat ing research
int o com m unit y healt h pract ices, m any act ors can be
iden t if ied in t er m s of t h eir in f lu en ce on com m u n it y
c a r e : a ) d i r e c t a c t o r s i n t h e l o c a l s t r u c t u r e o f
com m unit y healt h act iv it ies ( user s, local com m unit y
workers and part ners) ; b) indirect act ors in t he social
ser v ices and healt h net w or k , and legal, polit ical and
act or s su ch as h ealt h an d social ser v ices agen cies,
polit icians and t he r esear ch com m unit y( 19). Ther e is,
how ev er, an incr eased pot ent ial for collect iv e act ion
aim ed at a com m on goal or proj ect when rigid form al
r u l e s a r e se t a si d e a n d t h r o u g h t h e cr e a t i o n o r
em ergence of inform al spaces not subj ect t o any form
o f c o n t r o l ; t h i s o p a q u e s p a c e a l l o w s f l o w i n g
discussion( 20). A pre- est ablished agenda and t echnical
v o ca b u l a r i es i m p o sed t o p a r t i ci p a n t b y m u n i ci p a l
healt h com it ies increase t he inequalit ies of part icipat ion
bet ween healt h professional and populat ion( 21). People
who are invit ed t o t alk freely about t heir proj ect m ight
hold back if t hey t hink t hat cont r over sial infor m at ion
m ight be publicly disclosed.
Ar t i cu l a t i n g p r o f e ssi o n a l e t h i cs w i t h i n a n u r si n g
m ilit an cy
D e s p i t e t h e g r o w i n g i m p o r t a n c e o f
p a r t i c i p a t i o n a n d c r i t i c a l c o n s c i o u s n e s s i n p e e r
e d u c a t i o n w i t h H I V / A I D S p r o g r a m s , n o s t u d y
under lines or ev en m ent ions t he danger s inv olv ed in
con du ct in g peer - edu cat ion , ev alu at ion an d r esear ch
when living in t he com m unit y. Com m unit y act ion and
dev eloping social policies ar e legit im at e concer ns for
t he nur sing discipline and pr ofession. How ev er, m ost
nur sing t heor ies ar e ar t iculat ed ar ound eit her holist ic
or unique concept ions of people as individuals. These
co n ce p t i o n s i n h i b i t t h e a n a l y si s o f l a r g e r so ci a l
s t r u c t u r e s a n d t h e i d e n t i f i c a t i o n o f c o m m u n i t y
a p p r o a c h e s t h a t c a n l e a d t o p o l i t i c a l g a i n s( 2 2 ).
Under st anding t he indiv idual out side his cont ex t has
led t o an u n der st an din g of n u r sin g car e ou t side it s
polit ical cont ex t .
V i e w i n g h e a l t h a s a n i n d i v i d u a l m a t t e r
r elegat es t he social and polit ical causes t o t he r ealm
of t h e im p licit an d u lt im at ely n eg lig ib le v ar iab les,
which can lead t o a loss of healt h t o t he background.
By v iew in g h ealt h as a social obligat ion , t h er e is a
n e e d t o d e v e l o p c o m m u n i t y n u r s i n g c a r e t h a t
con t r ibu t es t o cr eat in g, m ain t ain in g an d pr om ot in g
healt hy env ir onm ent al, social and polit ical cont ex t s.
Every year, t he local riverside populat ion of Am azonas
( Br azil) su f f er s “ en ch en t e” [ f lood s] d u r in g Ju ly, b y
opposit ion t o t he “ seca” [ dr yness] of Oct ober per iod.
Those nat ural disast ers m ust be recognized and t aken
int o account as im port ant const raint s for public healt h
pr ogr am ext ension in t hose isolat ed ar eas, given t he
ad d it ion al d if f icu lt y f or t h e p assag e b et w een r u r al
com m unit ies and m unicipalit ies. Fluvial t ransport , like
“ r ecr eo”, is t h e u n iq u e w ay t o r each t h ose d ist an t
c o m m u n i t i e s a n d s h o u l d b e m e a s u r e d i n t h e
evaluat ion of local com m unit y healt h nursing pract ices,
w hile t he nat ional et hic and policy assum ed equalit y
in h ealt h car e d ist r ib u t ion . En act in g et h ical p r act ice
in v olv ed w or k ing in t h e spaces ‘in- bet w een’ v ar ious
players, encount ering t ensions and conflict s in values,
m ak in g ch oices an d ch oosin g t h eir r espon ses( 2 3 ). I n
t his cont ex t of v ulnerabilit y, quest ions t hat int r oduce
a polit ical agenda in com m unit y healt h nursing pract ice
are inevit able. Nurses already draw upon several kinds
of knowledge, including art , em piricism , personal and
et h ics as w ell as socio- p olit ical k n ow led g e( 2 4 ). Th is
knowledge m ight bring an underst anding of t he nurses’
and pat ient s’ socio- polit ical cont ext as well as t he way
in w h ich societ y v iew s t h e r ole of n u r ses an d h ow
t h ey u n d er st an d societ y an d it s p olicies. Acq u ir in g
t h ose sk ills, t h at en t ail t ak in g p osit ion s, w ill p ose
ex plicit ly t he challenges in t er m s of polit ical opt ions
and cleav ages in - bet w een pu blic healt h inst it u t ion s,
n u r s e s , p a t i e n t s a n d t h e i r s o - c a l l e d v u l n e r a b l e
com m u n it ies.
FI NAL CONSI DERATI ONS: LEARNI NG FROM
EXPERI ENCES
Frequent ing groups and collect ives and sharing
t heir everyday life gives a bet t er underst anding of t he
s o c i a l c o n d i t i o n s t h a t h a v e a n i m p a c t o n t h e i r
aut onom y wit h regard t o healt h. I n rem aining close t o
t he local act ors direct ly involved in a healt h prevent ion
an d pr om ot ion pr oj ect , n u r ses dev elop a pr iv ileged
posit ion enabling t hem t o t hink while in act ion. Physical
m ovem ent in react ion t o t he concret e realit y of a healt h
p r ob lem ( f ield p r esen ce of p r act ices) lead s t o t h e
creat ion of int uit ive t hinking in light of com plicat ed and
unprecedent ed sit uat ions, t o t he abilit y t o com e up wit h
original solut ions or t o find ways t o m eet t he real needs
of a given group or com m unit y.
The t ies of solidarit y and belonging developed
i n i n f o r m a l , m u t u a l - h el p a ct i o n g r o u p s r ep r esen t
int er est ing av enues for r esear ch on t he dev elopm ent
o f k n o w l e d g e r e l a t e d t o h e a l t h p r e v e n t i o n a n d
prom ot ion. A realist ic and inclusive view is necessary
in t he set t ings in w hich nur ses oft en w or k . I n t hese
set t ings, one has t o k now how t o act in em er gency
sit uat ions and how t o m ake decisions in t he absence
of cert ainty, wit h lim it ed m eans and int rusive problem s,
independent field of professional act ion. The aut onom y
o f p u b l i c a n d c o m m u n i t y h e a l t h n u r s e s c a n b e
dev eloped t hr ough t heir becom ing conscious of t heir
personal choices, t heir values and t heir com m it m ent s,
an awareness of t he reasons, explicit or im plicit , behind
t heir act s, w hich derive from t heir know ledge of how
t o act in societ y. A given societ y has life sit uat ions t hat
differ w idely fr om t hose im agined in an abst r act and
universalist ic not ion of healt h. I f we want t o be agent s
o f ch an g e an d n o t o p p r esso r s t o g r o u p s l i v i n g i n
cont ext s of vulnerabilit y, w e also have t o go t hr ough
t h i s p r o cess o f em an ci p at i o n an d d ev el o p m en t o f
per son al an d collect iv e au t on om ies t h at is par t an d
p ar cel o f o u r co n v i ct i o n s. Z ú ñ i g a ar g u es t h at t h e
sy st em at izat ion of ex per iences possesses a pow er of
convocat ion for a collect ive expression of professional
k now ledge( 7). Or iginally cr eat ed in t he sev ent ies and
e i g h t i e s , i t p r o v i d e s a m e t h o d t o r e d e f i n e t h e
int erpret at ions and m odels of social pract ices from t he
peculiar Lat in Am erican realit y( 25). I t m ight be a useful
t ool for healt h pr ofessionals t o face t he challenge of
descr ibing t heir “ indescr ibable” field pr act ices.
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