Socialization of nurses in the Family Health Strategy: contributions to professional identityPereira, Juliana GuisardiI Oliveira, Maria Amélia de CamposII
- ICentro Universitário Adventista de São Paulo. São Paulo, São Paulo, Brazil.
- IIUniversidade de São Paulo, Escola de Enfermagem. São Paulo, São Paulo, Brazil.
To verify how socialization of nurses in the Family Health Strategy (FHS) influences their professional identity.
Exploratory, descriptive research, whose theoretical-methodological framework was dialectical hermeneutics, anchored in the premises of the Sociology of Professions. Data were collected through semi-structured interviews with 27 nurses from the FHS of the city of São Paulo. The resulting empirical material was subjected to Discourse Analysis.
The choice for Nursing was influenced by previous knowledge of the profession and by the affinity with care. Socialization was not limited to what was absorbed, including the search for an individual professional identity and collective sharing.
Nursing care is built in daily practice, mobilizing the nurse for an action that includes herself, the relationship with the other and the conditions in which the work is performed, opening the opportunity for identity reconstruction, consistent with the concreteness of the work.
Nursing, Primary Health Care, Family Health Strategy, Socialization, Professional Practice
The Family Health Strategy (FHS), established in Brazil just over 20 years ago as the main strategy to reorganize Primary Health Care in the country, has led to changes in the health work process, allowing nurses in particular to transform their professional action. There was an expansion of the scope of practice, evidenced by nursing consultations, risk assessment, home visits, health monitoring and surveillance actions, care for vulnerable populations, adoption of drug prescription protocols, care of users, families and communities, among other strategies for care. In this sense, the nurses started to take the front line of the FHS teams by covering assistance, administrative and educational actions that contributed to strengthen SUS and bring advances to the professional category(1-2). This change, coupled with the more general historical transformations in society, suggests that a reconfiguration of the professional identity of the nurse working in Primary Health Care is underway in Brazil, which is also observed at the international level(3-4).
Professional identity is based on collective representations and is evidenced by the way in which a particular professional group identifies itself with its peers and with the other groups (identity for itself) and how it is identified by them (identity for the other)(5). It is intrinsically linked to professional socialization, understood as a continuous process that enables the acquisition of skills and recognition of all those who exercise and share the same activity or trade, permanently connecting work situations and personal trajectories, as well as relationships with others and with themselves(6).
For a long time, the concept of socialization has been restricted to the mechanisms of child socialization, that is, the interiorization and inculcation of ways of feeling and thinking through the institutions through which the individual passes through childhood to adulthood. Only more recently did professional socialization become more prominent, because the spheres of training, work and employment are considered important in the social identity of people(5).
The insertion in the work allows the subjective engagement (commitment) and, consequently, the projection of a future for oneself and for the professional collective(6). Thus, the understanding of professional socialization as a mere incorporation of professional habitus or ethos is surpassed by a conception that considers it as a process of investing itself rather than building itself. In this perspective, it is necessary to establish personal strategies to construct the professional trajectories, as well as the "self-presentation", that allow the projection of an aspirated identity and the reciprocal recognition among the subjects involved(5-7).
According to this view, the postmodern subject does not have a permanent identity; it would be constructed historically and continuously from the way it is challenged by cultural systems. Thus, the subject brings together multiple and often contradictory identities - possible identities - with which he identifies himself temporarily(6,8).
It is believed that the nurse is constantly challenged to rethink her practice, her tools and work process in the face of socially instituted transformations(9).
The process of professional socialization of nurses who work at the FHS. It sought to verify in the training and work experiences how the professional identity of these nurses has been configured. The guiding question of the study was: What were the influences of socialization processes in the construction of professional identity of nurses of the FHS?
The study respected the ethical precepts related to research with human beings established by Resolution 466 of December 12, 2012, of the National Health Council (Conselho Nacional de Saúde). The research proposal was submitted to the Research Ethics Committees of the Escola de Enfermagem da Universidade de São Paulo (EEUSP) and the Municipal Health Office (SMS - Secretaria Municipal de Saúde) of the city of São Paulo. In the presentation of the results, the interviewees were assigned according to the order of interviews, from 1 to 27, to ensure their anonymity.
Type of study
This is an exploratory and descriptive research.
The research was carried out in six Basic Health Units (BHU) serving according to the FHS care model, in a Technical Health Supervision of the Health Coordination of the Western Region of the city of São Paulo. The data sources consisted of nurses who had worked for at least three years at the FHS in order to characterize an expressive work experience. Of the 31 nurses who worked at the BHU/FHS in the region, 27 participated in the study, since one was on medical leave and three did not have the minimum time of performance stipulated.
Data were collected through semi-structured interviews conducted at the workplace, according to nurses' availability, from December 2013 to February 2014, with an average duration of 35 minutes. The script contained questions related to academic and professional history and the construction of professional identity. Participants were characterized as to age, gender, academic background, work time at the FHS, workload, work regime, monthly income, participation in associations and health professionals.
The material of the interviews, duly recorded and transcribed, resulted in discursive texts that were submitted to Discourse Analysis, as advocated by Fiorin(10) and adapted by Car and Bertolozzi(11). The technique seeks to reflect the conditioning factors of production and the apprehension of the meanings of the word, considering that "it expresses ideological positions at stake in the socio-historical process in which the forms of relation are produced"(11). After the transcription, its integral reading and the selection of excerpts relevant to the research were carried out. The selected discourses were recomposed in thematic phrases organized according to the degree of similarity, forming groups of themes or nuclei of meaning. For the interpretation, dialectical hermeneutics, which deals with the comprehension of texts, was used based on the critical distance in the reconstruction of social life, exploring denied values in the communication processes(12).
As for the sociodemographic profile, 23 nurses were female, which is why we use the writing of the text in the female, without starting a gender discussion. The mean age was 35 years; the average time elapsed after undergraduate degree was nine and a half years and the duration of the FHS was six and a half years. Seven had previously worked as nursing technicians, four as nursing assistants and two as Community Health Agents; 26 had taken some latu sensu graduate course and one was studying; three had completed the stricto sensu graduate course, of which two were masters and one doctorate. The weekly workload was 40 hours a week, in a bargaining regime, two of which had a link with the city of São Paulo. The average monthly income was 8.5 minimum wages. No interviewee participated in any professional associative movement.
The following are aspects that characterized the construction of the professional identity of the nurses interviewed in the moments and situations considered key to their socialization process and which preceded their entry into the world of work. These aspects are grouped according to the influences on the decision to attend nursing undergraduate course, the professional models during undergraduate degree, the motivations to work in the FHS and the beginning of the professional activity in the FHS.
Influences on the decision to take an undergraduate degree in Nursing
The results showed that the choice for the nursing undergraduate course was influenced by previous knowledge of the profession, through contact with relatives or friends who worked in the area and identification with care. Although four nurses reported having made a random choice, the conscious choice for the profession prevailed, for identification with the profession, care and Health area.
Identification with the profession
I have some family members who are nurses. Before I came in, I already had an idea of the role; I came to accompany them in a few moments to see if that was the case [what I wanted]. (N7)
When I finished a vocational training in Ophthalmology, I started to work in a service, and since I didn't have a nurse on that floor, I ended up doing a lot of the role of the nurse: organizing the schedules, doing the scales, organizing what the flow would look like. I began to realize that the work of the nurse has much more autonomy than my prejudice allowed me to see. (N23)
Identification with the care and with the Health area
I wish I could have more direct contact with the patient, a profession that gave me the opportunity to have a close relationship. And I thought the nursing would give me this. (N27)
One thing that may have been a very striking factor was when I stayed with my father hospitalized. I was 14 years old and my father was in serious condition. My mother worked and I stayed with him in the hospital. Maybe in my unconscious this issue of my father was deep inside and it was my choice. (N22)
I went to read about health professions and when I informed myself I realized that Nursing was the one that I identified with the most. (N12)
In fact it was more by guessing. I said, ‘I think that's it.' I went, I identified with and I liked it. (N1)
Professional models during undergraduate degree
As for the professional models during undergraduate degree, the main references fell on professors and field nurses present in the school socialization process. Even those who denied the existence of specific professional models reported that they observed the characteristics of professors and nurses to build what they believed to be their own professional identity.
In Collective Health I had a lot of contact with two professors and I mirrored them to this day. They were the model that helped me determine my world view, my vision of the health-disease process, my vision of society, and how to build my identity. (N11)
Nurses services/internship fields
When I was taking an undergraduate course I had many professionals that I inspired in them, professionals with adequate and not adequate attitudes and from there I was thinking: - "I want to be this way, I don't want to be this way, I'll try to act differently". (N16)
You know I don't? I didn't get inspired by anyone at the time, I was just learning. (N18)
Sometimes we even get a little from each professional's skills, we select the good things from each one, and you get your way to work. But, overall, I don't have a reference. (N2)
Motivation to work at the Family Health Strategy
The motivation to work at the FHS arose during undergraduate internships and to identify themselves with the job characteristics inherent in Primary Health Care. It is noteworthy that seven interviewees claimed that entry into this field of action occurred involuntarily.
Characteristics of work in the Family Health Strategy
Since when I was taking an undergraduate course I wanted the PSF (Family health Program), because I thought it was the place that the nurse would have more autonomy and I did not want to be subordinated to anyone. (N11)
I really like this issue of care management. It is a very gratifying thing because you can manage from the family you visit, the activities of your team, to the planning of actions along with the city hall. It's a very, very dynamic thing, all the time. You have an impressive autonomy in the PSF, which few other places give you. (N25)
I got married, I decided to have children and wanted a little more quality of life. I didn't want to work on holidays anymore, on duty. And I didn't even know what Family Health Strategy was. I have a cousin who is a doctor and works on Strategy, who told me: - "Why don't you go to Family Health Strategy? -"But what is that?!" He explained to me... –"I think I will try". And they called me to take the test; my son was about ten days old. I left desperately trying to find material to study, I passed and I am here until today. I liked it and got surprised. (N23)
It wasn't a choice, it was the chance of life [laughs] because when I was in the undergraduate course I wanted more the hospital part. When I went to make the choice to do the curriculum internship, I didn't have a vacancy in the hospital anymore. I did everything you can imagine not to come [laughs]. I cried, I went to the undergraduate course coordinator, the head of the department, and the TCC counselor. But there was no way, I had to come here. When I came, I just fell in love [laughs] ... (N17)
Foundations for the beginning of professional activity at the Family Health Strategy
When questioned about the foundation they used when the professional activity began at the FHS, the nurses mentioned the daily demand of the work, which was preparing them, as well as the support of colleagues. Others studied on their own or sought training. The experience gained during undergraduate course also.
The daily life of individual work
When I first started working here, everything was very new. I got out ‘raw' from college, had almost no basis to work, I had no experience. I needed to get mature, to grow. And it was the day-to-day that gave me it. And from that day, we reflect, we work. So experience gives us this. (N14)
Collective support among nurses
When this Unit started working, no one had experience. Everyone was lost together [laughs]. And we were learning by force, in the day to day. One helped the other, asked for help, gave ideas. It was a joint construction. (N3)
Study by own initiative
The first week I was in shock, it was a lot, a lot of information. I would come home and talk: -‘I need to read'. Do you know that desperation of you wanting to know everything? (N2)
They do an initial training - which should be at the beginning - called "Momento Um". I worked for two years of working. (N14)
The experience accumulated during undergraduate degree
The experience I was having from the PSF as assistant and the knowledge acquired in the undergraduate degree itself helped me. (N27)
The present study allowed the apprehension of more general characteristics of socialization regarding the formation and the actuation of the nurses, such as the vocation, the identification with the care and professional values, the financial viability, that we attribute to continuities; and specific questions related to socialization for the FHS performance, such as affinity and satisfaction at work, mastery of theoretical contents and, especially, autonomy for structuring the work process itself of the category, which we consider progress.
The professional choice is strongly influenced by the representation that one has about the career, that is, the image that a person builds throughout the life from the encounter with the social, economic, cultural experiences, besides the images transmitted by information vehicles. When one makes one of many possible choices, it is not simply the choice of a career; the occupational area is closely related to the meaning given to life, based on images and conceptions about the profession. In addition, the candidate for a higher education is choosing who will be in life(13-14).
Several studies have investigated the reasons why people choose Nursing as a career(13-17). Women and men who enter the area bring with them varied experiences - origins, ambitions and different life histories. In their personal trajectory, they were able to capture the possibilities to live their lives, to find in some measure the professional power and to face the problems related to their choices and to the work. For example, this occurred in the case of the professionalization of American nursing in the late nineteenth and early twentieth centuries, when an important brand of choice for nursing was associated with the meaning and power that the nurse's identity brought to personal life within the families and local communities(14).
In this study, it was verified that the coexistence with close people who were Nursing professionals or laymen who provided care in their nearby social network, such as relatives, friends and neighbors, opted for the construction of the image of the nurse as a reference for care and Nursing as a significant social practice for the interviewees. Having attended Nursing professionals or having worked in Health previously, for 48% of the interviewees, allowed to introduce values and attitudes that in some way made sense to the postulants, as it led them to choose the professional practice in the area. In other words, it was not just an approximation, but an immersion in the profession.
Identification with the ideals of the profession/care also contributed to the professional choice. The image of the nurse that people already have before starting the course is that of a close person with a high degree of responsibility, an important figure. This idea seems even stronger when there is previous contact with the nursing professionals, potentializing the decision to follow the profession(15,18-19).
In an integrative review about being a nursing student, it was also observed that the tendency towards identification with the nurse profession is linked to personal and family experiences with Nursing and care. The previous contact with the Health area boosts the reflection based on lived experience, influencing professional choice(19).
In this study, some nurses had previously worked as Community Health Agents, nursing assistants or security agents in BHU and reported that this previous experience motivated them to choose Nursing at undergraduate degree. One of them had also taken care of the hospitalized father as a teenager. In a research about the meaning of the profession for students of the first period of undergraduate course in Nursing, it was also verified that the experiences with the care prior to the Nursing course were essential and facilitating for the construction of the professional socialization that, in that case, occurred through work as an auxiliary or nursing technician(18).
The vocation to work as a nurse was also mentioned. According to Perussi(20), the vocation consists of a "choice of life, a personal project, a subjective engagement" that allows the professional to face the difficulties in the performance of his actions, being responsible for the union between the motivation for the career and the professional life project. Although words such as compassion or altruism have not come out explicitly, they have been made veiled.
The vocational model goes back to the institution of professional nursing, reflecting the ideals proposed by Florence Nigthingale, for which nurses should not join the profession by chance. Reinforcing the mystique of the profession, Florence felt that the option for Nursing should come in response to a call, the assumption of a commitment that would imply denial of self in favor of those to whom care would be given. The devotion was no longer religious, but to care, the patient, the institution and the doctors. Until now, the vocational model remains in the individual and collective imagination when it comes to choosing Nursing as a profession(15,21).Irrespective of random or purposeful choice, Nursing seems to have emerged as a work possibility that would bring some kind of satisfaction, be it personal, family or otherwise, such as financial viability. It is known that the process of reflection on professional possibilities is encouraged by the material needs that the person faces(16). Many students end up opting for the course due to the family socioeconomic condition, being motivated by both internal ideals of professional fulfillment and the need to acquire economic stability, which leads them to choose Nursing, even without much knowledge about it(18).
Regarding the issues related to the socialization of nurses at the FHS, this study evidenced that they competed for the moment of questioning about the professional choice, the skills, the experiences and the possibilities that were projected from the previous contact or the research about the of the profession; and what was supposed to be the future professional life. Among the expected attributes for the FHS nurse, the theoretical contents domain, the humanization and the autonomy, the characteristics of the work in Primary Health Care and the satisfaction in the work, including personal needs were mentioned. It should be noted that, in defining such attributes, nurses are actually talking about themselves, describing the professional image they project to themselves.
Also mentioned were characteristics attributed to the required profile of public health nurses, found in other studies, such as availability to the host and listening, bonding with the user, need for mastery of theoretical content and varied technical skills(21-23). These characteristics seem to have been aroused even in undergraduate degree, especially in the contact with professors and professionals in the fields of practical teaching in services of Primary Health Care.
The diffusion of norms, values and behaviors made possible by the school formation corroborates the construction of a professional identity claimed by a certain group(5). The participants are developing feelings of belonging to a professional group as they are exposed to values, professional culture and knowledge to be adopted by future nurses. This process, however, does not occur only through the transmission of a professional culture, as shown below.
Among the nurses who reported not having identified professional models during initial training, one mentioned that they had an earlier interest in care; another said that she chose the course with great certainty of what she wanted. Although there has been a denial of the existence of professional models, the contribution of moments of socialization during initial formation is evident. The interest and the conscious search for the profession seem to have been the motivation for the professional choice, which denotes the existence of a mental model of nurse that they wanted for themselves.
This is in line with the conceptions of Dubar(5), Bonelli, Oliveira and Martins(7) and Hall(8), regarding professional socialization. Dubar (dealing with the role of institutional socialization, whether at school or at work) rejects the idea of socialization as the incorporation of a habitus. It is considered that the relationship with a system or institution is a strategic opportunity for individuals to reach their goals. The encounter of a person with a certain trajectory of life with a system does not inevitably lead to the reproduction of ways of being (understood by the author as ways of feeling, thinking and acting), the worldview, beliefs and culture of that system. Rather, it would be one of the possibilities, among many others, that one could do from his reading of reality.
Bonelli, Oliveira and Martins(7) also affirm that, although students of the same profession share similar values during the socialization process, their trajectories and careers will be different and this will imply heterogeneity within the professional group.
The results of this study showed that, through contact with professors and field nurses, the nurses went through the process of learning a collective professional culture, the "we nurses". This process of socialization, however, did not exclude the possibility of incorporating the "me nurse" that they projected for themselves.
For those interviewed, the motivation to work at the FHS still originated in undergraduate degree. The motivation corresponds to a set of conscious or unconscious conditions, used by a person to explain an act and that induces certain behaviors, in order to seek the achievement of objectives. It is a dynamic phenomenon that can undergo modifications in function of internal and external conditions, and the re-readings that the person makes of experiences and situations that he/she experiences(18). In this sense, the results lead us to believe that during the school learning process, the affinity with the nurse's work process in Primary Health Care and, more specifically, in the FHS, motivated them to act at this level of performance.
Entering the labor market represents a moment of transition or adjustment between the professional identity for itself (proposed identity) and the professional identity for the other (assigned), which marks the meeting between the biographical and relational process(5,25). Many of the nurses' experiences were characterized by leaving college and entering the FHS immediately. This was because this care model was being implemented in the city of São Paulo and the nurse's work in this context was something to be built, a story to be told. With the exception of some guiding documents of the Ministry of Health or the state and municipal governments, at that time there was no consolidated reference on who the nurses were and what the FHS nurses in the Municipality(26).
The practical experiences lived in initial training are extremely relevant since they are lived in the first person. When confronted with practice, nurses turn to memory and to early experiences, which become a facilitator in acquiring professional maturity. However, the reality of health work is much more complex than performing practical activities in undergraduate internships. Until she is recognized professionally, the nurse needs to accumulate some practical baggage, acquired in the situations she faces in her day to day work. This process of learning through lived situations allows to give meaning to the knowledge learned, increasing its competence, until reaching the professional expertise. This constant professional reassurance in the early years is the first step to getting out of the "work as a nurse" state and becoming "a nurse"(18,27-28).
In the case of this particular study, there is a process of searching for "being a nurse of the FHS", although permeated by contradictions like continuities and advances, but which point to the effective possibility of conquering and demarcating its space of action and reconfiguration of professional identity of the category, depending on their practice.
The data of this research should be considered, taking into account its limitations, characterized by a cross-sectional study in a short period of time in a single Technical Health Supervision of a Brazilian municipality.
Contributions to the sectors of Nursing, Health or Public Policy
The present study contributed to evidence an active movement in the construction of the professional identity of the nurses of the FHS, in addition to a role prescribed by the institutions that regulate professional performance, which involves the concreteness of the work performed by them.
The results of this study reveal characteristics of continuity and advances in the professional socialization process of the FHS nurses. Influences to choose the profession resemble the findings of previous studies, such as the coexistence with nursing professionals within the family or in the social circle, the care of some sick family member, previously worked in the area of Health and the identification with the profession. In this particular, the service ideal of the nurse is emphasized, to the detriment of possible economic motivations and social status.
Advancement can be noticed by a relational process of the construction of the professional identity, both individual and collective, that occurs in the work, not circumscribing to the socialization constructed during undergraduate degree. This corroborates the fact that the FHS is a relatively new context of action, due to changes in the care model, in which the work process is still under construction.
Nursing care, built in daily practice in health services, mobilizes the professional to reconcile the role prescribed by the institution and the position occupied by the nurse in the social division of labor, as well as the way the professional re-elaborates the references had about the profession. Although these mechanisms were initially coincident, today the tendency is to increase the gap, which has opened the opportunity for identity reconstruction for the Primary Health Care nurse.