Systemic social practice of nurses in luhmann's perspective

Abstracts

Objetivou-se compreender o significado da prática social do enfermeiro na perspectiva luhmanniana e possibilitar um debate acerca da construção de um código específico para a área que vá além do tradicional código saúde-doença predominante no sistema de saúde, cuja comunicação socialmente relevante é a doença. Utilizou-se como referencial metodológico a Grounded Theory e como técnica de coleta de dados uma entrevista realizada com 35 participantes, entre maio e dezembro de 2007. A codificação e análise dos dados permitem concluir que apostar na enfermagem como um sistema funcionalmente diferenciado implica em desenvolver um código binário que potencialize a saúde como comunicação socialmente relevante e o ser humano como um ser social, inserido em uma realidade complexa e multidimensional.

Cuidados de enfermagem; Papel do profissional de enfermagem; Responsabilidade social; Teoria de sistemas

ORIGINAL ARTICLE

Dirce Stein Backes^I; Marli Stein Backes^II; Alacoque Lorenzini Erdmann^III

^INurse. PhD in Nursing Philosophy. Professor of the Nursing Department at Centro Universitário São Francisco - UNIFRA. Member of Grupo de Estudos e Pesquisas em Administração de Enfermagem e Saúde (Study and Research Group on Nursing Adminsitration and Health). Santa Maria, RS, Brazil. [e-mail]

^IINurse. Studenty of the Nursing Doctorate Programa at Federal University of Santa Catarina. Member of Grupo de Estudos e Pesquisas em Administração de Enfermagem e Saúde. Florianópolis, SC, Brazil. [e-mail]

^IIINurse. PhD in Nursing Philosophy. Full Professor at Federal University of Santa Catarina. Head of Grupo de Estudos e Pesquisas em Administração de Enfermagem e Saúde. Florianópolis, SC, Brazil. [e-mail]

Correspondence addressed to

ABSTRACT

The objective was to understand the meaning of the social practice of nurses in Luhmann's perspective and allow for a discussion about the construction of a specific code for nursing; one that would go beyond the traditional health-disease code prevalent in the health system, whose relevant social communication is the disease. The Grounded Theory was the methodological framework. Data collection was performed by interviewing the 35 participants between May and December 2007. Data coding and analysis resulted revealed that assuming that nursing is as a functionally differentiated system implies on developing a binary code to enhance health as socially relevant communication and human beings as social beings who are part of a complex and multidimensional reality.

Key words: Nursing care. Nurse's role. Social responsibility. Systems theory.

RESUMEN

Se objetivó comprender el significado de la práctica social del enfermero en la perspectiva luhmanniana, con el sentido de posibilitar un debate acerca de la construcción de un código específico para el área, que vaya más allá del tradicional código salud-enfermedad predominante en el sistema de salud, cuya comunicación socialmente relevante es la enfermedad. Se utilizó como referencial metodológico la Grounded Theory y como técnica de recolección de datos la entrevista, efectuada a 35 participantes entre mayo y diciembre de 2007. La codificación y análisis de los datos permiten concluir en que apostar a la enfermería como un sistema funcionalmente diferenciado, implica desarrollar un código binario que potencialice a la salud como comunicación socialmente relevante, y al ser humano como a un ser social, insertado en una realidad compleja y multidimensional.

Descriptores: Atención de enfermería. Rol de la enfermera. Responsabilidad social. Teoría de sistemas.

INTRODUCTION

The different functionally differentiated systems, among those the health systems, must find alternative ways and, at the same time, sufficiently complex to respond properly to the emerging social problems^(1-2). The solution for the problems is not found by searching for strategies out of the society or out of the system, but by creating internal strategies, based on the integration of order and disorder, certainties and uncertainties, it is possible to achieve new and different views.

In Luhmann's perspective, the system's environment is the condition to keep the identity of the social systems, since the identity is only possible through differentiation⁽¹⁾.

The system establishes relations and interactions with its constitutive elements based on the demands established around it. Therefore, systems are oriented by their environment, not only in an occasional way and through selective adaptation, but in a special way through their functional structures.

In order to be functionally differentiated, in Luhmann's conception, a certain social system needs to guarantee its own communication through a binary code⁽³⁾; that is, through a distinction code of two communicative possibilities, as in the health-disease code, which identifies the health system and enables it to generate new communication^(4-8).

Guaranteeing its own communication through a binary code implies, in this direction, to develop the distinction of two communicative possibilities, as previously mentioned. In the health system, for instance, communication is established through the health-disease differentiation code. In this relation, however, the disease is frequently considered as the positive point and health as the negative point of the differentiation process. Consequently, the knowledge of doctors and other health professionals is oriented based on the individual's disease and the socially relevant communication is reduced to the disease^(7-8).

In order to be considered an autonomous and functionally differentiated system, nursing must gradually guarantee its own communication through a specific code⁽⁶⁾; but from a relation of dependence and interdependence with the other systems so as to respond in a broad, proactive and resolutive way towards the social function. In Luhmann's conception, there is no relation of importance of a system over the other in this systemic interdependence, but a relation of difference, complementarity and dialogicity.

From this focus, is it possible to think of a specific code for nursing as systemic social practice, different from the traditional health-disease code that prevails in the health system, whose socially relevant communication is the disease? How can we consider the complexity of the health-disease process aimed to overcome the reductionisms of the hard sciences that try to dominate their object and generalize conclusions? Which new knowledge needs to be generated or broadened in nursing/health in order to comprehend and broaden the multiple variables that involve the health-disease process?

There are already reasons to think of a specific binary code for the nursing area. German researchers, more specifically, have discussed some codes that may be considered by the nursing system⁽⁴⁾. One of them concerns the care-carelessness, other concerns the need for care - no need for care and a third concerns the competence for the care - non-competence for the care. Not aiming to come to conclusive definitions, the author in question chooses, in his discussions, the code competence for the care - non-competence for the care, given that with this differentiation, the system is capable of guaranteeing its own communication, without excluding the other associative and interactive possibilities.

It is only possible to think of self-reference, that is, an autonomous system, through a specific code. In Luhmann's comprehension, autonomous systems are no longer based on moral and religious rules or social classes, but identified by having a differentiated function in the way of producing knowledge and the product of their praxis. In these conditions, the nursing system increasingly needs to broaden and define better the product of its praxis, in other words, its communicative specificity and identity in the current social context.

In this process, however, the nursing system cannot be considered an independent and/or disconnected system from the other partial social systems, since it is capable of only partially influencing the health living of the individuals, families and communities. A great part, maybe most of it, returns to other social systems, responsible for a certain dimension of the care to the human being as a singular and multidimensional being.

The importance of a system, from this focus, will no longer be in the structural and/or hierarchical position, but in the functional differentiation and in the capability of producing its own complexity to reduce the complexity of the environment. In other words, the nursing system or any other system will be characterized and recognized by the capability of developing and establishing new and always more complex communications, aimed at continuously regenerating the network of relations, interactions and associations.

For the German sociologists, nursing is a social practice by excellence. A practice, however, that was developed through the health-disease code and, consequently, under the hegemony of the doctors' knowledge. A science that was developed and consolidated based on care practices and on a context in which the disease focus prevails as the center of interests⁽⁸⁾. Another author observes that, in health institutions, the patient is often reduced to the disease and the doctor becomes God, The Creator⁽⁹⁾; a fact that contributes to the prevalence of a divisible, inefficient and unidimensional model of the health system.

Based on the reasons shown and on the attempt to broaden the discussions about the theme, the present study had the objective to comprehend the meaning of the nurse's social practice in Luhmann's perspective, aimed at enabling a debate about the construction of a specific code for the area, different from the traditional health-disease code that prevails in the health system, whose socially relevant communication is the disease.

METHOD

This is a qualitative exploratory study, oriented by the Grounded Theory method, also known in Portuguese as Teoria Fundamentada nos Dados (TFD).

Data collection constitutes a broad process in the Grounded Theory, since many things may be considered as data⁽¹⁰⁾. Nevertheless, this study used the technique of in-depth interview. Interviews were performed with a total of 35 participants from different states in Brazil and from different working areas, such as: a public university, a private university, two Basic Health Units, a State Health Department, a Social Inclusion Project and a Home Care Program. The participants were selected randomly by the researchers and through the signature of the Term of Free and Clarified Consent (TFCC). The considered inclusion criterion comprehended professionals who were recognized as social entrepreneurs and/or who were engaged in some social practice, whereas the exclusion criterion was applied for those who refused to sign the TFCC.

Among the participants, there were: twenty nurses, four doctors, an odontologist, a nutritionist, a pharmacist, two psychologists, a theologian, two educators, an administrative manager and two younger people, between eighteen and twenty-four years old, who develop social work and do not perform a specific professional activity.

Data collection and coding, stages that were processed in a systematized and comparative way as preconized by the Grounded Theory^(11-12); were carried out between May and December of 2007. The results will be discussed, as it follows, in Luhmann's perspective.

In order to keep the anonymity of the information, the study participants are identified in this text by the letter P (Participant) followed by a number corresponding to their speech.

The project was approved by the Committee of Ethics in Research of the Federal University of Santa Catarina (UFSC), under the number 052/07.

RESULTS AND DISCUSSION

The coded and analyzed data reflect that nursing has possibilities and potentiality to guarantee the functional differentiation of the nurse's social practice, even in a context marked by the hegemony of the doctors' knowledge and, consequently, of the focus on the disease.

For the interviewees, there is an expressive difference between the organizational and care dynamics of the nurse compared to that of other health professionals. One of the medical professionals exemplifies this difference saying that at all health services where he has already been to, he always had a nurse in charge of the service administration and that, for this reason, he has a very present nurse's figure as a compromised and responsible professional who is capable of running the health services (P9).

According to the perception of the interviewees, due to the fact of comprehending the individual as a whole, the nurse manages to establish a closer identification to the social needs of the individuals, families and communities, besides keeping a more intense interaction to the different realities. Nurses can perceive and apprehend the social needs and problems in a real and contextualized way. For some professionals, the work bonding and qualification favor nurses to have a greater commitment and systemic involvement.

The specific education... and the work bonding itself make the nursing profession more committed to the health system (P11).

I think the nurse has a great identification to the social questions. He sees much more materialized needs and the interaction is very intense. I believe the nurse has the role of being responsible for the health. He works the health concept in its plenitude, in his daily practice. He uses the arguments and tools of the other health professionals to establish the complete care... Nursing has a very consolidated image of care as a whole. The doctor comes quickly, looks at the patient and turns away, and the nurse takes care of the patient as a whole (P14).

In this direction, the results evidence that nursing has specificities that distinguish it from the other functionally differentiated systems, as it adds new elements to the social practice, through the emphasis on the health living of the human being as a singular and multidimensional being. In the comprehension of the interviewees,

the nurse has the health role, but must develop the health entrepreneurship (P10).

Differently from the medicine,

nursing has the health question next to the people, that is a characteristic of the profession (P16).

Based on the previous arguments, the socially relevant communication of nursing is the

care to the process of health living of the individual (P11), even if this individual is suffering with a disease. In this perspective, the nursing care is understood as a complex phenomenon by excellence, capable of transcending any dimension of space, time, function and system⁽¹³⁾; that is, capable of transcending the simplified focus of the traditional health-disease code, in which the individual is frequently reduced to the disease - sick individual.

For the interviewees, the nurse is one of the health professionals who gets more involved with the concrete needs of the individual and best comprehends the human living process in a broad and contextualized way. He is one of the professionals who is not limited to the physical or pathological dimension, as he tries to comprehend the individual as an integrated whole, as a complex and multidimensional being⁽¹⁴⁾. Therefore, he allows the establishment of bonds, systemic interactions and relations, both to users and to the other partial systems, aimed at guaranteeing the resolutivity of the health care, through the comprehension of the human being as an integral and integrating being, as reflected by the following speeches:

[...]sociologists could not have another classification... according to them, nursing comes from medicine. Over the control of the medicine. I don't think so. Because medicine's strong point is the pathology... If we look at the current social moment, if we develop a view about the pathology, then we will perish. It is necessary to develop health and nursing has the role of health (P20).

The nurse works the health concept in plenitude in his daily practice. He works the health concept in its plenitude, in his daily practice. He uses the arguments and tools of the other health professionals to establish the complete care... Nursing has a very consolidated image of care as a whole. The doctor comes quickly, looks at the patient and turns away, and the nurse takes care of the patient as a whole (P12).

We deal with the health care. The doctor deals with the disease care. We take care of the patient as a whole. In the team, the nurse articulates, he looks at the whole scenario. We provide a holistic and integral care, which is thus enterprising (P23).

Nursing has something that supports it and that is never going to die, due to the question of helping people satisfy their health needs. Other health professionals may also care, but they cannot handle a broader context of the people's needs. Nursing has the comprehension that it dominates a great part of the health activities (P28).

The customer, for instance, has much more freedom and trusts more in the nurse than in any other professional, due to his patience to listen. The nurse gives more affection, more attention, more security, and that is what people look for (P31).

Guaranteeing its own communication through a binary code, in Luhmann's perspective, implies the development of distinction of two communicative possibilities, capable of identifying the system and enabling it to generate new communication⁽³⁾. Differently from the traditional and hegemonic health-disease code, in which the focus of interests is the disease - sick individual, nursing has been distinguishing itself, as evidenced by the interviewees, due to its capability to interact and comprehend the multiple variables that involve the health living process of the individuals, families and communities. Its focus of attention and interventions transcends the physiopathologic dimension of the disease as an end in itself. This comprehension was evidenced both in the speech of users and professionals as they mentioned that whenever they need to send a relative to the Health Unit, they send him directly to the nurse because he is the professional who comprehends the patient in his real needs and tries to assist him in the best way he can. In this relation, the nurse distinguishes himself due to his ability and sensitiveness to comprehend the competence for the care - non-competence for the care, that is, to broaden the self-competence for the care of the individual and the family, most considered binary code for the differentiation of the nursing system⁽⁴⁾.

The competence for the care - non-competence for the care is reflected in the capability to integrate the order and disorder and, by means of a dialogic process, to broaden the interactive possibilities through the apprehension of the human being not only as an individual being, but as a social subject and the main actor of his own story.

There is no point in seeing Maria at the emergency with alterations in her blood pressure if I don't consider her reality, the husband who hits her, and the job she doesn't have. So this is the logic of not perceiving the subject of the action as an individual being, but seeing him as a social subject. And nowadays, nursing is the profession that mostly has this logic. By observing other professionals, the dentist, the doctor, the psychologist, the physiotherapist, it is possible to observe they are not very accurate regarding what they think and do (P18).

Another argument that evidences that nursing may be considered as a functionally differentiated system is related to the speech of one of the medical professionals, when mentioning that, as member of the Forum that coordinates the curricular changes for the entire country, discussions have increasingly tended to comprehend the specificities of the nurse's function, in other words, the specific communication of the nursing system. According to the perception of the interviewee, nursing has specificities that stand out in the nursing team, which are related to the organization, to the comprehension of the human being as a whole, to the interactive and integrative capability to different types of knowledge, therefore, to the way professionals act and react in face of adverse and contradictory situations in which users are sometimes found.

Nursing has a differential. It is the need to help people solve their health problems. Other professionals also care, but they don't get so intensely involved to the person's needs (P2).

I value everything the person says. I put myself in their shoes. If they tell me a situation, I try to imagine it and create meaning for what the person says... I try to give an answer or follow up the situation in the best way I can (P7).

The nurse is the professional who has the experience both from the psychological point of view and the physical and technical. He is the care connector in health. He identifies himself better to the user's needs than the other professionals. The nurse has already consolidated this knowledge. Other health professionals, such as the psychologist, the nutritionist, the pharmacist, do not perform this role as intensely as the nursing professional (P11).

In Luhmann's perspective, the systemic functional differentiation broadens and strengthens the conception of the human being as an active, participative and interactive being in the social life. Integrating the system environment, the human being is capable of gradually increasing his own complexity to reduce the complexity of the environment, in other words, through the process of subjectivity and insertion in the interactive processes, the human being establishes dialogic and dialectical relations to the different social actors and sectors. From this focus, nursing has the possibility to go beyond the reductionism caused by the focus on the sick individual and to enable a new code of differentiation centered in the health living process of the human being, by strengthening practices of education and health promotion of individuals, families and communities⁽⁸⁾.

Thinking of nursing as a functionally differentiated and autonomous system means, in Luhmann's perspective, to develop a code of functional differentiation that is integrated and articulated in network with the other partial social systems. In the health team, nursing already plays an articulating and integrating role due to its capability of connecting and interconnecting the different types of knowledge, as reflected by the following speech:

[...] the nurse is a professional with defined abilities, with his own life. However, I am sure he is a fundamental connecting link, he has a vital complementary role in the health team (P19).

From Luhmann's systemic-complex view, it is possible to reason that the nurse's systemic social practice is constituted and at the same time constitutes a movement of system-environment differentiation, strengthened by the multiple relations, interactions and association among the functionally differentiated systems. From this point of view, the systemic differentiation is a fundamental condition for the development of proactive and enterprising actions in the social field.

Socially undertaking something through a functional differentiation code implies to invest forces in order to develop new referentials capable of overcoming the traditional and hegemonic health-disease differentiation code, whose socially relevant communication is the disease. It implies to develop referentials focused on the health living of individuals and families, that is, practices that focus on the welfare of the human being in its different dimensions.

From Luhmann's focus, the nursing area has specific characteristics that distinguish it from the other functionally differentiated systems and, at the same time, it has a socially relevant communication centered in the comprehension of the human being as a singular and multidimensional being. Thus, by comprehending the human living process as a whole, there are enough reasons to state that the care focus in nursing as a systemic social practice aims at the health living or the health of the individual, inserted in a network of social relations and interactions. In this context, the nurse gradually tries to innovate, create and lead new ways of social intervention, either though education, research or extension.

CONCLUSION

Comprehending the meaning of the nurse's social practice in Luhmann's perspective, in order to enable a debate about the construction of a specific code that goes beyond the traditional health-disease code prevalent in the health system, does not constitute a simple discussion nor one that could be easily accepted, mainly in a society marked by the hegemony of some over others, or in a society where the disease is the object of political and ideological interests. Therefore, it is at least a necessary and pertinent discussion in order to handle and stack up against the increasing complexity of the social problems, which have a direct relation to health matters.

As a central profession in the health system, nursing stands out due to its interactive and integrating care practices, which have been acquiring increasing repercussion both in the education and promotion and in the recovery and protection of the individuals' health. Without great premeditations, it is possible to reason that nursing is an eminently social profession that has been increasingly configured as the profession of the future, due to its possibility of comprehending the individual not as a sick being, but as a complex being with a self-organizing potential who may be a participant and the author of his own story. Nevertheless, nursing must invest in proactive attitudes, capable of promoting the health of the individuals by broadening real possibilities and opportunities.

Trusting in nursing as a functionally differentiated system implies to develop a specific binary code. A code that focuses the nurse's social practice on the generation of new communications centered in the broadening of the competences - self-competences for the care - of individuals and families. This process requires, however, innovation, creativity, boldness and the capability to lead and visualize new areas of professional activity through education, research and extension. Similarly, it requires a change in the relational and care model through the development of strategic actions that strengthen the health living as a socially relevant communication and the human being as a social being, inserted in a complex and multidimensional reality.

Luhmann's systemic thought evidences, at a practical and theoretical level, that traditional methods are becoming less efficient to intervene in a resolutive and proactive way in the so called health and social matters, since the human being is inserted in a network of complex relations and interactions that can only be comprehended in light of referentials that include the multidimensionality of the phenomena.

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Systemic social practice of nurses in Luhmann's perspective

La práctica social sistémica del enfermero en la perspectiva Luhmanniana

Publication Dates

• Publication in this collection
  22 Mar 2011
• Date of issue
  Mar 2011

History

• Received
  09 Feb 2009
• Accepted
  26 Apr 2010