REVIEW ARTICLES

Looking for turning points in nursing: do they exist?

ABSTRACT: Given the information about environmental disasters and their ecological and social impacts broadcast daily in recent years, it is important to research at the health-environment interface. This study aimed to discuss the state-of-the-art knowledge constructed by nursing on environmental issues in the Medline database from 1997 to 2010. This qualitative, systematic review, performed in June 2010, found 35 references, 16 of which were examined. The analytical categories constructed were: environmental hazards; the conception of environment and nursing actions; environment as nurses’ working environment; interaction between individual and environment and its influence on health-disease processes; and nursing training and its relation to environmental issues. It was concluded that production in the field is limited, occasional, and connected with interviews and critical thinking, which function as “turning points”. It remains to know how many people are aware of them.

INTRODUCTION

In recent years, there have been daily serving of information about environmental disasters and their ecological and social impacts, which are experienced by the whole world and not by specific points of the planet.

And the promotion of these situations requires some discovering and uncovering the eyes and ears of humanity, in order to join the collective. It requires frequent and grounded discussions and debates about the legitimacy/illegitimacy present in the perception of the universe; it requires changes. After all, these are not more than mere evidence or probabilities; science itself, despite some skeptics, acknowledges: life on the planet is threatened.

Clearly, the complex industrial systems and services are the main force of destruction of the environment and in the long term, the main threat to the survival of humankind itself. Consequences of global capitalism that, in the current model, is unsustainable and needs to be urgently renovated or there will be no future. Human organizations need to seek the condition of ecologically sustainable¹. And this is not only for economic development but for the sustainability of the web of life itself.

It is imperative to find a mutation point for the planet. And this is a moment of paradigm shift, translated into a multifactorial and multifaceted crisis that ultimately, one hopes, incurred in the rescue of holism between man and nature, a profound shift in thinking, perception and values. Like Capra would say, a transition from planetary dimensions².

Undoubtedly, the survival of humanity depends first on the ability to understand the basic principles of ecology and to live in accordance with them. And second, from an ecological project, and this means applying ecological knowledge in reshaping social institutions in order to bridge the gap that separates the creations of the human being ecologically sustainable¹.

And is nursing in this way? Would there be mutation points in the profession to seek ecological knowledge? What has been published in nursing in terms of the environment? And has that vision taken these productions?

If the eco-literacy should be a sine qua non for politicians, business leaders and professionals from all sectors, it is necessary to take it as an important part of education, from primary schools, to universities, educational extension1 and the work itself.

For this reason, the interface approach to health and the environment is an important issue for researchers from different fields of knowledge, and so much more on health. And if it enables the analysis and intervention to preserve life on the planet it is necessary to know which direction this topic has taken in order to research and consolidate a body of knowledge in this area which can be such as the inherent implications of this relationship and serve the basis for the adoption of guidelines and strategy actions³.

From this point, we understand the objective of this literature study: discuss the state of the art production in nursing in environmental issues and their correlation with health in an attempt to learn how the subject has been discussed and analyzed. Find in systemic and ecological concepts a North, a way to reflection.

METHODOLOGY

This production is a qualitative systematic review, processed through a retrospective survey of indexed productions from 1997 to 2010 in the MEDLINE database.

The literature research, carried out in June 2010, found references indexed by keywords: environment, ecology, sustainable development, waste disposal, health services (synonyms Index: disposition and/or disposal of waste from hospitals or biological waste) management, waste, health, health and environmental services and also diseases related to the environment (aspect: nursing).

Each of these descriptors was combined (and) with the descriptor nursing being one and another, included in the search through the index field of the base. Only with the descriptor environment related illnesses we opted for the inclusion of the word nursing in the aspect option, in an attempt to better define the search.

By drawing this path, 35 references were retrieved. Of these, only 16 observed the inclusion criteria— were in English and offered free access to the abstract or full text for analysis.

Because it is a quest to claim to know the strands of thought that guide nursing publications in terms of the environment, the productions that remained were translated, read and reread with the intention of outlining its features. Observing as much as possible: publication type or study, year, source, object, or intended discussion, study population, concepts and benchmarks adopted in environmental discourse established.

Starting from this initial systematization, we chose to analyze topics such as data processing, attempting to discuss them and interpret them from the conceptions and values of a healthy environment. From this analysis emerged the following thematic categories: Environmental hazards; Design environment and nursing actions; Environment as nursing work environment; Individual-environment interaction and its influence on health-disease process; Training for nurses and their relationship with environmental issues.

DO MUTATION POINTS REALLY EXIST?

Trying to understand the discourse of nursing on the health-environment interface is entering an intersection of shadows: if there is conceptual breakthrough in terms of theoretical concepts of health (which includes a complementary relationship between humans and the environment), in practical terms and applicability, the actions of interrelationship are not expressive or conceptual only.

Hence the expression crossing shadows, which somehow means movements in search of debate; although the desired connections are more theoretical purposes and for an anthropocentric approach of holism, they are somewhat distant from the logic of global interplanetary idea.

It is an ideology that has the environment as something important to the individual, but which falls short of fully integrated systems, the organic indivisible contexts, understanding the environment and man in the same web. Still, what has been published represents changes.

However, the positivist Cartesian paradigm still dictates the validity of which is investigated in nursing, guiding natural and social sciences, and perpetuating the legitimacy of the division between nature and human.

That means, even if it is about the environment and weave in nursing research it still has to make its roots in Cartesian discussions that have one dominant anthropocentrism in human context. Although one understands the importance of the environment on health (seen more in a sense of what surrounds me, that's out of me) and that its approach is essential to understanding the whole of the individual, it is a whole of individual and not of globe.

The fact is that the assumptions that hitherto have guided research on environmental issues have not answered fully, contemporary needs. Obviously, there is a demonstrated inefficiency in finding that, given the complex relationships and interactions among subjects, objects and the world, there is little or no appreciation of the subject as integral actors and social determinants of environmental concerns.

There is, as already verified by a Brazilian author³, a gap in knowledge in this area, displayed on the few studies addressing the role of health professionals in relation to environmental issues, it is well over view of a few. In addition, the work, when focusing on specific aspects of the process, results in generic propositions, which some refer to the analysis of the interrelationship between health and environment in the training or professional practice approach.

This search endorses the conclusions of Brazilian studies: the productions encountered when crossing environmental descriptors and descriptor in nursing is low and fairly recent (mainly 2004-2009), and is particularly directed to theoretical reflections on the matter, very little is in producing concerning practices. What denotes the paucity of traced studies and the very approaching of the theme, although there is a discussion on co-links between health and environment.

After all, a lot is done centered on epidemiological variables and real anthropocentrism, little progress toward a ecocentrism, the prudent knowledge for a decent life⁴.

In that search, in particular, we found 16 publications, 11 of which fall under the category of reflective articles, reports or interviews with single authorship or at most two reviewers; being indexed in scientific journals, mostly in the area of nursing. Among the remaining, two represent practical research, journals indexed in a reflective case study, and three theoretical revisions.

About what is inferred that publications relating to the environment and health are limited to discussing the opinion, the action, the experiences of some practitioners mattered in the subject. And if there is a predominance of theoretical reflections, one can consider and provide for some difficulty in reaching the real needs and demands of the population, because there is a demand not met by studies that contribute to effective interventions in practice, and which are based in interdisciplinary proposals.

The call that is made here is the effect that this important dimension of environmental issues should not be limited to individuals (though perhaps get them), but extend to the collective, to the extent that our problems are global, our logic solutions must also be global. If the emerging paradigm knowledge is full, having as universal or undivided wholeness, it is necessary to understand its need to reach deeper levels.
This idea of collectiveness will mean the gradual formulation of a conceptual network and the development of corresponding social organizations, one aware of the other, so that they can communicate and cooperate².

The specificity of this analysis is also important to reflect on the content taught in publications, here categorized into thematic variables analyzed below:

Environmental risks

It includes publications with information and ideas about specific practices of certain entities and/or individuals and social groups involved with environmental issues and the reduction of environmental risks in the use of medical technologies and health actions (for example: recycling and reuse of materials, reduced use of toxic materials)^5,6.

Also, information about the risks of environmental toxicants⁷.

Environmental design and nursing actions

This category refers to the investigation of conceptual meanings of the environment for nurses in primary care, showing a view of the environment as a space for human relationships, whether they are produced in work, family coverage or in the community, with the understanding that a health ecosystem approach requires building strategies that integrate the environment in promoting health⁸. It also conglomerates reflections on the pioneering of nursing in addressing the health interface environment, despite the few publications in the area and the importance of nursing work in promoting appropriate environmental actions and their (historical) relationship with health^6,9-11. Also, case studies about nursing actions to building laws for the development of environmental justice (in defense of vulnerable populations)¹².

Environment as a work environment of nursing

This category, in turn, brings:

Information about what the American Nursing Association has carried out and helped legislate to ensure more adequate working environments¹³. As investigations of the impact of critical structural variables (issues of the work environment and its organization) in the determination of injury and accidents in nursing¹⁴ and patients¹⁵.

And yet, information/tips that help develop the work of nurses at home¹⁶.

Individual-environment interaction and the health illness condition

This category refers to a reflection on the influence that the environment has on the health of individuals and the importance of knowing and understanding through this environment- health link; bringing historical contexts to the approach of the environment in nursing⁹.

It also gets back to the approach of interactive perspective between individual and environment, as well as their correlation in health and disease (theories and their origins, interdisciplinarity between different research actors and subjects/disciplines) process¹⁷.

It further included revisions on patients with electromagnetic hypersensitivity in relation to their environment and about the management of patients with complex diseases and implications of genetic discoveries in relation to the influence of the environment on genes¹⁹.

The nursing education and its relationship with environmental issues

This category provides information on training and education of nurses around environmental variables, effected by some entities²⁰.

And also about addressing the environmental issues in the curriculum and nursing education (historical, institutional examples, speech on the importance of the relationship between: the nursing contribution in building laws and knowledge in terms of the environment)¹⁰.

From this exposure, it can be inferred that there is an attempt of assessing the environmental issue, bringing it to debate, but it seems to be more punctual initiatives from authors or the journals themselves, linked in interviews and reflexive texts like that trying to get the attention of humankind on planet needs, namely: to be saved, and with it, save the man.

There is a struggle of personal work and some training entities by changes which, when published, scream along with the screams (catastrophes) of the planet. These are true points for mutation. Now, how many are aware of that?

Part of the studies, when dealing with environmental, focus in the image of man in the center of the universe, as in the health-disease process there is environmental determinism. However, there are few more contextualized analysis of environmental issues and highlighting the different social actors associated with it. However, these are mutation points, because they can go beyond simple search to stay in the epidemiology of the disease, that in the instant care to treat, during and in health promotion activities, not just about epidemiology, but also about importance of environmental protection (pollution, recycling, etc.).

Although, we may want to question about the conceptual base that anchors similar thinking. This, considering that, today, we can no longer give rise to an anthropocentric ethics that perpetuate the legacy of the domination of nature by man. Instead, we find an ethical appreciation of the natural environment in which humans and nature are part of the same complex, dynamic and interdependent system, and therefore understand each other³.

Of course, as stated in some of the productions found in the works of Capra^1,2, this aspect of reflecting on and treating, nursing has a pioneering spirit. Just let us go back to the past to find the historical legacies of one profession concerned with the environment and its relationship with health.

It is worth remembering that the striker of modern nursing, Florence Nightingale, was dedicated to the care environment, expanding the scope of vision of the body to space nursing care. Although, now, we must do it towards a new concept of the planet, not just as throbbing with life, but as itself a living independent being².

Hence this is the reason why the seizure of the problem cannot give up under the aegis of mechanistic assumptions and targets; it is necessary that new assumptions guide the research on this complex environment that we are talking. Assumptions that enhance its complexity, from the infinite set relations, not to seek certainties, but rather from the uncertainty of action addressing other perspectives. Assumptions that do not divide society and nature, subject and object, reason and emotion. Finally, environmental problems must be understood according to the context in which it operates, through the eyes of multiple social actors with which it is interacting, searching through several domains of knowledge, build a rationality in which the environment is not isolated, nor is mere support for human existence, but is the human existence, is the whole³.

And therein lies the value of research that tries to learn about the concepts taught in nursing in terms of eco-literacy. Understanding them can demonstrate where are the teaching points of mutation and as them or with their help; one can multiply this desired change.

Likewise are relevant investigations (here found only one) on the concepts of environment and its interface with the assumed health nursing. The answers can provide ideas of where and how to start eco-literacy to those who are already in work, and therefore not only formed, but mostly, forming other individuals.

Thus, without attempting to account for the magnitude of the issue, we risk weave some questions for future productions: which values health professionals have attributed to environmental issues? Institutions are concerned with possible health damage they may cause to the environment? Were they prepared to watch taking into account any environmental preservation? Up to what extent care for the environment is part of the professional care³?.

CONCLUSION

It is known that the entire earth's ecosystem is a dynamic web of living and non-living forms at different levels. And while all living organisms exhibit their individuality and are relatively autonomous in its functioning, the boundaries between organism and environment are often difficult to determine. Living organisms, being open systems, remain alive and functioning through intense transactions with their environment.

This justify the search for the amplitude of the publications in terms of environment and nursing which meant the realization that there are still many spaces to be filled, questions to be answered and reflections to be drawn before reaching effective responses on many environmental problems, their mechanisms and interactions with health; prior to actualize conduct that would really reflect on the viability of effective strategies and actions to build planetary races.

Certainly, it was not yet found the path of investigation that may include a look that integrates the various dimensions involved in environmental issues, as well as to give voice to the various actors involved. However, there are points of and for mutation; the need is to multiply them.

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