ORIGINAL RESEARCH

Obstetric nurses' skills as mediators of the educational process: sociopoetic study

Rafael Ferreira da Costa^I; Iraci dos Santos^II; Jane Márcia Progianti^III

^I Obstetrical Nurse. PhD student at the Graduate Nursing Program of the State University of Rio de Janeiro. Brazil. E-mail: rafaobs@hotmail.com
^II Nurse. PhD in Nursing. Full Visiting Professor of the Graduate Nursing Program at the State University of Rio de Janeiro. Brazil. E-mail: iraci.s@terra.com.br
^III Obstetrical Nurse. PhD in Nursing. Full Visiting Professor of the Graduate Nursing Program at the State University of Rio de Janeiro. Brazil. E-mail: jmprogi@uol.com

DOI: http://dx.doi.org/10.12957/reuerj.2016.18864

ABSTRACT

Objective: to show the skills of obstetric nurses as mediators of educational practices with groups of pregnant women. Methodology: followed the philosophical principles and theoretical fundamentals of sociopoetic theory and used the dynamic technique known as 'experience of geomythical places'. Data production was submitted to thematic category analysis and described on the basis of sociopoetic studies. The study participants were obstetric nurses, a social assistant and pregnant women receiving care at a health service in Rio de Janeiro City, Brazil. Data was collected from May to July 2014 at the School of Nursing of Rio de Janeiro State University. Results: it was shown that the skills of obstetric nurses as mediators of educational practices are centered on being welcoming, bonding and fostering feelings of security, which come from competent care and technical and political commitment. Conclusion: such skills contribute to mediating towards women's empowerment.

Keywords: Health education; obstetric nursing; pregnant women; women's health.

INTRODUCTION

Health education with pregnant women, characterized as non-formal and non-group education, occupies a privileged place in various health services, and should be seen as a transformative tool in the field of sexual and reproductive health of women.

In this sense, it is noteworthy that in this field, many nurses mediate educational activities that promote the peaceful experience of pregnancy, the mother-baby bond and greater acceptance of pregnancy, the free expression of sexuality and the demystification of the labor pain, which provides a pleasurable experience of pregnancy and physiological birth¹.

Educational practices, when carried out in prenatal care, may be strategies that enable women to choose and make a decision about what is best for themselves, in a clear demonstration of the search for their main role and autonomy².

Given the above, the objective of this work is to present the skills of obstetrical nurses as mediators of educational practices with groups of pregnant women.

LITERATURE REVIEW

Health education can be understood as an expression of nursing care that is materialized through educational practices in health³, whether collective or individual practices, because they are guided by the pursuit of an interdisciplinary perspective and citizen autonomy⁴.

Groups of pregnant women represent micro spaces that are in constant change caused by the relationships that are established there⁵. Thus, in the perspective of shared construction of knowledge, everyday situations can emerge in group activities and generate new professional, personal and institutional expectations, and, occasionally, in the field of women's health, they may contribute to the formation of specific work groups, as for example breastfeeding, sexuality, care of the newborn, childbirth, as state the abovementioned authors⁵.

We emphasize that this shared conception which meets the directions of the National Policy for Integral Attention to Women's Health (PNAISM)⁶ confronts the results of studies that indicate the traditional model of education as persistent in the field of health and nursing, sometimes in a hegemonic way, and sometimes intertwined with other models^3,5,7.

However, many obstetrical nurses who joined the movement of de-medicalization of the process of childbirth walk against the hegemonic vertical model of health education. They are mediators/facilitators of dialogic and critical education actions within the groups of pregnant women. These actions aim at the process of women's empowerment which means extension, reinforcement or attainment of power; affirming the right of citizenship on different spheres of social life⁸.

METHODOLOGY

The socio-poetic approach was selected. This, as approach for research in human and social sciences including nursing and education, is considered a philosophy and social practice of care and education and research in the teaching-learning process⁹.

This approach has five philosophical principles: the establishment of the group-researcher (GR) as an analytical object, considering the research participants as co-producers of knowledge; the favoring of the participation and appreciation of dominated cultures and of resistance, in the reading and interpretation of data; beyond reason, the consideration of the whole body as a source of knowledge production; the use of artistic and creative techniques in the production of data on learning, knowing and researching; the emphasis on ethical, political and spiritual dimensions in the construction of knowledge, collectively elaborating the meaning and dissemination of the research¹⁰.

Regarding the formation of GR, three obstetrical nurses known by the researchers were initially invited and they were asked, through snowball technique, to indicate the names of other obstetrical nurses and pregnant women who were involved with educational practices in health. This made possible to contact 13 pregnant women and 16 nurses. These made up the small purposive sample of people in the GR.

In this sample, five pregnant women and seven nurses accepted the invitation and participated in the survey. The criteria for formation of the GR were that all obstetric nurses acted as mediators of educational groups with pregnant women, developed educational practices in the perspective of shared knowledge, fleeing from the vertical model, and who agreed to participate in the research.

With regard to pregnant women, it was considered relevant that they had participated in at least one group of educational practice with the mediating nurses, that they had gestational age up to 34 weeks, to avoid the risk of reaching the period childbirth which would make them be absent in the production of data, and that they accepted to participate.

Production of data happened in four meetings with the GR. In these meetings, a theme was initially suggested by researchers, which was negotiated with the group after the presentation of the questions guiding the research with openness to redefining and making new paths before the axes that emerged²⁰.

In production data held in the sociopoetic workshops, a dynamic activity of sensitivity among subjects was initially developed in order to encourage the imagination. After this activity, the technique known as Dynamic of experience of geomythical places (DEGP) was applied, making the guiding question of the technique explicit - If the geomythical places (land, road, stream, bridge, ridge, threshold, well and failure) represent educational practices in the pursuit of autonomy/empowerment of women, how would they be?

Considering the geomythical places as theoretical category and the GR responses as empirical categories, a table showing these statements and their individual themes was elaborated and exposed to the GR during the counter-analysis.

After GR validation, it was possible to convert them into subtopics to be allocated in themes through agglutination, similarity and relevance, leading thus to the category.

The classification of data within the body of this artistic technique allowed highlighting the dichotomies, alternatives and choices present throughout the production data among GP members, composing this way, the classificatory sociopoetic study¹¹.

This study was approved by the Ethics Committee of the UERJ, Opinion nº 655.319 of 15.05.2014, and all the cost of participating in the GR were covered by researchers.

RESULTS AND DISCUSSION

The skills of obstetrical nurses were manifested in educational activities in health, in the speeches of the GR, when they were referred, emphasizing the friendly relationship, the creation of bonds and the promotion of the sense of security. We opted for the discussion of the first two themes together, due to the cross-sectional relation present in the terms.

Hosting as a technical-assistant and relational action/creation of bonds

Leveraged by the spciopoetic artistic technique, the imaginary of the GR brought to light characteristics or qualities of professional actions of obstetrical nurses. These, when implemented, transform the physical environment and generate positive feelings in pregnant women and in their families, strengthening their resources of coping with the reality:

Thus, the health service is perceived as conducive to care because it creates the feeling of warmth and coziness, with transparency of its activities, functioning as an invitation to all who seek care there. This is achieved through postures and lines that add to the knowing/doing the de-medicalization of care in women's health, present in the professional actions of obstetrical nurses, here considered skills.

The space is transformed from these skills, being described as cozy on the earth, similar to the nest where the bird is born and is welcomed by its mother who provides affection, food, including to the soul, as according to one of the philosophical principles of sociopoetics, the body should be understood in its entirety: rational, emotional, intuitive, sensitive, imaginative and spiritual¹¹. Surprisingly, the well is perceived as a cozy place with light to guide, a place where fear must not have room, despite the adversities.

The welcoming attitude of the obstetrical nurse towards the client and her family members is a continuous action of the nurses' skills such as posture and accountability, which contribute to the construction of bonds. In turn, the creation of bonds, such as the sense of well-being and the desire to return to the institution, assumes the persistent welcoming attitude in all stages of the contact between the customer and her family with the service.

Receiving the client/family in a given physical space such as a room, and listening to her demands, to offer the possibilities available, even if they do not meet fully the expectation, is something that may generate more respectful relationships in which listening is a prime action for making people feel welcomed, supported with empathy and conception of the entire human being, involving the five bodily senses¹².

Thus, the research showed that hosting extrapolates the concept of cordial reception for an active listening to the woman and her family, as well as the ability of interpersonal communication, whether spoken, written or through bodily expressions ¹³. The great challenge is giving meaning to the hosting beyond the moment of reception, valuing the stance to be adopted, which generates subsidies for analysis and management¹⁴.

Although there is an institutional moment for the hosting, when women seek health services and are interested in being followed, where the work process is explained and participants visit all health unit, with screening of demand and openness to questions, the speeches of the GR show a timeless hosting that runs through the different moments lived in the relations between obstetrical nurses and pregnant women, becoming feelings of well-being and inner satisfaction which pave the way for the return to the service for new experiences:

Thus, the bridge represents the ability that nurses have in caring for pregnant women, regardless of age or number of children. With this, pregnant women consider that the summit is in the experiences lived in the relations in the health unit, spontaneously coming back to have other children because they consider the moments shared there pleasant.

Therefore, the ability to host that obstetrical nurses have in the educational process occurs to the extent that they recognize the importance of social construction of health needs. This assumes the character of affirmation of the defense of life, walking against the flow to the reproduction of capital that makes up the medical-industrial complex and its characteristics as a biomedical model of customer submission to health professionals, medicalization, biologicist and impersonal attention¹⁵.

Thus, the educational practices, when negotiating the care, considering the popular knowledge of the users which communicates with the scientific knowledge of obstetrical nurses, become an exchange project where the creativity of everyone involved enhances nursing care technologies:

In this perspective, professional security should express to users a model that is in line with soft and relational technologies, with potential to care as imagined or desired, that is, the production of new processes in health, able to establish themselves as new references to users¹⁶.

It is in this mutation between new and old knowledge that sociopoetics bets, by having as characteristic a practice of resistance in the area of knowledge production, from the consideration that we are all producers of science and philosophy, emphasizing humility and opposing to the present omnipotence in Western science¹⁰.

The reception can be understood as a technical and assistance foundation of health services, one of the stages of the work process where dialogue and negotiation take place. It is pointed out that attitudes of commitment and interest in the population's health problems, listening and treating users in a humanized manner is important¹⁴.

Negotiation is a dialogical act between technical references and experiences that will define and distinguish the health needs of people, with health professionals aware of that negotiation of needs¹⁵.

In addition, the reception involves subjective and individual questions, search for meanings and for the not said¹⁵, converging with sociopoetic principles when searching for the meaning of what is hidden or buried in the unconscious¹⁰.

It is through the nurses' posture of treating women with dignity, in the de-medicalized perspective, taking responsibility as a service for their needs and considering their subjective expressions in a communicative relationship, the obstetrical nurse receives and demonstrates one of the skills as a mediator in educational practices.

This walk of humanized care culminates in the bond, a process that when built, provides new meetings between the service/professional and the clientele, based on the credibility and trust in a health facility with no bureaucratic characteristics and where individualities are valued¹³.

In this sense, in the field of women's health, the link is essential and represents the approximation between human relations, stimulating the professional to be responsible for promoting health and well-being of this clientele¹³. It appeared, then, that the skills of hosting and creating bond are intertwined and conditioned, as they are born from human relationships established within a historical and temporal context between obstetrical nurses and pregnant women.

The form of treatment and the experiences lived and meant result in the care process, where educational practices fall and consolidate the obstetrical nurse's ability of hosting and creating bond.

In the universe of bonds, spirituality and faith appear wrapped in a violet light, where energies circulate among these people, represented by the mother earth, which is the basis from which flow the spiritual senses. So, the energy within the GR has roots in the earth, the relationship between obstetrical nurses and pregnant women is able to flow through channels that are open to receive exchanges in the educational relationship, considering their life stories and gender socialization:

In this sense, spirituality in sociopoetics is a dimension to be valued and sought, as it is manifested in the relationship of man with nature and with the world, individually and collectively, and the GR has the unique role of channel of expression of spiritual senses. Specifically, in this study, with women nurses and pregnant women, the question of female gender, traditionally buried by the patriarchal discourse, has ethical epistemological implications, highlighting the importance of balance, in scientific studies, of the relationship between social work of women, the characteristics of the work of men, and spirituality¹¹.

Understanding health education as a field of practice and knowledge of the health sector that has been occupied more directly with the creation of links between professional action and the daily activity and the thinking of the population, it proposes - to take the unconscious, creating a culture of social, emotional and spiritual care, in which emotion and intuition are put into operation in the health work, balancing its relationship with reason in the therapeutic action¹⁷.

Sense of security promotion

The process of hosting/creation of bond expected in the interaction between nurses and pregnant women culminates in the third ability of obstetrical nurses - to promote a sense of security that, in the bridge or bridges and streams, represents an action of interaction and guidance where there is tranquility and hosting, because they connect people who rely on doing and knowing of obstetrical nurses and of that health unit:

This ability can be combined with three others identified as important in the educational activity carried out by the nurse: links between theory and practice, using dialogue as a strategy for the transformation of the reality in terms of health, and instrumentalizing subjects with adequate information¹⁸.

The construction of the profile of skills for educational activities developed by nurses in the perspective of subjects involved showed that one of the indicated skills was to promote acceptance and build bonds with the assisted subjects, aimed at understanding, recognizing and assuming a commitment with the health needs of the population¹⁸.

The route is the bridge, the ability to update its practice and to communicate dialogically with the clientele (represented by the flows) has been built along the life of the professional among obstetrical nurses, which were available to change the practice before the principles of humanization of labor and birth, considering health policies in the area of ​​women's health and opportunities in the field, in a movement against the hegemony of the biomedical mode in which they were formed.

Thus, the promotion of sense of security by the obstetrical nurses is also a skill in the educational process. With respect to their knowing/doing, given the peculiarities of the pregnant woman and her family in the construction of a nursing care particularized and shared. It stands out as a key point for changing the current medicalized model in women's health, because the users recognize security, acceptance and satisfaction with the care provided by nurses, in a de-medicalized service as determinants in the restructuring of the medicalized care model into a humanized model¹⁹.

The humanization of health care, like policy, represents or appears as the crucial point in the ridge, opposite to the technicists relations established in recent decades. Similarly, the GR considered that, although there is a threshold, it should come more generous and less selfish, in referring to the activities controlled by rules and routines of many health services:

Thus, to humanize care means to recognize that people have desires, needs and rights, and that the product of the therapeutic relationship is to meet the health needs of those who need care¹⁴. Therefore, the care ruled by the defense of life in face of its fragility and complexity, needs to set a distance from the perspective of repetition of procedures¹⁵.

It is in this ability of obstetrical nurses, mediators of the educational process, that their competence and technical and political commitment find basis, because without it, the service will not be sustained neither as institution or as de-medicalized care model, due to its historical counter flow in the scenario women's health.

In the dialectical sense, the skills of hosting and creating bonds of obstetrical nurses during pregnancy promote a sense of security, but the latter founded on competence and technical and political commitment that sustain the former.

Thus, in the case studied, their skills as mediators of the educational process are supported by three pillars, the hosting as technical assistance practice, the creation of bonds and the promotion of the sense of security.

Here, the idea of ​​not thinking about practice simply from the theory, because the criterion of truth and purpose in the practice substantiates the theory, and the more consistent is a practice, more consistent is its theory; and a practice is transformed from a theoretical drawing. Thus, the more precarious is a practice, the more precarious will be the theory and vice versa²⁰.

In this sense, the competence and technical and political commitment of obstetrical nurses is based on a de-medicalized know-how, built from the critical know-how on the medicalized domain, still prevalent in Brazilian obstetrics. However, the adoption of medicalization as the implementation of a care guided by respect for the right to choose of women facing different forms of perinatal care, such as using non-invasive technologies of care in their reproductive cycle²¹, have turned their practice in the sense of qualitatively feeding towards the implementation of a humanized care.

Thus, nurses, mediators of educational practices, use the technical expertise and commitment as a means to achieve their political commitment to transform reality in favor of women's health and, consequently, transform the medicalized model in obstetrics.

The identification of purposes requires political competence mediated by technical competence; the construction of methods to achieve the purposes requires technical competence mediated by political competence, concluding that the absence of technical and political competence hampers advances in education and in the society²².

Nurses value the educational dimension in the daily care activities, through individual guidance or group activities. It is crucial to understand that the technical competence of a educating agent is also political.

The skills of obstetrical nurses, mediators of educational practices, collaborate in order that the nurses themselves, the patients and their families accumulate forces to unify the struggles for consolidating the progress obtained in the de-medicalized care field.

CONCLUSION

The ability of hosting is a technical-assistance basis that requires posture at work and generates benefits for analysis and management, because it is from the active listening of singularities and subjectivities of pregnant women and their families that the establishment of dialogue/communication/negotiation is possible for meeting their needs and there are points still to be worked to change the reality in health.

Similarly, the creation of bonds - ability of obstetrical nurses - appears in the feelings of confidence and trust in the service, with the fundamental accountability for promoting the health of people, considering the spiritual meaning of care.

Finally, it is in the articulation between theory and practice produced by the obstetrical nurse, by means that may instrumentalize pregnant women and their families with adequate information, towards changes in the practice, observing the policy of humanization that the third professional skill presents - promoting the sense of security.

REFERENCES

1.Progianti JM, Costa RF. Práticas educativas desenvolvidas por enfermeiras: repercussões sobre vivências de mulheres na gestação e no parto. Rev Bras Enfem Brasília. 2012; 65 (2): 257-63.

2.Pereira ALFP, Bento AD. Autonomia no parto normal na perspectiva das mulheres atendidas na Casa de Parto. Rev Rene. 2011; 12 (3): 471-7.

3.Sousa LB, Torres CA, Pinheiro PNC, Pinheiro AKB. Práticas de educação em saúde no Brasil: a atuação da enfermagem. Rev enferm UERJ. 2010; 18 (1): 55-60.

4.Acioli S. A prática educativa como expressão do cuidado em saúde pública. Rev Bras Enferm, 2008; 61 (1): 117-21.

5.Pereira AV, Vieira ALS, Amancio Filho A. Grupos de educação em saúde: aprendizagem permanente com pessoas soropositivas para o HIV. Trab Educ Saúde. 2011; 9 (1): 25-41.

6.Ministério da Saúde (Br). Política Nacional de Atenção Integral à Saúde da Mulher: princípios e diretrizes. Brasília (DF): Ministério da Saúde; 2004.

7.Dantas MBP, Silva MRF, Feliciano KVO. Subjetividade e diálogo na educação em saúde: práticas de agentes comunitários em equipe de saúde da família. Rev APS. 2010; 13 (4): 432-44.

8.Baquero RVA. Empoderamento: instrumento de emancipação social? – uma discussão conceitual. Revista Debates (Porto Alegre). 2012; 6, (1): 173-87.

9.Gauthier J. O oco do vento: metodologia da pesquisa sociopoética e estudos transculturais. Curitiba (PR): CRV; 2012.

10.Adad SJHC, Petit SH, Santos I, Gauthier J, (organizadores). Tudo que não inventamos é falso: dispositivos artísticos para pesquisar, ensinar e aprender com a sociopoética. Fortaleza (CE): EdUECE, 2014.

11.Santos I, Gauthier J, Figueiredo NMA, Petit SH. Prática da pesquisa nas ciências humanas e sociais: abordagem sociopoética. São Paulo: Editora Atheneu; 2005.

12.Barbier R. A pesquisa-ação. Brasília (DF): Liber Livro Editora; 2007.

13.Mendonça FAC, Sampaio LRL, Linard AG, Silva RM, Sampaio LL. Acolhimento e vínculo na consulta ginecológica: concepção de enfermeiras. Rev Rene. 2011; 12(1): 57-64.

14.Takemoto MLS, Silva EM. Acolhimento e transformações no processo de trabalho de enfermagem em unidades básicas de saúde de Campinas, São Paulo, Brasil. Cad Saúde Pública. 2007; 23(2): 331-40.

15.Filho JBC, Vasconcelos EMS, Ceccim RB, Gomes LB. Acolhimento coletivo: um desafio instituinte de novas formas de produzir o cuidado. Interface – Comunic Saude Educ.2009; 3 (31): 315-28.

16.Franco TB, Merhy EE. A produção imaginária da demanda e o processo de trabalho em saúde. In: Pinheiro R, Matos RA, organizadores. Construção social da demanda: direito à saúde, trabalho em equipe, participação e espaços públicos. Rio de Janeiro: Uerj; 2005. p.181-93.

17.Vasconcelos EM. Espiritualidade na educação popular em saúde. Cad Cedes.2009; 29 (79): 323-34.

18.Leonello VM, Oliveira MAC. Competências para ação educativa da enfermeira. Rev Latino-am Enfermagem. 2008; 16(2).

19.Progianti JM, Porfírio AL, Vargens OMC, Lorenzoni DP. A preservação perineal como prática de enfermeiras obstétricas. Esc Anna Nery. 2006; 10 (2): 266-72.

20.Saviani D. Escola e democracia. 42ª ed. Campinas (SP): Autores Associados; 2012.

21.Vargens OMC, Progianti JM, Silveira ACF. O significado de desmedicalização da assistência ao parto no hospital: análise da concepção de enfermeiras obstétricas. Rev esc enferm USP. 2008; 42 (2): 339-46.

22.Saviani D. Pedagogia histórico-crítica: primeiras aproximações. 11^th ed. rev. Campinas (SP): Autores Associados; 2013.