ORIGINAL RESEARCH

Critical thinking as a competence for nurses' practice in the family health strategy

Joana Angélica Andrade Dias^I, Helena Maria Scherlowski Leal David^II, Sonia Acioli^III, Rosângela da Silva Santos^IV, Flavia Pedro dos Anjos Santos^V

^I Nurse. MS. Doctorate Student. State University of Rio de Janeiro. Brazil. E-mail: joanauesb@gmail.com
^II Nurse. PhD. Adjunct Professor, State University of Rio de Janeiro. Brazil. E-mail: helenalealdavid@gmail.com
^III Nurse. PhD. Adjunct Professor, State University of Rio de Janeiro. Brazil. E-mail: soacioli@gmail.com
^IV Nurse. PhD. Adjunct Professor, State University of Rio de Janeiro. Brazil. E-mail: rosangelaufrj@gmail.com
^V Nurse. MS. Doctorate Student. State University of Rio de Janeiro. Brazil. E-mail: fpasantos@uesb.edu.br

DOI: http://dx.doi.org/10.12957/reuerj.2018.30505

ABSTRACT

Objective: to think about nursing care in the Family Health Strategy, and about critical thinking as a competence for performing it. Method: this reflective, theoretical study was built up by reading legislation and scientific articles taken from the Regional Portal of the Virtual Health Library, and was structured around two thematic axes. Content: the care practices performed by nurses in the Family Health Strategy are assistive, administrative and educational; may be individual or collective; entail technical, organizational and best practice considerations; and thus demand a critical thinking competence in order to be performed safely and responsibly. Conclusion: it is important for critical thinking to be taught to, and learned by, undergraduate nurses working in the Family Health Strategy. This calls for teaching that is critical, reflective, creative and flexible, and guided by methodologies that position students as the active subjects of their own training.

Descriptors: Nursing practices; nursing; critical thinking; family health strategy.

INTRODUCTION

Two years after its creation, the Family Health Program (FHP) has become a priority strategy for consolidation and expansion of the basic care, as a substitute for the conventional care practices, based on teamwork guided by the development of health promotion, disease prevention and recovery, rehabilitation and maintenance of users' health.¹

From this, arises a proposal to change the existing health care model with the reorganization of the health services and emphasis on the health needs of users, demanding different skills and abilities from the professionals that will compose the teams, especially the nurse, who has developed their practices using the technical-scientific knowledge with the appropriation of ethical, humanitarian and citizenship values, in order to contribute to the construction of new ways of acting and producing resolutive care. ²

In this strategy, this professional has attributions ranging from the organization of activities to direct the care to the user and the community,³ performing care practices of educational, care and administrative nature, being that this latter involves the management, supervision, planning, organization, monitoring and evaluation of the actions that correspond to the health needs of the community.^4-5

It is understood that as a member of a family health strategy (FHS) team, nurses need to be able to think critically, considering that from this, they will more easily find solutions to the problems that appear in the daily life of their work, especially because this way of thinking is an essential component for decision making.⁶

It should be highlighted that the critical thinking (CT) is frequently used in the nursing literature to describe processes associated with the work developed by nurses with the users, and it is also understood as "an essential component of the professional responsibility and the quality of the nursing care".^7:342

This study aims at promoting reflections about the nursing practices performed by the nurse in the FHS and the CT as a necessary competence for its development.

It is a theoretical-reflexive study constructed by the reading of legal documents, such as the National Curricular Guidelines (NCG) for Undergraduate Nursing Courses, as well as the bibliographical survey, done through scientific articles dealing with the FHS, nursing practices at the FHS, and on nursing CT, collected through the electronic search in the databases of the Regional Portal of the Virtual Health Library. After reading the articles in full and selecting those considered important for the study, the research was structured in two reflexive thematic axes, as described below.

The nursing care practices developed by nurses

As mentioned before, the nurse inserted in the the family health context carries out care practices recognized as care, administrative and educational,³ which translate into actions of direct or indirect care and materialize in the actions and individual or collective ways of doing from the values, knowledge and culture that precede them.⁸ It is therefore necessary that we abandon the theoretical knowledge that can contribute to the transformation into something mechanized and determined by conditions that can reduce them into pre-established schemes, such as protocols, standards, regulations, among others.⁹

These practices are impregnated with technical, organizational and good care practices, and the first is expressed when procedures are performed, although through it, it is also possible to establish a therapeutic relationship through the approximation between the user and the nurses at the time of their performance.⁸

It should be emphasized that the implementation of procedures is directly related to the nurses' care practice, however, it is essential that it is guided by the centrality of the user's health needs and by the building of a bond, reaffirming their interrelationship with the subjective dimension of care.¹⁰

The organizational sense is configured when the nurse starts to perform activities of an administrative nature, such as planning, coordination, supervision, meetings and training of the team, focusing on the organization of the therapeutic space; while the sense of good care practices is related to the educational work, as well as the assistance offered by identifying the health needs of the users enrolled in the family health unit (FHU), be it in the office, at home or in the community, being denominated in this way due to the understanding that through them it becomes possible to construct spaces that facilitate the attention, listening and dialogue.⁸

In a study that aimed to know the care practices performed by primary care nurses, the home visit, educational activities and the nursing consultation emerged as the ones that stood out the most, although some administrative practices, the embracement and care practices or technical procedures such as vaccination, dressings, vital signs verification, among others, have also been identified, albeit less emphatically.¹¹

The home visit is recognized as a nursing care practice of those who work at the FHS, as it occurs in a space in which care, dialogue, intervention and bonding occur daily,^4,11 making it possible to know the social context and the health needs of the registered families, as well as an approximation to the determinants of the process of illness of these families,¹² which facilitates the planning and implementation of care.

The educational practice permeates the every practice of the nursing care, including the care practice, in order to raise possible significant changes that lead to a social transformation,¹ not limited to passing on information but encouraging users to make a critical view of themselves and of the world by ensuring that they become active subjects in the process of taking care of their own health and by exercising their citizenship. ¹³

It should be highlighted that many educational practices have not yet incorporated the understanding of the determinants of the process of becoming ill, nor the needs, demands and knowledge of the population, occurring more as an information process instead of an educational one, since it foresees an active movement of knowledge appropriation, built in a shared way through the articulation between subjects that have different knowledge and common interests.¹⁴

Regarding the nursing consultation, it is emphasized that this constitutes a private activity of the nurse supported by Law No. 7,498/1986 ¹⁵ which regulates the professional practice of nursing and by the Resolution No. 159/1993 of the Federal Nursing Council¹⁶ and it is an important moment in the educational practice because it is guided by listening to conflicts, difficulties and problem solving, in addition to providing a better knowledge about the social, emotional and family context of the users, as well as promoting their autonomy and strengthening their relationship with the professional.^11,17

In addition, for the purposes of the FHS to be consolidated, it is imperative that the care practices, especially the home visits and educational activities, are carried out in a perspective that stimulates the co-responsibility of the users in the care of their health.

The welcoming attitude and the sensitive listening are fundamental for the creation of an environment of trust and mutual respect, making the encounter between the nurse and the user a unique moment for the construction of healthier ways of living and also for the elaboration of strategies that can contribute to a social transformation.²

Thus, the nurses' practices have the potential to provoke significant changes in the health context of users, based on practices permeated by critical reflection, considering that the attitude and critical thinking of this professional can contribute to the substitution of the purely technical and biological character of the care for a more focused approach to the comprehensive care of the users and to their health experience as a right.

It is therefore perceived the need for nursing to carry out its care practices with innovation and balance, in order to promote a more horizontal care, in which the interface with other professionals and other practices can also contribute to the reconstruction of its social role, in addition to establishing connections between different knowledge, practices and people, so that a closer approximation with comprehensive care can take place.¹⁸

Thus, it is relevant to ensure the working conditions of the nurses, so that their practices do not occur in a fragmented, biologicistic and disconnected way, which is disconnected from the user's singularity, leading to the emptying of their performance potential in the FHS; ¹⁰ in addition, that their professional training is based on criticality since the graduation, so that they can develop the capacity to mobilize different knowledge and practices for the formulation of strategies, which can enable better health conditions for the population, as well as greater professional appreciation.

Reflections on the CT as a competence for the implementation of care practices

The CT is understood as essential to any area of human performance, especially when it encounters the need for decision making and/or problem solving.^19,20

Unlike the thinking used to perform a routine task, "it is deliberate, purposeful and informed",^6:60 besides the fact that it uses logic, intuition and creativity and is guided by policies, procedures, laws and ethical principles. When applied to nursing, it is driven by the needs of the user, family and community, as well as by the need for competent and efficient care.

It encompasses skills and attitudes necessary for the development of the clinical reasoning or judgment by the nurse, and consequently for safe and quality care, as well as interrelated elements such as the technical-scientific knowledge, user assessment, clinical experience and ethics, which provide support at the moment of making decisions, ²¹ and why not mentioning the popular knowledge, the one that is impregnated with ideas, opinions, values, beliefs, culture of a group, hence the understanding that this professional needs to develop a critical thinking in all the spheres, that is, from the execution of practices until the deepening of the theoretical knowledge by the investigative practice. ²²

It makes possible to understand the contradictions present in the phenomenon, as well as to think about the possible interventions to be carried out,²³ characterizing itself as a way of thinking that involves knowledge, experiences, dispositions (attitudes or habits of the mind) and intellectual abilities.²⁴

In order for it to be developed satisfactorily, it must be constantly practiced, and the the nurse must have technical, interpersonal and intellectual competence, as well as scientific, ethical and legal knowledge, among others.²⁰ acquired both during the university and professional training, which proves that it is a competence, since in addition to correspond to the product of learning, it also bases the actions of human beings,²⁵ in this specific case of the undergraduate student during the performance of practices/curricular internship, and the nurse who works at the FHS.

Therefore, this professional must have characteristics and attitudes such as responsibility, honesty, curiosity, creativity, autonomy, discipline, confidence, discernment, intuition, tolerance, proactivity, justice, practicality, respect for diversity, courage, patience, persistence, empathy, being reflexive, among others,²⁰ without which they will never be able to carry out good care practices, be they technical or organizational.

Although the Resolution No. 03 of November 7, 2001 of the National Board of Education and Board of Higher Education approving the NCGs of the Undergraduate Nursing Courses²⁶ do not explicitly present the CT as a skill to be acquired by the nursing graduate, it is referenced in at least three articles that compose it. In the third article, which deals with the professional profile established for the bachelors in nursing, it is described that besides being generalist and humanist, the training of the nurse must be critical and reflexive, which leads us to believe that undergraduate nursing school professors need to value it in their classes, be they theoretical, practical, theoretical-practical or an internship, in order to contribute as early as possible to the development of this way of thinking by the undergraduate student.

It should also be highlighted the article four of the aforementioned resolution, especially section I, which states that nurses must perform their practice, whether in the area of collective health or in any other care space, in an uninterrupted and articulated manner in all levels of the Unified Health System, in a critical and reflexive way aiming at finding solutions to the problems of society,²⁶ pointing again to the need for this competence to be developed since the graduation in nursing; considering that without the ability to think critically, the nurse will not be able to adequately solve the problems of the individual, family or community under their care.

Another article of this Resolution, which also focuses on the CT, is the fourteenth article (items I, V and VI), which states that the teaching offered by nursing undergraduate courses should be critical and reflexive, with the implementation of methodologies and pedagogical teaching strategies that promote the reflection and the articulate "knowledge; the know-how to live together",^26:6 helping the graduate develop key attributes for their training, such as learning to learn, to be, to do, to live together and to know, which are essential for the implementation of care practices at the FHS.²⁶

Thus, it can be seen that without the CT it is impossible to perform the care practices at the FHS with quality, which is why the professors who teach in Nursing Undergraduate Courses need to make changes in the way of teaching/learning, starting to value and encourage the development of this competence not only by means of theoretical classes, but mainly when performing the care, administrative and educational practices, during the practice and internship activities in the FHS field, in order to help graduate students become more critical, reflexive, ethical and political nurses capable of developing care practices that may actually impact the health of the families residing in the FHU's area where they will work.

CONCLUSION

The FHS is a field of action of the nurse in which the most diverse care practices directed to the user, family or community are performed, demanding from this professional several competences, among which to think in a critical and reflexive way, enabling them to make assertive decisions, as well as assuring a higher quality to them.

The study made it possible to understand that the practices promoted by the nurse in the FHS are impregnated with technical, organizational and good practice senses and they are part of direct or indirect care actions, since many of them are performed with the user, family or community, as for example, the nursing consultation, embracement, group meetings, educational activities and technical procedures, while others such as meetings and training of the team, organization of the unit, planning, supervision, evaluation, among others are carried out far from the users, but aiming at a better care directed to them, reinforcing the understanding that this professional must begin to develop the CT ability while they are still a student.

Thus, it is reaffirmed the importance of the CT to be taught/learned from the graduation period, so that the undergraduate student may, in the future, become a nurse capable to develop the educational, care or administrative practices in the FHS in a more proactive, critical, ethical, reflexive, creative, safe and responsible way, which requires a more critical, reflexive, creative and flexible teaching based on active methodologies that place the undergraduate nurse as the active subject of their own formation.

REFERENCES

1.Andrade ME, Clares JWB, Barretto EMF, Vasconcelos EMR. Percepção do enfermeiro quanto à atuação educativa na estratégia saúde da família. Rev enferm UERJ. 2016; 24(4): e15931.

2.Santos FPA, Nery AA, Matumoto S. Care provided to patients with hypertension and health technologies for treatment. Rev. Esc. Enferm. USP. 2013; 47(1):107-14.

3.Caçador BS, Brito MJM, Moreira DA, Rezende LC, Vilela GS. Ser enfermeiro na estratégia de saúde da família: desafios e possibilidades. REME rev. min. enferm. 2015; 19(3): 612-9.

4.Kebian LVA, Oliveira SA. Práticas de cuidado de enfermeiros e agentes comunitários de saúde da estratégia saúde da família. cienc. cuid. saude. 2015; 14(1): 893-900.

5.Freitas GM, Santos NSS. Atuação do enfermeiro na atenção básica de saúde: revisão integrativa de saúde. Rev. Enferm. Cent. O. Min. 2014; 4(2): 1194-203.

6.Alfaro-LeFevre R. Aplicação do processo de enfermagem: uma ferramenta para o pensamento crítico. 7ª ed. Porto Alegre (RS): Artmed; 2010.

7.Bittencourt GKGD, Crossetti MGO. Habilidades do pensamento crítico no processo diagnóstico em enfermagem. Rev. Esc. Enferm. USP. 2013; 47(2): 341-7.

8.Ferreira VA, Acioli S. Prática de cuidado desenvolvida por enfermeiros na atenção primária em saúde: uma abordagem hermenêutico-dialética. Rev. enferm. UERJ. 2010; 18 (4): 530-5.

9.Bourdieu P. Esboço de uma teoria da prática. In: Ortiz R, organizador. Pierre Bourdieu: sociologia. São Paulo: Ática; 1983. p. 46-81.

10.Santos FPA, Acioli, S, Palmarella VP, Machado JC, Souza MS, Couto TA. Práticas de cuidado da enfermeira na Estratégia Saúde da Família. Rev. bras. enferm. 2016; 69(6): 1124-31.

11.Acioli S, Kebian LVA, Faria MGA, Ferraccioli P, Correa VAF. Práticas de cuidado: o papel do enfermeiro na atenção básica. Rev. enferm. UERJ. 2014; 22 (5): 637-42.

12.Kebian LVA, Pena DA, Ferreira VA, Tavares MFL, Acioli S. As práticas de saúde de enfermeiros na visita domiciliar e a promoção da saúde. Revista APS. 2012; 15(1): 92-100.

13.Couto TA, Santos FPA, Rodrigues VP, Vilela ABA, Machado JC, Jesus AS. Health education under perspective of family health teams users. J. Nurse UFPE on line [Internet]. 2016 [cited 2017 May 22]; 10 (5): 1606-14. Available from: http://www.revista.ufpe.br/revistaenfermagem/index.php/revista/article/view/9147/pdf_10142

14.Acioli S, David HMSL, Faria MGA. Educação em saúde e a enfermagem em saúde coletiva: reflexões sobre a prática. Rev. enferm. UERJ. 2012; 20 (4): 533-6.

15.Presidência da República (Br). Casa Civil. Subchefia para Assuntos Jurídicos (Br). Lei nº 7.498, de 25 de junho de 1986 Dispõe sobre a regulamentação do exercício da enfermagem, e dá outras providências. 1986; [cited 2017 July 18]. Available from: http://www.planalto.gov.br/ccivil_03/leis/l7498.htm

16.Conselho Federal de Enfermagem (Br). Resolução nº 358, de 15 de outubro de 2009 Dispõe sobre a sistematização da assistência de enfermagem e a implementação do processo de enfermagem em ambientes, públicos ou privados, em que ocorre o cuidado profissional de enfermagem, e dá outras providências. 2009; [cited 2017 Aug 29]. Available from: http://www.cofen.gov.br/resoluo-cofen-3582009_4384.html

17.Bernardes AG, Pelliccioli EC, Marques CF. Vínculo e práticas de cuidado: correlações entre políticas de saúde e formas de subjetivação. Ciênc. saúde coletiva (Online). 2013; 18(8): 2339-46.

18.Assis MMA, Nascimento MAA, Pereira MJB, Cerqueira EM. Comprehensive health care: dilemmas and challenges in nursing. Rev. bras. enferm. (Online). 2015; 68(2): 333-8.

19.Almeida LS, Franco AHR. Critical thinking: Its relevance for education in a shifting society. Revista de Psicología.2011; 29 (1): 175-95.

20.Amorin MP, Silva I. Instrumento de avaliação do pensamento crítico em estudantes e profissionais de saúde. Psicologia, Saúde e Doença. 2014; [cited 2017 Sep 25]; 15 (1): 122-37. Available from: http://www.redalyc.org/pdf/362/36231157011.pdf

21.Crossetti MGO, Bittencourt GKGD, Lima AAA, Góes MGO, Saurin G. Elementos estruturais do pensamento crítico. Rev. gaúcha enferm. 2014;35(3): 55-60.

22.Dias JAA, David HMSL, Vargens OMC. Science, nursing and critical thinking: epistemological reflections. J. Nurse UFPE on line [Internet]. 2016; [cited 2017 July 17]; 10 (supl. 4): 3669-75. Available from: http://www.revista.ufpe.br/revistaenfermagem/index.php/revista/article/view/9911

23.Chaves MMN, Larocca LM, Peres AM. Enfermagem em saúde coletiva: a construção do conhecimento crítico sobre a realidade de saúde. Rev. Esc. Enferm. USP. 2011; 45(esp): 1701-4.

24.Oliveira LB, Díaz LJR, Carbogim FC, Rodrigues ARB, Püschel VAA. Efetividade das estratégias de ensino no desenvolvimento do pensamento crítico de graduandos de Enfermagem: uma metanálise. Rev. Esc. Enferm. USP. 2016; 50(2): 355-64.

25.Perrenoud P. Desenvolver competências ou ensinar saberes? A escola que prepara para a vida. Tradução de Laura Solange Pereira. Porto Alegre (RS): Penso; 2013.

26.Ministério da Educação (Br). Conselho Nacional de Educação. Câmara de Educação Superior (Br). Resolução nº 3, de 7 novembro de 2001 Institui as diretrizes curriculares nacionais do Curso de Graduação em Enfermagem. Brasília (DF): CNE; 2001 [cited 2017 July 18]. Available from: http://portal.mec.gov.br/cne/arquivos/pdf/CES03.pdf