RESEARCH ARTICLES

Conditions of discourse production by nurses in educational practice with adolescents

Manuela de Mendonça Figueirêdo Coelho^I; Karla Corrêa Lima Miranda^II; Antônio Marcos Tosoli Gomes^III; Lia Carneiro Silveira ^IV

^I Nurse. Ph.D. student of the Graduate Program in Clinical Care in Nursing and Health at the State University of Ceará. Professor in the Undergraduate Degree in Nursing from Metropolitan College of Grande Fortaleza. Ceará, Brazil. Email: manumfc2003@yahoo.com.br
^II Nurse. Ph.D. in Nursing from the Federal University of Ceará. Professor in Undergraduate Courses in Nursing and Graduate Program in Clinical Health Care of the State University of Ceará. Fortaleza, Ceará, Brazil. Email: kfor026@terra.com.br
^III Nurse. Doctor of Nursing by Anna Nery School of Nursing; Associate Professor in the Nursing School of the State University of Rio de Janeiro. Brazil. Email: mtosoli@gmail.com
^IV Nurse. Ph.D. in Nursing from the Federal University of Ceará. Professor in the Graduate program in Clinical Care in Nursing and Health at the State University of Ceará, Leader of the Psychoanalysis Laboratory of the State University of Ceará. Email: silveiralia@gmail.com

DOI: http://dx.doi.org/10.12957/reuerj.2015.9618

ABSTRACT

This qualitative study aimed to understand the conditions of speech production that support nurses’ utterances in health education practice with adolescents. The theoretical framework used was French Discourse Analysis as set out by Orlandi. Data were collected from May to August 2012 through guiding questions proposed in the dynamics of the Creative and Sensitive Method, in semi-structured interviews of 15 male nurses working with the Family Health Strategy in a municipality of the metropolitan region of Fortaleza, Ceará, Brazil, and linked to schools registered with the Health in Schools Program. It was concluded that the imaginary constituted and maintained by the traditional educational approach shapes the discourse production conditions of nurses who educate. These nurses retain the perception that adolescents should be educated as devoid of desires and subjectivities, and cite the Health in School Program as a policy intended as an incentive to clinical biology.

Keywords: Nursing; education, nursing; health education; adolescent.

INTRODUCTION

Health education is defined as care technology that must promote autonomy, however, there are still observed practices with vertical approaches, whose participation of adolescents is simplified to spectator / receiver of information^1,2.

It discusses the importance of dialogical educational practices with different people trying to consider the subject and undress institutionalized hygienists practices^3,4.

It is wondered why health education practices based on the traditional model still prevail in nursing practices. For a chance to answer, it is necessary to consider the understanding of health education practices from nurses with adolescents in a perspective that transcends what is done for reading how that do is constituted.

In order to infer that do, the theoretical analysis of French Speech on Orlandi reading was used^5-8, on the proposition of speech production conditions as essential constituent to know what sustains health education practices based on the traditional model. Working with the reading proposed by such analysis enables the unveiling of constituents that consolidates in a complex way for not being deliberately exposed on the lines, but rather obscure in-between. For understanding of this scenario, it is necessary to understand the story, not limited to what was said, but in how that saying is built or said⁵.

Therefore, the objective was to understand the conditions of speech production that subsidize the nurses´ enunciations in health education practice with adolescents. This understanding enable to understand the praxis, realizing what place this nurse is speaking about and what components are involved in educational processes of those subject to direct positive reinvention in the educational experience of nursing. In the perception of the genesis of the do, it is believed in the reinvention of this educational care.

THEORETICAL REFERENCE

The analysis of discourse shows instruments for understanding of senses linked to time and space of the practices, mediated by speech, by history and its social context. Thus, the speech is described as a space of assimilation between language, ideology and meaning for those who deliver it⁶.

This referential works with the contradictions of other disciplines. It embraces the exteriority excluded by Linguistics and adds the language that the social sciences reject depending on the exterior, focusing the subject and in situations. For the analysis of speech, social constructs the language, whose discursive compositions refer to the world for that being and not the world as it is⁷.

Absolving the setting that maintains the discursive of the subject becomes fundamental in the analytical process of production of meaning. The conditions of production of speech can be classified as strict (immediate context) or large (socio historical context)⁸. This immediate and historical exteriority mixing with the produced speech, lead to the linguistic materiality, discursive formations in search for transposing the opacity of the text ⁷.

The production conditions of the speeches guide what the say and do of the professional and have fundamental points. The first one is presented in the relationship of senses, in the speech´s involvement with other possible or imagined words and remaining in a broad process, without beginning nor end absolute definite. In sequence, the anticipation mechanism allows the speaker to anticipate the meaning of the interlocutor, forwarding the argument according to the predicted impact. As a third point, the relations of forces present where this speaker is placed, what is his role for the other one, place understood as social representations space establishing the field of meanings, being a constitutive part of the sense of saying ⁹.

METHODOLOGY

The qualitative approach guided the production and data analysis. The Creative and Sensitive method¹⁰ was chosen, composed by: group discussion, participant observation and creativity dynamic.

The study subjects were all 15 nurses of the family health strategy teams in municipality of the metropolitan region of Fortaleza, linked to municipal schools registered in the Health Program in Schools. It was worked with nurses operating in the Health Program in schools because they would have educational work with adolescents.

The data were produced between May and August of 2012, by performing three dynamics of sensitivity and creativity. During the dynamic titled Almanac , the nurses produced individually an almanac that portrayed the inference about health education and how this practice was conducted with adolescents. The dynamics were held in spaces given by the Secretary of Health of the municipality. Despite the eccentricities of each meeting, it had as central axis four moments: reception and presentation of the research environment; exposure of participants and explanation about the meetings, followed by reading and signing the Informed Consent term (TCLE); enunciation and discussion of the questions of the semi-structured interview for the production of the Almanac: How do you describe health education? How do you accomplish your educational practice with the adolescents? And individual analysis: after completion of the productions, the professionals adduced the almanacs, scaling, thus, knowledge and expertise in health education with adolescents¹⁰.

The lines spoken during the dynamics were recorded and transcribed, materializing the corpus of the study, checking the linguistic materiality to not superficialization of the discursive corpus¹¹.

Subsequently, analytical devices offered by speech analysis were applied, aiming to extract from the production the building guidance of production of speech conditions. The devices used were: polysemy, paraphrase, metaphor, interdiscourse and silencing.

The paraphrase is what remains, the speakable, the ever-present memory. The polysemy represents the rupture, the displacement in the continuous movement of the symbolic construction and history. The interdiscourse presents the possibility of interpretation of the saying that is within the story, considering that this saying is erased in the subject, and he will say it as his property, with his interpretation. The metaphor is present where a word is not placed as a figure of speech, but settles on a transference process, redefining the sign. The silencing is presented through what was not said. Such devices are essential for understanding the constitutive conditions of production of reported speech: relations of sense, forces and antecipation⁶.

The ethical imperatives were considered, according to Resolution number 466∕12¹², of the National Health Council, Ministry of Health. The project was approved by the Ethics Committee in Research, of the State University of Ceará, according to opinion number 11584251-9.

RESULTS AND DISCUSSIONS

The nurses argued about health education and spun enunciations presenting the relationships of educational practices directed to adolescents with the constitution of the practice scenario. The projection of the speaker (nurse) and interlocutor (adolescent) in relation to the object (health education) join with the possibilities of scenario (Health Program at School, school). Such projections were represented, respectively, by the understanding of who was the adolescent in the imagination of the professional; and the Health Program at School (HPS) and the basic health unit, as socio-political scenario that provided this meeting.

Who is this adolescent?

The understanding of being an adolescent by the professionals was focused on movements of anticipation and relations of forces between the speaker (nurse) and the interlocutor (adolescent). Such mechanisms are essential for construction of the imaginary formations that closely relate with discursive sequences of the speaker in relation to the object (health education) and to the interlocutors, meaning production conditions of unique speeches^6,7.

During the discussion about the chapter built in the almanac on educational practices of health professionals directed to adolescents, the understanding of them as being sexually active was present, and this practice was an indicative of risk. It should be considered that sexuality has specifically concept for adolescents, where they sometimes confuse sexuality with genital, and most of them do not have an open dialogue on this topic (either with parents or professionals)¹³.

Nurses in all three meetings were concerned to early pregnancy, with a situation full of irresponsibility and inability of autonomy to decide to get pregnant:

It's much more complicated, but it is a necessity, because they think they know everything, they are experienced [...] I realized also in the pre-natal, there were not adolescents in the prenatal care, today I have three of them. (N1)

The production of co-responsibility implies incompleteness of saying referencing the pregnancy, and may suggest allusive silencing to the possibility of this happening as weakness in its assistance. This co-responsibility proclaims through what is not explicit in some moments, the inability of the adolescent thinking or taking conscious decisions, especially as regards the experience of pregnancy, an oversight occurred, in which the very idea of an act thought and desired is not allowed due to the reflective impossibility of the adolescent.

It must try to understand that the organization of the personality of these human beings is still incomplete, especially because currently this period begins earlier, taking the adolescent to delay some choices and compromises, because the adolescence appearance, does not necessarily mean maturity. To encourage this crossing, an adult can and should accompany him, in a perspective of support, nor too far to let them feel helplessness, but not too close not providing their subjective development and autonomy¹⁴.

The nurse should be a contributor, but the experience of sexuality is something very intimate from the adolescents, and thus respecting choices and confirming responsibilities¹⁵.

The recognition of being a complex and unique phase permeated the discursivity of the group, showing the imagination of these professionals about the adolescent built by anticipatory movement. These projections were notorious in explicit sayings, which presented the personal professional experience as something good for the relationship with the adolescent.

It is a discovery phase! Then here comes the question of our taboos, prejudice, because we don't talk too much about the change of the body, about their own sexuality, so how to talk to the teenager about it. [...]? (N1)

The speech above determines the personal projection of nurses about the adolescent. While using their personal inferences, the unsaid of these speeches is a possibility of lack of theoretical subsidies that direct nursing care for the adolescent, basing him on an imaginary projection of common sense, not being disregard, but is not necessarily the total representation for nursing care.

The nurses, presenting their personal difficulties, however through the unsaid, perceive the peculiarities of this phase they show their theoretical weaknesses in working with adolescents.

So, my biggest difficulty is to realize and confront this diversity that has among teenagers thoughts, mostly. (N4)

then... I put here that health education in teenagers is not an easy thing. You have to use a different language. (N5)

During the discourse movement, it was realized in enunciations not only the recognition of experiential components as natural adolescent process, but a saying held as process factors for professional practice, in which knowledge could be challenged by the dynamics of adolescent world, depriving them of sovereignty of knowledge. The symbolic game, presented here for what was not said, expresses the ideological work of these professionals in relation to be an adolescent.

O HPS and the basic health unit

The HPS has the need of clinical and psychosocial services to school children and adolescents. Their fundamentals include promotion, prevention measures and health assistance to nutrition, to prevention, drug use, violence prevention, sexual and reproductive health, among others¹⁶.

The Interministerial Ordinance number 1.910, of August 8, 2011, associates the renewal of the commitment terms of the HPS between the Municipal Health and Education Secretary to the agreement of executables goals on the program for the financing transfer¹⁷.

In this agreement, two essential components of action coverage are defined, making the financial transfer to the fulfillment of such goals: clinical and psychosocial assessment (component I) and health promotion and prevention (component II)¹⁷.

Based on the fifth clause, item b, of Ordinance number 1.910/2011 that talks about the inclusion of the topics of the program on teaching political projects of schools, the Intersectoral Working Group of the municipality establishes the component II would be the responsibility of the school, with educators and health team as supporters¹⁸.

It is also instituted, in 2012, the "D" day of health promotion, named as Health Circuit. The circuit is a multidisciplinary action of family health teams and Core Support to Family Health (NASF) in educational institutions linked to the HPS. These teams should go monthly to schools, during a whole day, and perform the clinical and psychosocial care determined by the component I, in order to achieve the amount agreed on program accession¹⁵.

It was opted to show the development of the HPS in federal and municipal area, by understanding that this process became decision-making and history producer for conditions of action/enunciations of nurses. The discursivity is entered from the effects of the language in the story that is close relationship of language with the exteriority⁴.

Depending on the context and how it is placed the term
HPS by nurses, they metaphorically act as a practice of health education, as represent the program that establishes, or in some other time represents the actions taken by health (clinical care). Such misconception unveils its ideological component, when transfers the meaning of that word (the program for education and health), where the context of acting is translated by the deployment of the health circuit, prioritizing clinical care rather than educational.

So, my HPS, is the way I build education in health [...] and so unfortunately we cannot perform the HPS (educational practices) with this student, we have problems […]. (E12)

Such metaphor was present in the three sensitivity and creativity dynamics, revealing the strong presence of health circuit (varied clinical care), in the actions of the program, raising questions:

And as HPS we also develop activity in the school now with this new model circuit, we always have ..., since when the team …, NASF, this issue of HPS, then we embrace this commitment, have the young teenager as focus, connected to the HPS, so each team, team that is in HPS, whether or not we will have to develop it with the teenagers. (N2)

Do you have health education with adolescents? (N3)

Yes ... with teenagers. Once a month, at the time of the PET, we went twice a month every 15 days, now on the circuit we have to take all the professionals, we are having once a month, monthly. (N2)

The presented dialogue showed the dichotomy of the circuit deployment as health strategy on attention to the adolescent. Here, the HPS has been a Program, a guideline, closely connected to clinical/biological practices, supported by political constituent in federal and municipal sphere.

As regards the possibility of educational practices, it remained an unsaid that called the actions of these professionals directed by protocols, in which they should be followed very strictly, producer of strangeness and questions about the implementation of actions that deflect the advocated.

From that perspective of the protocols of care, harden nurses´ practices, reflected on not doing the same¹⁶. Such proposition is relative to the organization of work processes in the field of health that motivates the reflection on the governmental/formal scheme as complex access regulator and consumption of health services. To run from it, it should be consolidate a regulatory scheme subsidized by the relations of health and community workers, whose care is experienced by real beings. When shaping according to the knowledge produced in this relationship, it would be care reinvention probably distanced of the norms of the managers¹⁹.

It was noticed, during questioning about the HPS, difficult to define clearly the goals and guiding actions, because as referenced, the nurses have a metaphor of the program as educational practice, sometimes questioned such practices performed in the program. When questioned about what would be the circuit, one of the professionals confirmed biological actions, but have unnoticed answers on social issues, as if all had the same development and goal.

These circuits are more clinical care or have the part…? (Researcher)

Circuit is more attendance, physical and clinical insight at the same time, because you both take pressure, height, weight, as you ask if he is suffering bullying, if he has some kind of ... If someone has already suffered some prejudice, you ask if he has the record, if he goes through some problem, you ask if he has a cough, if he's ... (N15)

It was also sustained in the paraphrastic speeches of maintenance of vitality of the school environment, as if the educational essence does not survive outside of this place.

I think that health education is related to the school [...] and I put here too that health is a part needing to walk with education, I think both, they tend to complement a lot [...] so we think health education and teenager, we relate to school soon. And I think the HPS as was spoken comes to officiate this relationship health with the school, with the teenagers themselves. (N5)

The space devoted by the school as educational is reinforced by the deployed policy, marking historical signification processes and basing on the direction provided by the conditions imposed in this case by the HPS, gaining thus dominant status⁸.

It is marked a saying with the proposal that education is about to happen in school, and was appointed as single and fertile space for educational practices. Studies suggest the school as important scenario for educational practices^20-22.

This discourses are strengthened on problems presented by nurses in the educational practice with adolescents on family health basic units.

The teenager ... You hardly see the adolescent in a health unit. He just goes on the planning day, the girl, the boy you never see, or in prenatal or in family planning[…] or unless we have the group of teenagers, who last year I had and it was so, it was a short time, it was only a season ... (N3)

The difficulty of adolescents´ relationship with the health equipment such as polysemous construction was addressed, bringing this subject to family planning, contradicting the affirmation of the adolescent not attending the basic unit. Furthermore, the situational diagnosis was pointed as more frequently in girls in sexual and reproductive health programs. It was noticed that there was a speech that evolved to enhance the educational care, as it remained relegated from the biological clinical care. It was a saying that it was made to silence what could not be said, as this saying entailed projections and personal and professional introjections not expected of an educator nurse, and the absence of health equipment power as a space of relations.

Stimulating the creation of educational and preventive equipment spaces of health, stating that in such spaces, when promoting educational practices that support the care plans of individuals, there is the consequent improvement of the service and link promotion and partnership between professionals and community²¹. Working with the affective component, along with the cognitive educational practices, becomes instrumental in the construction of knowledge²³.

CONCLUSION

The conditions of production of speech, supporting the practice of health education carried out by nurses, point to a traditional lineage of socio-cultural and political aspects that insists on dismissing the subject of their spaces and realities, adding that befit them in a macro perspective at the expense of their subjectivities.

The adolescent is shown as a point of tension in this emblematic problematization because understanding him and meaning him portrays the imaginary and unveils relationships of forces between those subjects, because this is the educator who is positioned as healthcare professional, holder of the true knowledge for this adolescent.

Understanding the construction of this way gives the opportunity of reflections that needs to be dismembered, revived, to resize the traditional pedagogy, present yet, in spite of so much criticism. Understanding that the scenario keeps this traditional ideology, it is proposed the overcoming prescriptive model of new health education practices, by understanding the subject while professional and under to understand each other. It is also understood that the conditions of production of speech from the perspective of discourse analysis are intimate and natural of each subject and their territory. Thus, these findings may not be generalizable, configured as possible limitation of this study, in spite of being presenting, here, as catalyst of reflections.

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