Inglês (pdf)
Artigo em XML
Referências do artigo
Tradução automática
Enviar este artigo por email
Citado por SciELO 
Similares em
SciELO 
Permalink
Introduction
Social representation (SR) refers to the knowledge or conceptualization of common-sense knowledge that is produced socially by a social or cultural group. It is the way in which the individual in his social interaction appropriates and interprets the daily social reality of health or a profession, and it depends on the relationship he establishes with reality and the meaning he attributes to it (Wachelke & Camargo, 2007) based on subjective experience of each person, as well as in the communication processes. The social representations of a given phenomenon are anchored in their own psychological and social processes (Jeoffrion, Dupont, Tripodi, & Roland-Lévy, 2016). This, as a socially accepted system of meaning, shows how scientific knowledge is transformed into lay knowledge, and assumes itself as a dimension of knowledge that allows consensus, organizes the sense and the meaning about a reality (Moscovici, 2000).
Nursing SR has changed throughout the history of mankind, and during the 20th century there has been a progressive professionalization and integration in higher education, leading to the achievement of different academic degrees (Meleis, 2007). The evolution that the Nursing Sciences felt over the last century stems from the investigation of nurses who developed theories that explain, predict and sustain professional practice and teaching (Ribeiro, Martins, & Tronchin, 2016; Meleis, 2007). However, the affirmation of the Nursing discipline has not always been accompanied by developments in its SR, so it has deserved the attention of the investigation in what concerns to understand what the nurses, other health professionals, professors or lay people look at about the profession's references, or about Nursing care or its autonomy (C. Silva et al., 2019; Sousa et al., 2019; Xavier, Lourenço, Santos, Oliveira, & Novais, 2019; Bellaguarda, Silveira, Mesquita , & Ramos, 2018; Mota et al., 2018; AR Silva, Padilha, Backes, & Carvalho, 2018; Santos, Alves, Silva, & Gomes, 2017; Ribeiro et al., 2016; Santos et al., 2016; Ferreira Martins & Dias, 2010; Gomes & Oliveira, 2010; Gomes, 2007). Nonetheless, few studies focus on the evolution of SR of undergraduate nursing students (Mendes et al., 2016; Mendes & Mantovani, 2010).
The aim of this study is to understand the SR of the discipline and profession of Nursing by students and tutors of the Nursing degree course. As a result, it is possible to reflect and discuss the SR built during the course from the perspective of the actors involved in the teaching and learning process.
1. Literature review
The theory of social representations was developed by Moscovici (1976) where he demonstrated the role of social representations for the establishment of a consensual reality, highlighting their social and cognitive function in the assimilation of new social ideas and practices, as well as their orientation function communication and social behaviour (Rosa & Arhiri, 2019).
The theory of social representations is based on the postulate "that all reality is represented , that is," appropriated "by the individual or group, reconstructed by his cognitive system and integrated into his value system" (Jeoffrion et al., 2016, p. 5). Social representations emerge from the communicational processes resulting from judgments that “have repercussions on social interactions and changes, responding to expectations of interpretation of the observed phenomenon” (M. E. Silva & Moura, 2011, p. 76). These principles have implications for the SR of a profession or professional group since more than the perspective of personal experience it reflects an idea or concept of a socially constructed reality manifesting the opinions, attitudes or stereotypes of a group or community (Rodrigues, Motta, & Ferreira, 2013; Rodrigues & Souza, 2005; Bauer & Gaskell, 1999).
SR has four essential functions in social dynamics and practices namely knowledge, identity, guidance, and justification, and for this it is necessary to analyse not only its content, but also its structure (Abric, 2011a). In the study of social representations, one of the most used analysis approaches is the structural approach, whose best-known theoretical contribution is the central nucleus theory. In the genesis of the SR of a phenomenon or object, a figurative nucleus is identified that refers to the selection and decontextualization of its elements, this meaning being reconstructed by anchoring in the values and norms of the social group. RS is organized around a stable nucleus, the figurative nucleus, and the remaining elements are categorized, interpreted, and organized according to it (Dany, 2016). In consonance with this idea, it can be said that a representation is formed by two systems composed of qualitatively different elements: a central nucleus and a peripheral system. For Abric (2011a) the central nucleus is related to collective memory giving meaning, consistency, and permanence to the representation, being, therefore, stable and resistant to changes; the peripheral system is responsible for updating and contextualizing the representation.
The professional identity of nurses is influenced by the models of clinical practice that should provide the structure and values that support not only the practice of care, but also teaching and research, which are based on six pillars: autonomy, responsibility, responsibilities professional relationships, the model of providing customer care, shared management and compensation and reward mechanisms (Ribeiro et al., 2016).
In a study carried out by Mendes and collaborators (2016) on the social representations of hospital care and primary health care by students of the Nursing degree course, it was demonstrated that the representations focus on the disease / patient and the role of the nurse in the treatment, prevention and care, not valuing health promotion and social determinants of health.
For Portuguese nurses, the social representations of the current dynamics of the profession, the milestones of its evolution and future professional perspectives are divided between the training acquired over the years, the conceptualization of care by the Order of Nurses , job instability and progression career (Mendes & Mantovani, 2010). Another study shows that for nurses the idea persists that professional practice must be combined with vocation, dedication and personal fulfilment in any context of care provision (Gomes & Oliveira, 2010). It is from the tensions between the tradition of care and innovation that the Nursing SR is being built for professionals, presenting in the centrality of their discourse a reflection on the attitudinal and sentimental dimension linked to clinical practice (Gomes, 2007). It should be noted that the nurses' discourse shows the predominance of the biomedical model as a guide for care, but it also reveals a holistic understanding of the person / client targeted by this care (Sousa et al., 2019).
2. Methods
This is a descriptive and comparative study framed in a qualitative paradigm that had as theoretical support the Theory of Social Representations, namely the structural approach or the theory of the central nucleus.
2.1. Sample
It is a non-probabilistic sample for convenience, having defined as inclusion criteria for the participants the following: being a student in the Nursing degree course, being a clinical teaching tutor at the higher education institution that integrated this study; be over eighteen years old, and voluntarily accept to participate by completing the data collection instrument.
A group of 125 students enrolled in the 1st cycle of undergraduate studies in Nursing participated in the academic year, with 39 distributed in the first year, 36 in the second year, 27 in the third year and 23 in the fourth year of the course. The participants are mostly female (85.6%, n = 107) and have an average age of 20.87 ± 3.54 years, varying between 18 and 36 years.
A group of 70 tutors participated, with an average age of 36.40 ± 9.22 years, ranging between 21 and 59 years. The majority are female tutors (88.6%, n = 62). Regarding the academic degree, 82.9% (n = 58) are bachelors’, 11.4% (n = 8) are masters and 5.7% (n = 4) are doctors.
2.2 Data collection instruments
Data collection was carried out through an online questionnaire composed of two parts, the first referred to the sociodemographic characterization and the second part a Free Word Association Test built by the researchers. Free Word Association Test is characterized by being a projective test, which allows the apprehension of the cognitive representations of a social group spontaneously but revealing implicit or latent content that can be concealed in discursive practices (Abric, 2011b). The application of this instrument also makes it possible to apprehend the elements of the central and peripheral nucleus of a representation (Rúbia et al., 2012). This technique is structured by evoking responses based on an inducing stimulus, which allows to put in evidence semantic universes related to a given object (Abric, 2011b).
In the construction of the instrument, the technique of multiple free word association was used, with the elaboration of three questions inducing stimulus and asking the participant to answer with five words or expressions without response restriction (Dany, Urdapilleta, & Lo Monaco, 2014). The three inducing stimuli used in Free Word Association Test were: Nursing, Nursing care, being a nurse by presenting variations of expression, when I think of… I remember…
Data were collected between November 2017 and February 2018, by sending the questionnaire to all participants.
Participation in the study was voluntary, guaranteed anonymity and confidentiality, and given the possibility for participants to withdraw from the study without prejudice. A favourable opinion was obtained from the Ethics Committee on the procedures for safeguarding the ethical principles and rights of the participants (opinion 07/2017) and authorization was obtained for the Board of Directors of the higher education institution.
2.3. Data analysis
The data analysis followed the analysis procedures already carried out in other studies in the field of RS (Ferreira et al., 2019; Oliveira, Figueiredo, Nina, Oliveira, & Novais, 2019; C. Silva et al., 2019; Xavier et al., 2019). The responses were transcribed to a text file and submitted for analysis using the Iramuteq 0.7 alpha 2 software (Interface of R pour les Analyzes Mutidimensionnelles de Testes et de Questionnaires). A textual corpus was prepared in a database created in the Open Office Calc 4 Software that allows an analysis to be carried out using a matrix that involves variables, categories, and word lists. After that, a statistical analysis of the frequencies of the categorical variables was performed as well as a matrix and multiple frequency analysis and a prototypical structural analysis (Camargo & Justo, 2016). In this study, starting from the word evocation matrices of the student participants, the descending hierarchical classification (DHC) was also performed using the Reinert method. As the number of tutoring participants is lower and, as a consequence, the speech produced is less than necessary for the multivariate analysis required in the DHC, only the structural analysis of the central nucleus of the textual corpus of these participants was performed.
3. Results
The results of the DHC analysis are represented by the dendrogram (figure 1).
The four quadrants graph (figure 2) of the students' discourse is presented, which contributes to the central nucleus, the first and the second periphery and the contrasting elements.
Then the students' text corpus was divided by the variable - year of course and it was possible to verify the existence of some differences in the structure of their speech. In the speech of the 1st year students, the words “help” and “care” appear with a lot of expression followed by a lesser expression “care”, “relationship” and “art”, which constitute the totality of the its central core. In the first periphery, these students emphasize the words "responsibility", "health", "empathy", "work", "communication", "affection" and "hospital" with greater emphasis.
In the 2nd year, students have the word "responsibility" with greater expression and representation in the central nucleus, followed by "caring", "treatment", "communication", "active listening" and "care". This central core is composed of 21 words. The first periphery consists of 16 words and stands out with greater expression words like "helping", "knowledge", "empathy", "affection", "well-being", "effectiveness" and "professionalism".
The group of 3rd year students also present, in the central core, the word "responsibility" as the most expressive followed by "helping", "caring", "pride", "work", "dream" and "autonomy". In its first periphery, among the 14 words, they focus on the following: “empathy”, “dedication”, “knowledge”, “availability”, “love”, “professionalism” and “competence”.
In the 4th year, the students highlight in the central nucleus the following words: "caring", "helping", "relationship", "communication" and "scientific_knowledge". In its first periphery the words that stand out are "empathy", "responsibility", "knowledge", "dedication", "technique" and "care".
From the analysis of the data collected from the tutors, a structural analysis was performed (figure 3).
It is observed in the central nucleus and in the 1st periphery the concentration of most of the tutors' discourse, demonstrating that there is a consensual similarity of the Nursing SR.
4. Discussion
From the analysis of the textual corpus in the DHC, without a priori categorization, three categories emerged called «Nursing discipline», «care» and «values», being clear the balance between «care» and «values». From the students' perspective, "care" is hospital-centered due to the emphasis on the "hospital" concept, marked by the "availability" of health professionals and "listening" as fundamental in the care process in "disease" and "health" in order to be able to “treat” the “people”. These results are in line with the results of the study carried out by Mendes et al. (2016), corroborated by the data presented by the Order of Nurses that demonstrate that the fact that 50% of nurses work in a hospital context, marks the representation of students who enter the course degree. “In pedagogical terms, this model is considered massifying, passive and with harmful effects on the training of health professionals” (Mendes et al., 2016, p. 348), since it gives a reductionist view of knowledge in the scientific domain of Nursing.
The "care" "(...) expresses the cognitive dimension of representation, possibly originating in the classic analogy between Nursing and care, historically constituted (...)"(Santos et al., 2017, p. 4). Considered as the landmark of Nursing, «care» is represented from the point of view of maintaining health or identifying potential needs combined with the expertise of nurses for decision-making and implementation of care through technical procedures and the art of Nursing ( Sousa et al., 2019). Students also appraise "values" such as "love", "affection", "solidarity", "surrender", "understanding”. These values guide the assumption of care and allow them to train them as nurses, because Nursing as a discipline of knowledge is characterized by a “(…) body of knowledge, knowledge, affectivity, attitudes and practices related to nurses, their professional identity, their decision-making power and their freedom to act” (Santos et al., 2017, p. 2). The «Nursing discipline» is characterized by the participants by the technical domain, the help relationship, the assertiveness, the holistic view, the scientific knowledge, and the research. Therefore, globally, representation for students in the profession is based on three main pillars (Nursing, care, and values). These results pose great challenges for higher education institutions in the preparation of future professionals and in the affirmation of the epistemological bases of Nursing (Santos et al., 2017). It is worth noting the fact that fourth year students praise scientific knowledge and research as fundamental, which reveals their representation of Nursing as a science with its own body of knowledge and that is in constant evolution, which is why a permanent update is necessary. From the pedagogical point of view, this students’ view should be highlighted and used to increase their development of knowledge and skills throughout the course, as well as to foster the need for further training and evidence-based practice in future professionals.
In the structural analysis of the students' discourse, it appears that SR is anchored in a central nucleus that understands Nursing as the “work” that aims to “help” and “take care” of “health”, through “values” such as “affection", "solidarity", "delivery", with skills of "communication", "listening" and "helping relationship", which is directed to "people", in the "hospital" by implementing "treatments" and “techniques”, which aim at “well-being”, “prevention” and “health promotion”.
Considering the conceptual framework of nursing care of the Ordem dos Enfermeiros (2012, p. 10), which understands that they are based on a therapeutic relationship, it is noted that this “(…) develops and strengthens itself along a dynamic process, which aims to help the client to be proactive in achieving their health project ”. It is in the intersubjectivity of the relationship with the other that the nurse assumes the “responsibility” of “helping” and “caring” for the “person”, as it is in this “caring” relationship that combines his technical competence with scientific rationality, with ethical experience of their profession and discipline of “knowledge” (Renaud, 2010) . When thinking about Nursing as a profession, it should be understood that to “take care”, the nurse does not only value knowledge as structured, organized and elaborated knowledge, but “also values the technique, as it expresses the complexity of care and the skills of the know, do and be a nurse ” (Vale & Pagliuca, 2011, p. 106).
The social representations of Nursing for students will be modelled when analysed separately by year of course, since 1st year students associate it with lay representations of being a nurse, directly related to the execution of techniques and with an image of vocation and values. On the other hand, students who are close to the end of the course anchor their representation, emphasizing in the first place the importance of scientific knowledge. These results are in line with those obtained by Duarte and collaborators (2012) who conclude that students at an early stage of the course value the practices and behaviours of attention and affection in care, and finalist students combine these aspects with the development of scientific and technical-instrumental skills to respond to people's care needs.
The groups of 2nd and 3rd year students value “responsibility” as a domain of competence for future professional practice while 1st year students are still beginning their contact with Nursing as a domain of knowledge and profession. Therefore, these still do not have a representation of the responsibility of the role of the Nurse, namely the domain of professional, ethical and legal responsibility required of the General Care Nurse. In the group of 4th year students, "responsibility" does not have the same relevance in their discourse, giving prominence to "scientific knowledge" and demonstrating that, in the field of care provision and management, students consider the importance of "acting with respect for fundamentals of the profession and discipline, namely, applying the most appropriate knowledge and techniques in Nursing practice; and incorporate, in practice, valid and relevant research results, as well as other evidence ” (Ordem dos Enfermeiros, 2011, p. 14).
The 2nd and 3rd year students are in an intermediate phase of their skills development and are aware of the limits of their knowledge, as they still have an academic path to be built, so they assume “responsibility” in their SR response to "health" "care" by assuming its role in "planning" "care" in the face of "needs" to "help others" demonstrating "autonomy", "dedication" and "excellence".
The SR expressed in the structural analysis of the tutors' discourse is strongly connected to the evocation of "caring", "helping", "dedication" and "person". This fact is related to the central role of tutors in the professional training of future nurses, in real contexts of clinical practice "(...) without manipulations or adjustments to carry out the teaching-learning processes"(Esteves, Cunha, Bohomol, & Santos, 2019, p. 1811). This evidence demonstrates the transfer of the conceptualization of “caring” by tutors to students who absorb their professional models, during their educational practices in a real setting (Esteves, Cunha, Bohomol, & Negri, 2018).
Since clinical supervision is a dynamic, systematic, interpersonal and formal process, between the tutor and the student (Ordem dos Enfermeiros, 2018), it allows students to identify service nurses, where clinical practices take place, as models for the construction of professional identity (Mueller, Mylonas, & Schumacher, 2018).
In the same way words such as “empathy”, “responsibility” and “love” present in the tutors' discourse emerge in the students' verbatim as nurses' values. In a study by Vale and Pagliuca (2011) on the process of building the concept of nursing care, these values emerge as attributes for understanding the concept of care and the interaction between discourse and practice. According to the same authors (2011, p.112) “love expresses a “know-how” based on science, art, ethics and aesthetics, directed to the needs of the individual, the family and the community”.
Unlikely the fourth-year students, the representations of tutors have little place in the field of Nursing. Taking into account the growth of this dimension over the four years of the Nursing degree course, its little expression in the results of tutors may be due to the fact that, in the professional context, continuous training does not include the domain of scientific knowledge and discipline as a priority. In addition, nurses' focus, and involvement in research in clinical practice contexts is not encouraged, since the construction of their professional identity leads them to “job and career instability” (Mendes & Mantovani, 2010, p 214).
Conclusions
The nursing SR of students is modelled throughout the course and is based on three pillars: the discipline of Nursing, care, and values. The structure of their representation changes over the course due to the modelling that is established during the supervisory relationship with the tutor tutors, but all participants evoke “helping” and “caring” with greater relevance for this representation. The tutors show that they have a Nursing SR and of being a nurse, centered on “caring”, “helping”, “dedication” and “person”, demonstrating to be more structured than that of students considering their professional experiences and academic path, acting in this way as the professional development model.
Higher education institutions also play a fundamental role in building professional identity with repercussions in the profession's SR. The structuring paradigms that support, in the different schools, the study plans are decisive in the transmission of the values that guide the student in the construction of his representation of the discipline and profession of Nursing.
Thus, there must be a close relationship between the higher education institution and the clinical practice contexts, namely with the tutors involved in supervision processes.
The main limitation of this study is related to the fact that it was carried out only in a higher education institution, and being a qualitative study it is dependent on the context, so the generalization of results should be carried out with caution. However, this study shows that there is a conceptualization and modelling of the SR of the profession by students who are context-dependent on clinical practice. However, it is not clear what is the process that leads to this modelling and how it is similar or different from models run by the academy. This study also points to another path in research, namely, to measure the impact of training in clinical supervision of tutors on the development of students' skills. Considering that they pass at least 120 ECTS in all study plans in a clinical context, it helps to understand how this increased competence influences the way students learn. In addition, this research proposal will allow the conceptual approximation between tutors and students from the point of view of the Nursing discipline.
