De la práctica de la enfermería a la teoría enfermera. Concepciones presentes en el ejercicio profesional

Résumé

Faced with the existing debate about the relation between disciplinary and professional aspects of nursing raises this thesis, which objective is to learn the conceptions that nurses have about the paradigmatic concepts of nursing, human care, person, health and environment, identifying the aspects related with educational training and professional experience that have influence on shaping these conceptions. We begin with an analysis of the state of the profession and discipline. As crux and reason for being of nursing, people and groups health cares are taken. The profession is reviewed from the different fields of practice – clinic, teaching, management and research –, to focus the study on the current image of nursing and nurses and on the phenomena that have influenced its configuration and most recent evolution. Also a reflection exercise about internal and external approaches is done/conducted, taking as reference the points of view developed by Domínguez (1985). In order to study in depth the connections between profession and discipline, the training process that qualifies professionals is analysed, emphasizing learning in clinic practicals. Finally scientific foundations that characterize nursing as a discipline are analysed, reflecting on its creation, development and application in practice. Research is posed and developed in two phases. In the first one, using qualitative research methods such as focus groups and content analysis, a first document is prepared with a group of selected experts, where 10 ideas about the paradigmatic concepts are formulated in terms of dimensions and attributes. This document is validated by a second group of experts consisting of 10 nurses representative of different areas of practice and randomly selected by criterion of minimum time of experience in at least two areas of professional practice. The process of formulation and assessment of each concept’s dimensions is analysed based on the contributions from the groups of experts and a first document is drawn. From this document, done with the first group of experts’ work and its nominal validation by the second group of experts, a semistructured questionnaire is composed with open and closed questions and sets of values type Likert with 5 joining points. The possible biases of the questionnaire are posed and strategies to prevent possible errors. The questionnaire consists of 4 sections with questions related with data about: (1) general characteristics of nurses participating in the study, (2) training received, (3) conceptions existing in professional practice –10 dimensions for each concept are offered and the 3 most meaningful must be selected– and (4) assessment of professional practice. The second phase begins with a pilot test to validate the adequacy of the statement, the comprehension of questions, the categorization of answers, possible rejects to any of the questions, enough time to adecuate fill in the questionnaire, and the questionnaire’s general assessment of the participants, coming from health centers different from those where the study is being conducted and selected by probalistic random sampling. Once the questionnaire is desinged, our target population is taken as a nonprobalistic sample of 243 practising nurses from public centers of primary and specialised health care, choosing the Comunidad Autónoma de Madrid for convinience and representativeness in relation to the national level. In order to access the target population, the research project is introduced to the nursing directions of hospitals and primary care areas selected, their support is requested and a positive collaboration is always received. The data of questionnaires has been recorded, validated and tabulated with the software BarbWin (v. 6.0). In addition to the marginal data, these fields were tabled as head of columns: age, gender, years of experience, degree, education (continuing, speacilization and graduate studies), center type, and hospital unit and pofessional capacity. The results show that nurses surveyed manifest fulfilment about internal and personal matters and insatisfaction with the more external and collective ones. Nurses of the study manifested higher rate of satisfaction in relation with internal and personal matters than with more external and collective ones. Confusion has been observed when trying to define the profesional field, with marked tendency to consider the interdependent role ahead the autonomous and dependent ones, the last two with similar appreciations. Deficiencies in training and knoweledge about the discipline are detected. This influences the diversity of conceptions about paradigmatic conceptions, being fewer different dimensions selected in relation with paradigmatic concepts when the theorical and metodological background of nurses increases. The selected dimensions are mainly related with statements of models that frecuently appear in academic curriculum, but also conceptions from models rarely represented in the curriculum are identified. According to the classification of care models of Kérouac et al. (1996) in different orientations, the sample of nurses related the idea of: (1) human care with the “opening-up to the world orientation”, (2) person with “public health orientation”, (3) health and evironment with “illness orientation” and (4) nursing care with “person orientation”. Following Kérouac et al. (1996) and first attending the dimention most frequently mentioned, that is also the most appreciated when evaluating them independently from their ranking in selection, nursing care is defined as an “interactive process between a person with physical, intelectual, emotional, cultural and spiritual components who needs help to achieve the desired balance, harmony and stability, and the nurse who offers that help for cares in an individual and unique way. All this considering physical, social and cultural elements significant for the person”. As the most critical aspect of our study, we can state that exists a wide distance between epistemology matters and real practice, becoming specially pronounced in last years of professional practice, but with no statistical significant relation neither with professional satisfaction nor with personal perception of training received. We conclude with a set of proposals from different areas of professional practice, especially from teaching, because this is the field of this thesis’ author, with the aim to reduce the gap between discipline and profession and propose meaningful contributions to improve health care quality, life of persons attended, and satisfaction of those involved in care process.