Connections among nursing, nutrition and social work, pioneering female careers in the healthcare area

Abstracts

Estudo histórico-social sobre a emergência das profissões de nutricionista e de assistente social, entre os anos 30 e meados do século 20. O trabalho trata das circunstâncias do surgimento dos cursos de nutrição e de serviço social no interior da Escola Anna Nery/UFRJ, e compara as funções desempenhadas por enfermeiras, nutricionistas e assistentes sociais à época. As fontes primárias de pesquisa encontram-se no Centro de Documentação da Escola de Enfermagem Anna Nery/UFRJ e incluem documentos escritos e depoimento oral. As fontes secundárias foram artigos, livros e teses. A análise de textos e documentos evidenciou que a Escola teve papel decisivo na emergência dessas novas profissões, que vieram contribuir para uma melhor organização e funcionamento dos serviços de saúde e para a prestação de uma assistência mais completa à clientela. Ao mesmo tempo, sua característica feminina veio, ainda, favorecer a inserção de mulheres no mercado de trabalho qualificado na área da saúde.

História da enfermagem; Ciências da nutrição; Serviço social; Assistência social

ORIGINAL ARTICLE

Connections among Nursing, Nutrition and Social Work, pioneering female careers in the heathcare area^*

Nexos entre enfermería, nutrición y servicio social, profesiones femeninas pioneras en el área de la salud

Pacita Geovana Gama de Sousa Aperibense^I; Ieda de Alencar Barreira^II

^INurse. Graduate at the ANSN/FURJ. Member of the Brazilian Nursing History Research Center - FURJ. Contributing Professor from UNIGRANRIO. Rio de Janeiro, RJ, Brazil. [e-mail]

^IINurse. Founder Member of the Núcleo de Pesquisa de História de Enfermagem Brasileira - Nuphebras/UFRJ (Brazilian Nursing History Research Center). Researcher 1A - National Council for Scientific and Technological Development (CNPq). Leader of the Research Group "A prática profissional e a formação da identidade da enfermeira brasileira" (The professional practice and the formation of the identity of the Brazilian nurse). Rio de Janeiro, RJ, Brazil. [e-mail]

Correspondence addressed to

ABSTRACT

This is a historical-social research about the emergence of the nutrition and social work professions between the 1930's and the mid 20^th century. This study analyzes the circumstances involved in the beginning of both courses, nutrition and social work, at Anna Nery School/FURJ and compares the work developed by nurses, nutritionists, and social workers at the time. The primary research sources are found at School of Nursing Anna Nery Archives Center/FURJ and among other documents they include written documents and oral speeches. The secondary sources were articles, books, and theses. The analyses of these texts and documents showed that the school played a decisive role in the emergence of these new professions, which contributed to a better organization and operation of health services and to a more complete care provision to the clients. At the same time, their feminine characteristics appeared to benefit the insertion of women in qualified work positions in the mental health area.

Keywords: Nursing history; Nutritional sciences; Social work; Social care.

RESUMEN

Estudio histórico-social sobre el surgimiento de las profesiones de nutrición y servicio social entre los años 30 y mediados del siglo 20. El trabajo basado en las circunstancias en las cuales surgieron los cursos de nutrición y servicio social en la Escuela Anna Nery/UFRJ, comparando las funciones realizadas por enfermeras, nutricionistas y asistentas sociales en aquella época. Las fuentes primarias de investigación se encontraron en el Centro de Documentación de la Escuela de Enfermería Anna Nery/UFRJ e incluyen documentos y testimonios orales. Las fuentes secundarias fueron artículos, libros y tesis. El análisis de los textos y documentos mostró que la Escuela tuvo un rol decisivo para el surgimiento de estas nuevas profesiones, las cuales contribuyeron para una mejor organización y funcionamiento de los servicios de salud, así como para la prestación de una atención integral al cliente. Al mismo tiempo, la característica femenina favoreció en la introducción de mujeres calificadas en el mercado de trabajo, en el área de salud.

Descriptores: Historia de la enfermería; Ciencias nutricionales; Servicio social; Asistencia social.

INTRODUCTION

The connections between the education and the performance of nurses, nutritionists and social workers are the object of the present study. The period considered for the study was from the 1930s to the middle of the 20^th century.

Until the beginning of the 20^th century, the Brazilian society was characterized as patriarchal, and the most important social positions were taken by men. Women still had their citizenship rights denied; their position in the society was socially and culturally unfavorable. They were fated to serve their husbands, raise and educate their children, and did not have the right to make decisions about their own lives. This cultural trait emphasizes the women's role as having the instinct of mother, caregiver and provider of success and welfare to the members of the family. Their opportunities of access to education were significantly lower than those of men. Female professionalization, started at the end of the 19^th century, happened in association with the traditional female roles. The woman remained in activities related to caring, educating and serving, which were understood as a gift or vocation⁽¹⁾.

One author⁽²⁾, when commenting the work of the feminist Joan Scott, remembers that the concept of gender goes through the social culture of gender-based roles established by society and defines how relationships must occur between man-woman, man-man, woman-woman, and not necessarily, only in the relationship man-woman. The construction of gender-based roles also guides the professional choice, establishing that women, by responding to the conditioning received since their childhood, must choose a career compatible with their female condition, such as an elementary school teacher, a secretary, or a nurse, among other occupations that are considered by many people as little qualified and competitive in the job market.

The marked historical and cultural transition that occurred in the first half of the 20^th century is evidenced by the rupture of the traditional female image and the arrival of new woman type-figures. Nursing constitutes an important vector of economical and social emancipation of middle-class women⁽³⁾.

In Brazil, Nursing was the first female academic profession, destined to support public health programs, the operation of healthcare services, and guaranteeing a high-standards operation. The graduated nurse, besides caring, was engaged in other activities, also essential to the well-being of the patient, but that today are the responsibility of other professionals.

The feeding care was already a concern for Florence Nightingale. During the Crimea war, she provided care to injured people, including the preparation of special diets. In South America, the Argentinean professor Escudero was the pioneer in the education of specialized professionals for the preparation of diets. He founded his school in 1933, and the Argentinean government offered scholarships to candidates from South American countries. After graduation, they founded a new career in their societies as they got back to their home countries⁽⁴⁾.

A nurse from Anna Nery School (ANS), Lieselotte Hoeschl Ornelas - LHO, who was only 21 years old, accepted a scholarship to take the course at the Instituto Nacional de la Nutrición Professor Escudero. She stayed in Argentina from 1940 to 1943, a period in which the nutritionist profession began to be outlined in Brazil. When she returned, she integrated the group of professors of the ANS as a Nutrition Instructor⁽⁵⁾.

Religious-based charity organizations were in charge of social problems. However, these agents lacked specialized and scientific training⁽¹⁾. The difference between Social Care and Social Work was established for the first time in the beginning of the 20^th century, by Mary Richmond, a North-American social worker. Doing Social Work involved not only the provision of material good to the poor, but also the act of working the personality of people and the social environment. Thus, it was the responsibility of the social worker to determine the individual history, study and investigate the social environment of that person, through interviews, informal conversations, home visits to friends, professors, bosses, etc. By observing, taking notes and making detailed reports, this professional would obtain a diagnostic and try to discover a way to get the help of the social environment for his cause. Mary Richmond named this as comprehensions: comprehension of the social environment and comprehension of the personality⁽⁶⁾.

In Brazil, the Social Work profession appears under the influence of the Catholic Church⁽⁷⁾, in the context of the country industrialization process, and helping the regulation process of the workmen's life, since, by offering conditions for their social and moral reconstruction, it also guided the workers' disciplining⁽⁸⁾.At the same time, the hospital starts to worry about preventing problems from the patient's personal life from hindering the recovery of their working ability and their social reinsertion.

The following purposes have been outlined for guiding the development of the study:

• Describing the circumstances of the arrival of the nutrition and social work courses and their connections with the Anna Nery School;

• Analyzing the inter-relations between the functions of a nurse and a nutritionist;

• Analyzing the inter-relations between the functions of a nurse and a social worker;

The relevance of this study comes from the importance of the knowledge about the historical common roots of the first female academic professions in Brazil and about how they contributed to the professionalization process of the woman in this society. This study will also enrich the Nursing History, by becoming a source for future studies both for undergraduate and graduate students.

METHOD

This study consists of a historical-social research, developed as a term paper by the first author, as a scholarship holder for scientific initiation at the Brazilian Nursing History Research Center. This work is inserted in the project The Brazilian nurse in the middle of the 20^th century: knowledge and practices and refers to the research group registered at the National Council for Scientific and Technological Development (CNPq) as The professional practice and education of the Brazilian nurse identity. It is worth clarifying that the major project to which this study is linked was approved by the Research Ethics Committee and this article is one of its products.

The primary written sources were found at the Escola de Enfermagem Anna Nery Archive Center of the Universidade Federal do Rio de Janeiro (ANNS/FURJ), by searching the following documentary catalogues elaborated by Vilma de Carvalho and Jussara Sauthier: Nursing Annals -Computerization of Publications from 1932 to 1954 (Annaes de Enfermagem Informatização das publicações de 1932 a 1954), published in 2002 by the AANS and Nursing Pioneers and Consolidation in Brazil – Historical Documents from AANS/FURJ from 1932 to 1950 (As pioneiras e a consolidação da enfermagem no Brasil – Documentos Históricos da EEAN/UFRJ - 1932 a 1950), published by the AANS in 2004. The selection included articles related to either nutrition or social work, within that time period.

The testimony given by the nurse LHO, a personality of the Nutrition history in Brazil, was also used as a primary source. The interview script was elaborated from the analysis of LHO's bibliographical data. It was recorded in cassettes and lasted four hours; the cassettes were then transcribed and revised. The interviewee signed an assignment term of the interview rights to the Archive Center - ANSS/FURJ, which allowed its incorporation to this collection and its free availability to the public.

The secondary sources were articles, thesis and books belonging to the Text Bank of the Brazilian Nursing History Research Center or to the collection of the Sectorial Library of Post Graduation of the ANNS, about the professions in question.

Tables were used as instruments to facilitate the chronological and thematic order of the documents. The analysis procedures consisted of the comparison of contents of texts and documents, as well as the contextualization of information. The preliminary report of the research was presented at the Permanent Seminar of the Brazilian Nursing History Research Center, in order to obtain a critical appreciation of the participants – in other words, researchers, master and doctorate students, scholarship candidates and holders for scientific initiation.

RESULTS AND DISCUSSION

The selection of articles from the aforementioned catalogues included articles that had titles with terms such as nursing, public health, social service, social worker, nutrition, dietetics or feeding. By carefully reading the 25 articles marked initially, 12 articles were selected: four of them about nutrition, seven about social service and one about both subjects, as described at Table 1.

Most of the selected articles were written by nurses, which was already expected since it is a Nursing Magazine, but LHO and Edith Fraenkel stood out, honorable nurses who accomplished great deeds for the nursing service as observed during the discussion of results. Even though it is a Nursing Magazine, a physician named Alvino de Paula has also written an article and pointed at the outlining of these new professions in the healthcare area. Another relevant fact stands on the presence of two editorials approaching the subject in question, the first about nutrition and the second about nutrition and social service.

Forty documents were initially marked from the second catalogue, and by rigorously reading these documents, three documents were selected and listed below on Table 2.

During the presentation of the results, the analyzed articles and documents from the table above will be, respectively, referred to as Art. and Doc. followed by their corresponding number.

Circumstances involved in the beginning of the courses of Nutrition and Social Service and their connections to the Anna Nery School

At the time, the theoretical program of ANS Nursing course presented four basic, ten medical, sixteen specific and five complementary disciplines, and among them there was one named Nutrition and kitchen. From the thirty-five contents of the theoretical program, dietetics had 45 hours dedicated to it, which corresponded to the third longest discipline period, only behind Nursing Arts and Anatomy and Physiology, with 105 and 60 hours, respectively (Art. 3). The practical program, on the other hand, comprehended two weeks of internship in the infirmaries and night service units of the Dietetics Laboratory at the Artur Bernardes Hospital. This internship field (currently, Institut Fernandes Figueira) had 112 beds, in which the students prepared the food to serve the hospitalized children (Doc. 1).

At the opening of the Child Dietetics Council, at the pediatrics clinic of the São Francisco de Assis Hospital, idealized by Rachel Haddock Lobo (RHL), professor Luiz Barbosa, who was the chief of this service in 1933, stresses the importance of the nurses and ANS students' performance in the education of mothers in a hygiene-dietetic regime and in activities aimed at children's feeding care (Art. 2). After the death of this ANS director, the council received her name. Art.3 also approaches the importance of the dietetic service at basic health units and clinics, since these are real schools of mothers, highlighting the role played by the Rachel Haddock Lobo clinics.

Due to the narrow relation between the work of a nurse and that of a nutritionist, the Nursing curriculum was supposed to include disciplines regarding nutrition and dietetics; in the same way, the Nutrition course was supposed to include disciplines such as Anatomy, Pathology and Nursing Techniques (Art. 11). The first step for the implementation of Nutrition Education in Brazil took place in 1943, with the specialization of the nurses from ANS, LHO and Firmina Sant'Ana in Argentina, assigned by Laís Netto dos Reys. In this same year, when the first Nutrition courses were set up at the Social Security Feeding Service, current Nutrition Institute of UNIRIO, these nurses/nutritionists were requested to integrate the board of professors of this institution⁽⁹⁾. In 1948, they also integrated the board of professors of the Nutrition Course from the Nutrition Institute of the Universidade do Brasil (currently, Universidade Federal do Rio de Janeiro)⁽¹⁰⁾.

On the other hand, in the 1930s, graduated Brazilian nurses, who worked in the public health area, started to point out the need to differ the real poor from those who claimed to be poor, in order to properly help those who really needed due to the aggravation of the social issue, caused by industrialization and urbanization(Art. 1). Likewise, the Superintendent of the Nursing Service from the Public Health National Department considered that some sort of social work with the population was necessary for a public healthcare nurse to play her full role. He had the opinion that, before being granted, any aid must be studied further and scientifically. The intention was not to create or reinforce the bad habit of dependence, produced by the charity given in an indifferent and precipitated way, but to provide conditions for the social and moral reconstruction of the individual, based on solutions for his financial/family problems. Therefore, helping others help themselves was the motto of the work in Social Service. In this context, the public healthcare nurse was seen as an essential collaborator, since it was her responsibility to visit the homes of these poor people frequently, during their prophylaxis and hygiene work. Through the observation and information of real and proven facts, the nurse would mandatorily know who really needed help (Art. 7).

While doctors and nurses described the nurse as the most indicated professional to perform the functions of social service (Doc.3), they indicated ANS as the most capable school to provide the Social Service course. A group of Brazilian nurses was favorable to the organization of a Social Service similar to the one existing in the USA and in Europe, adapted to the Brazilian environment though (Art. 1).

At the time of the discussion for the project regarding the law 595/1936, to establish the Universidade do Brasil (UB), the amendment number 1 of the Congresswoman Carlota de Queiroz defined that

Given the character of the complementary institutions, in the terms of this article, Universidade do Brasil is incorporated to the Academic College, aimed at complementary secondary education, and the ANS, aimed at the Nursing and Social Service education.

The American Bertha Pullen, who preceded RHL at the direction of ANS, was against the initiative⁽¹¹⁾, and in this position, she sent a letter to the General Director of DNSP. (Doc. 2) Despite of her efforts to neutralize that amendment, ANS was incorporated to the University of Brazil, including the Social Service course to be provided by her⁽¹²⁾.

As observed in the article published in the year of the Social Service course release at Anna Nery School, in 1937 (Art. 6), the purpose of a Social Service School would be to

prepare social agents to teach efficiently and individually the arts of living physically, morally and economically, to those who submerge in the turmoil of social problems and live without any directions.

The course should comprehend disciplines such as: Civic Education, Legislation, Psychology, Social Medicine, Social Care, Professional Ethics, Social Service History, Mental Hygiene, Pediatrics, First Aid and Organization and Filing Composition. The course should last for three and a half years, from which the last six months should be dedicated to the practice of individual treatment of cases. This treatment included:

• The study of moral and material causes, with the administration of the appropriate medicine;

• Avoiding palliative means, searching for the radical cure of the illnesses and preventing a relapse;

• Making the patient return as soon as possible to his normal and independent life;

• Cooperating for the elevation of the patient's level of material and moral life;

• Working in coordination with charity efforts from aid associations and foundations for people in need.

The Art.7 also describes the qualities of the social worker, explaining their similarity to those of a nurse.

In a 1949 Editorial, the magazine Nursing Annals claimed that, in the large cities of the country, there already were specific professionals in charge of feeding patients, as well as professionals who solved their social problems (Art. 9).

Interrelations between the functions of a nurse and a nutritionist

An American doctor defended the existence of a dietetic organization in the hospital, explaining that it would not affect the work of physicians, nurses or the social service; on the contrary, it would be very useful for the healthcare team (Art. 5). On the other hand, a Brazilian sanitary physician (Art. 10) had the opinion that, in the sanitary units, schools, factories and at home, the nutritionist should perform the functions of an alimentary educator, demonstrating the value and economical, sociological and eugenic advantages of rational and sufficient feeding. Regarding the relation between nutritionists and physicians (nutrition specialists) it is observed that there is a certain expectation of subordination, as it is evidenced in the following description of a nutritionist's activities:

• Organization and filing of the nutrition clinic;

• Converting nutrition prescriptions into diets; guiding their execution and distribution;

• Registering food waste;

• Controlling the nutritive condition of each patient;

• Informing the nutrition specialist physician regarding the changes examined;

• Disseminating the importance of appropriate and hygienic eating habits.

In the middle of the 20^th century, a nurse, who was also a nutritionist (Art. 11), had already indicated the tendency for entitling the dietitian with the exclusive care of everything concerning the patient's feeding, such as: copying the medical prescriptions from the charts, calculating special diets, determining the confection of diets, distributing them and observing the acceptance of the patient, in order to make eventual substitutions. From this point of view, the nurse would only be in charge of the food ingestion by the patient.

Given the arrival of the nutritionist profession, the nurse's attributions had to be revised. In order to meet the nutritional needs of the patients, it would be the responsibility of the nurse to:

• Help in the collection of data regarding the feeding standard of the patient and his preferences;

• Obtain a dietetic prescription when necessary;

• Provide appropriate feeding for the needs of the patients, and whenever possible, according to their preferences;

• Place the patient in a comfortable position for ingesting the food;

• Help the patient eat or administer his diet;

• Explain the patient the reasons for changing his regular diet;

• Observe and register the acceptance of food by the patient and the apparent appetite;

• Identify the patients who would need help, in order to prepare their diet after the hospital discharge⁽¹³⁾.

After acknowledging the importance of feeding in the recovery of the patient, the tendency for widening the functions of the nutritionist towards their patient was expressed in articles in the mid-20^th century. However, such changes would only happen in the mid 1960s.

Two North-American nurses later stated that dietitians were the ones supposed to plan meals and supervise their preparation, translating the dietetic prescription into food. They believed these professionals depended significantly on the Nursing team, to learn about problems that affected the patients' capability of feeding themselves, since the nurses monitor the patients 24 hours a day⁽¹³⁾.

Still in the 1960s, there were records that the nursing care towards feeding the hospitalized patient comprehended the following attributions:

• Including the feeding care into the care plan of the patients;

• Controlling the factors that influence the acceptance of food by the patients;

• Guiding and supervising the auxiliary team in the feeding care;

• Guiding patients and their family⁽¹⁴⁾.

In the following decade, professors from the Nursing School at Universidade de São Paulo, recognized that the patient's full care, which is the purpose of the Nursing service, included the nutritional care, giving the nurse the responsibility for developing activities such as:

• Guidance of the patient, family or community;

• Supervision of the acceptance of the food offered;

• Assessment of the feeding behavior change;

• Collaboration with the nutritionist in the diet planning and administration⁽¹⁵⁾.

Despite the emphasis given, by the mentioned articles, to the importance of administering a diet to hospitalized patients, the number of nurses and nutritionists in Brazil indicated the lack of these professionals, which pointed to a great difficulty in meeting the feeding and nutritional needs of the patients. According to a survey made by the Brazilian Nursing Association about the distribution of nursing professionals in state-owned organs, in 1956, thus 33 years after the establishment of the first Nursing course, the country had only 376 graduated nurses. Of those, 287 (76%) were in the Southeast; 59 (16%) in the South; 14 (4%) in the Northeast; 11 (3%) in the Central-west and 5 (1%) in the North. Regarding the number of nutritionists, eleven years after the release of the first Nutrition course, it was significantly low, with only 14 professionals, from which 6 were in the Southeast, 6 in the South and 2 in the Northeast; the North and Midwest regions did not have any nutritionist at that time. Nevertheless, at the end of the 1970s, thus 14 years after the mentioned survey, there were three General Hospitals in Belém do Pará that did not have any nutritionist. It is worth mentioning that, at that time, there were 28 Nutrition courses in the country, including the state of Pará. However, due to better job market conditions in other states, the professionals who graduated there eventually emigrated. The deficit of nutritionists generally overloaded nurses, who were also in an insufficient number^(16-17).

The opinion of the nurses interviewed in these hospitals, regarding the responsibilities of the Nursing Service in feeding the patient in the postoperative period, was related to patient care activities (postoperative patient in this case) such as:

• Checking the food acceptance by the patient;

• Feeding the patient, when necessary;

• Guiding the team regarding the postoperative patient feeding;

• Guiding and supervising the auxiliary professionals;

• Checking the comfort and hygiene conditions of the patient regarding his feeding;

• Assessing changes in the alimentary behavior of the postoperative patient.

• On the other hand, nurses do not consider functions related to the following activities to be their responsibility:

• Planning menus, according to financial and human resources;

• Establishing the techniques to be adopted in the preparation of food;

• Planning dietary education programs;

• Standardizing recipes;

• Analyzing the tasks of the team.

It is worth highlighting that there was no agreement among the interviewed nurses, in 1980, on planning dietary education programs. Of the total number of nurses interviewed, 73% - eight nurses - did not consider this item as the function of a nurse, whereas 23% - three nurses, did. Those nurses who considered it their function, possibly, thought of their educative action for food ingestion with the patient. It is possible to observe that, even in the 1970s and with the lack of nutritionists, the activities considered by the nurses as inherent to their function basically do not differ from those of authors of articles and books, previously mentioned and published in previous decades⁽¹⁷⁾.

CONCLUSIONS

The economical, social and political transformations that took place in the Brazilian society demanded the reformulation of the provision of health services, determining a new work division, and originating the paramedic professions. Nursing appears as a profession in the Brazilian Society before Nutrition and Social Work. ANS took on a decisive role in the institutionalization of these new professions, because the arrival of the Nutrition and Social Work professions were observed since the consolidation of the Nursing career.

Provided with the arrival of these two new careers in the health area, the Nursing career had its functions and activities redefined, in order to avoid any role overlapping. It is the responsibility of the nutritionist to take full care of the patient's feeding, its preparation and distribution, whereas it is the responsibility of the nurse to manage it and supervise its acceptance. The social worker is in charge of assisting the patient in any difficulties of his social life, which could affect his health or complicate his recovery. The primary action developed by the nurse was an important element for guiding social problems.

Despite of its peculiar characteristics, the professional roles of nurses, nutritionists and social workers are intimately related. Besides, if they contributed for the rationalization of the organization and the operation of health services on the one hand, they also contributed for the provision of a more complete care to their clients on the other hand.

Since these are professions that comprise activities developed by women, constituting professions that are characteristically feminine, they favored the increase in the number of women that are qualified in the health area in the job market. Therefore, this study contributed for the knowledge of the common historical roots of the first female academic professions in Brazil and of how they contributed for the professionalization process of the woman in our society.

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Correspondência:

Pacita Geovana Gama de Sousa Aperibense

Rua Enes Filho, n. 809c - casa 4 - Penha Circular

CEP 21011-290 - Rio de Janeiro, RJ, Brasil

*

Extraído do trabalho de conclusão de curso "Nexos entre a Enfermagem, a Nutrição e o Serviço Social, profissões femininas pioneiras na área da saúde", Escola de Enfermagem Anna Nery (EEAN), Universidade Federal do Rio de Janeiro (UFRJ), 2006.

Publication Dates

• Publication in this collection
  19 Sept 2008
• Date of issue
  Sept 2008

History

• Accepted
  11 Mar 2008
• Received
  01 June 2007