Technical attainment, practical success and practical knowledge: hermeneutical bases for child nursing care

Abstracts

Este estudo reflexivo buscou apresentar alguns traços dos conceitos êxito técnico, sucesso prático e sabedoria prática para ampliar a compreensão do cuidado de enfermagem à criança. O cuidado em saúde é tomado sob a perspectiva das práticas reconstrutivas e com caráter contingencial, destacando a importância da conexão entre êxito técnico e sucesso prático e a valorização da sabedoria prática, advindos da hermenêutica filosófica, no âmbito da filosofia prática. A enfermagem em saúde da criança pode lidar articuladamente com o êxito técnico e o sucesso prático e compreender a sabedoria prática na longitudinalidade do cuidado. A promoção da saúde, prevenção de doenças, recuperação e reabilitação da saúde da criança, de forma indissociável, deve estar em consonância com realidades contextualizadas e compartilhadas entre profissionais e famílias, buscando acompanhar o crescimento e desenvolvimento infantil, produzir narrativas, identificar experiências, escolhas e tomadas de decisão para a ampliação do cuidado.

criança; cuidados de enfermagem; enfermagem

Este estudio reflexivo buscó presentar algunos aspectos de los conceptos éxito técnico, éxito práctico y sabiduría práctica para ampliar la comprensión del cuidado de enfermería al niño. El cuidado en salud es entendido bajo la perspectiva de las prácticas reconstructivas y con carácter de contingencia, destacando la importancia de la conexión entre éxito técnico y éxito práctico y la valorización de la sabiduría práctica, provenientes de la hermenéutica filosófica, en el ámbito de la filosofía práctica. La enfermería en salud del niño puede lidiar articuladamente con el éxito técnico y el éxito práctico y comprender la sabiduría práctica en la extensión longitudinal del cuidado. La promoción de la salud, prevención de enfermedades, recuperación y rehabilitación de la salud del niño, de forma indisociable, deben estar en consonancia con realidades contextualizadas y compartidas entre profesionales y familias, buscando acompañar el crecimiento y desarrollo infantil, producir narrativas, identificar experiencias, elecciones y tomas de decisión para la ampliación del cuidado.

niño; atención de enfermería; enfermería

ARTIGO TEÓRICO

Technical attainment, practical success and practical knowledge: hermeneutical bases for child nursing care

Débora Falleiros de Mello^I; Regina Aparecida Garcia de Lima^II

^IEscola de Enfermagem de Ribeirão Preto, Universidade de São Paulo, WHO Collaborating Centre for Nursing Research Development, Brazil: Associate Professor, e-mail:[e-mail]

^IIEscola de Enfermagem de Ribeirão Preto, Universidade de São Paulo, WHO Collaborating Centre for Nursing Research Development, Brazil: Full Professor, e-mail:[e-mail]

ABSTRACT

This reflective study aimed to present some aspects of the concepts technical attainment, practical success and practical knowledge, with a view to a broader understanding of child nursing care. Health care is considered in the perspective of reconstructive practices, characterized as contingencies, highlighting the importance of the connection between technical attainment and practical success and the valuation of practical knowledge, based on philosophical hermeneutics, in the context of practical philosophy. Child health nursing can deal with technical attainment and practical success jointly, and also understand practical knowledge in the longitudinality of care. Health promotion, disease prevention, recovery and rehabilitation of child health should be indissociably associated with contextualized realities, shared between professionals and families, aiming to follow the child's growth and development, produce narratives, identify experiences, choices and decision making to broaden health care.

Descriptors: child; nursing care; nursing

INTRODUCTION

Nowadays, health practices have been marked by considerable scientific and technological development, despite serious limitations to effectively respond to individuals' and populations' complex health needs⁽¹⁾. Discussions on health care humanization, health care comprehensiveness, health promotion, as well as the principles of quality of life, equity, autonomy and users' rights have stood out in reflections on health practice organization^(1-4).

Nursing is a professional group that plays relevant roles, functions and responsibilities in health care. The essence and specificity of the nursing professionals is care for the human being, individually, in the family and community, with a view to the development of interventions to promote health, prevent diseases, recover and rehabilitate health. Through care, nursing assumes the responsibility for patients' comfort, welcoming, well-being and autonomy in care itself and in the coordination and intersection with other sectors, so as to offer health care⁽⁵⁾.

Nursing care can be considered a communicative act that demands specific knowledge and understanding of the context people live, work and get ill in. Nursing competency development needs not only theoretical and technical knowledge acquisition, but also appropriation and development of attitudes to improve the quality of the interpersonal relationship and of communication for care⁽⁶⁾.

Children and their families commonly contact the health system and need different health practices, no matter their fragility or damage, demanding professional attention in view of the health-disease and care process⁽⁷⁾.

In child health, despite advances in terms of child mortality reduction and expanded health service coverage, current challenges include the qualitative improvement of health interventions and the intensification of existing interventions, which lie beyond most children's reach in many countries however⁽⁸⁾. It is highlighted that child survival is not enough. Children need to be offered conditions to lead a high-quality life, allowing them to develop their potential and enjoy goods society produces.

Primary child health care focuses on child growth and development follow-up, maternal breastfeeding encouragement, child nutrition advice, immunization, accident prevention and care delivery to prevailing childhood diseases, which are considered the health practices to provide good health conditions in childhood⁽⁹⁾.

This study highlights the concepts of technical attainment, practical success e practical knowledge, addressed in recent research^(10-11). These concepts offer important elements to understand health care, and it is interesting to explore them in the context of child health nursing.

Hence, this study aimed to outline some characteristics of the concepts technical attainment, practical success and practical knowledge, relevant for a broader understanding of child nursing care.

The connection between technical attainment and practical success of child health care

To understand health care from a practical perspective, two extremely important concepts have gained increasing vitality: technical attainment and practical success^(10-11). These concepts originate in philosophical hermeneutics, in the context of practical philosophy, and are discussed to seek answers with a view to rethinking contemporary health practices.

The philosophical hermeneutics approach is related to a form of constructing/understanding the present-past-future, based on interpretative-comprehensive processes. These favor an understanding of something, the appropriation of a situation or some of its aspects, which was not clear before and became a problem for some reason, that is, it deserves to be reconsidered⁽¹²⁾. Philosophical hermeneutics emerges when a question arises and its application is formalized in a question, something that mobilizes, that bothers and demands to be thematized, in a movement that expresses a dialectical relation between question and answer⁽¹²⁾.

In the health area, many aspects related to health practices can be studied from a hermeneutics approach, because it involves constant tasks of knowledge interpretation and synthesis, offering conditions to acknowledge different interests and oppositions present in a given interaction, creating new possibilities for its resignification and reconstruction⁽¹⁰⁾.

Any health action has an instrumental sense and technical base, deriving from the constitution of health knowledge⁽¹¹⁾. Technical attainment refers to the instrumental sense of the action, presupposes the achievement of certain goals, following certain means. Technical attainment expresses relations between means and ends to control individual or populational health problems and adheres to the empirical-analytic logic of life and health sciences⁽¹¹⁾.

In child health, the concept of technical attainment can be analyzed in the relation between the use of therapeutic measures and the risk reduction of child health problems, including for example: prevention measures for asthma control (means) and the decrease of asthma crisis episodes (ends) or child vaccination (means) and the reduction of mortality rates due to immunopreventable diseases (end). In child health, concerns with the improvement of child health indicators are usual (reduction of child mortality and prevailing childhood diseases, among others), because these are important and reflect the development of a country or region. Child indicators represent not only numerical data to define an epidemiological situation, resulting in control and expressing technical attainment, but also include important issues of social relations, in which the circumstances involved in families and children's different situations and contexts are also relevant.

Taking care of the health of children and their families involves technical competencies and tasks, but cannot remain restricted to the search for technical attainment. In general, health professionals are concerned with good health practices through techniques, that is, through the achievement of good technical results. Obtaining good results is essential, but there is a need to go beyond the search for technical attainment and, also, to imprint comprehensive attitudes on the care process, gradually constructing new understandings of the situations families face. It implies paying more attention to a comprehensive whole that seeks to give meaning to the demands families and children take to health professionals and services.

The concept of technical attainment is closely linked with the concept of practical success. The latter refers to the value of the health action for subjects and populations. It covers a range of symbolic, relational and material implications of the health interventions and recommendations in subjects' daily lives. It is a concept that expresses the role of the means and goals of health actions in view of the values and interests subjects and populations grant to illness and health care⁽¹¹⁾.

In the above mentioned examples of child health, one can reflect on what it means for mothers/families to have a child with asthma, or what it means for mothers/families when the child does not have all of its vaccinations up to date, how they understand vaccination as protection, among other aspects. Practical success is connected with the understanding of senses and meanings. It becomes more meaningful for effective health care to talk to the mothers/families who experience the situation of having a child with asthma: what do you think your child has, what is it like for you, how is your daily reality of prevention measures for disease management, for periodical controls at health services and medication use, how are choices and decisions being made, how are difficulties to adopt nursing orientations in home care. Or for mothers/families who experience having children without all vaccinations up to date, what this situation is like for them, what has led to this, what daily reality is like, what they think about the diseases vaccines protect against, what difficulties they face to take the children to get vaccinated, among other issues.

The connection between these concepts is fundamental to construct a comprehensive whole of health interventions, contributing to health care. In the health area, there is a need to reconsider that care should not be moved exclusively by technique, but it is relevant for the search for technical attainment to be articulated with practical success, entailing the ethical challenge of not letting technique replace encounter and dialogue, seeking high-quality encounters⁽¹³⁾.

Concerns, therefore, are not only related to the efficacy of ends, but also of means, that is, the quality of communication in the process is extremely relevant. This is about a change in the way one considers health, in professionals' sensitivity and response capacity, without the central importance of instrumental aspects, but constructing care attitudes that include subjects as targets of and participants in health care. Thus, health professionals and subjects can set up a plan to understand attitudes and experiences, breaking barriers and sharing realities.

The impact of care delivered to children in health service may be limited if the fundamental role of mothers, families, responsible adults and caregivers in child health recovery, maintenance and protection at home is not taken into account.

Child nursing care in an integrative perspective implies that cure, prevention and health promotion actions are indissociable, constructing health care spaces in the family context. In that sense, child health nursing can articulate technical attainment and practical success in the longitudinality of care, seeking, in growth and development follow-up, interventions concerned with good health indicators (maternal breastfeeding encouragement, complete vaccination, accident prevention, development stimulation, among others) and that offer knowledge about the family dynamics, thematize interesting aspects (what mobilizes and unsettles), attempt to produce narratives, find out about choices and decision made in home care, strengthen virtues and daily experiences, interact and dialogue to expand care.

The valuation of practical knowledge in child nursing care

The concept of practical knowledge comes from practical philosophy, in the context of Aristotelian knowledge about rationality⁽¹²⁾. There are three different levels of rationality: epistemological, technical and practical^(11-12). The epistemological level involves theory and knowledge and is more immediately related with sciences. The technical level refers to activities to produce artifacts, create objects, produce goods and instruments, and is directed at the elaboration of principles about knowing how. The third level is that of practical knowledge.

Practical knowledge is characterized as a contingency, that is, it deals with eventuality, uncertainty, events and human experiences. It does not deal with perennial, causal and universal aspects. This knowledge does not produce objects, artifacts or instruments⁽¹¹⁾. It is a space focused on human interests. It is a non-cumulative knowledge, it can emerge from experiences, common or diverging interests, tensions and possible interactions. In this sense, although this knowledge is not less true, it does contain less certainty and determination. It is about constructing the search about the understanding of life, about the experiences and choices made in view of the different contingencies faced in daily reality⁽¹¹⁾.

Practical knowledge is related with the ability and the need to choose and, therefore, the need to know or find what is good in each concrete situation⁽¹²⁾. The essence of this knowledge is the contingency concept. It entails the idea of meeting with what comes up and what one can neither anticipate nor deduct by thinking.

In health care, the movement of reconstruction and articulation between technical-scientific knowledge and common sense is fundamental. For this purpose, communication, language, dialogue between subjects and concern with practical knowledge are important. To enrich health interventions, there is a need to reconsider curing, treating and controlling, as these may reveal to be limited and object-centered, and taking care of health goes beyond the construction of an object and an intervention in it⁽²⁾.

Paying attention to practical knowledge, that is, to the interests of people one delivers care to, implies responsibility for caregiving attitudes, centered around dialogue. In the perspective of Gadamer's hermeneutics, the sense of the dialogue is the fusion of horizons, which is the constitution of sharing, familiarization and mutual appropriation of what is unknown in the other⁽¹²⁾. Through the hermeneutical experience, the encounter between subjects is relevant to see the other, perceive that the other may be right and construct shared responsibility, permitting effective contact and solidarity between people⁽¹⁴⁾. Thus, in health care, it is important to seek the fusion of horizons between health professionals and subjects, interest and attentive listening to the other⁽¹¹⁾.

In child health, through reflections on practical knowledge, one can consider childcare in the family context, in its relations with health services, community, school and other social sectors. Paying attention to the interests and singularities of children and their families offers essential elements for the construction of care spaces, marked by the fusion of expanding horizons. This expansion occurs through language, in the construction of the dialectic question-and-response movement that privileges the establishment of a plan to understand the characters, scenarios, plots, narratives, choices, experiences and the temporalization between past, present and future.

Child health nursing care, in the growth and development process and in the family context, implies the organization of care and interventions in the biological, psychological and sociocultural dimensions. In this care, one deals with a range of mother/family experiences in the health-disease process, revealing the importance of knowing their values and interests and talking about life and health projects⁽¹⁵⁾. Understanding practical knowledge, that is, practical truth, related to reflexive knowledge, choices, human values and virtues, privileging dialogue between stakeholders and producing understanding, in which one reaches an understanding with the other, can resignify health care.

In general, nursing interventions in child health are based on the epidemiological profiles of the child population, with care plans that emphasize the identification of risk factors and prevailing childhood diseases, the description of control measures, home care guidelines, identification of signs of severity that require care by health services, priorities for health promotion, with interventions that involve children, families and in institutions like kindergartens and schools, among other foci⁽¹⁶⁾. However, it is important for child health nursing interventions to be directed at the fusion with families and children, with possibilities to apprehend world visions, experiences and meanings and permit closer contact with decisions made and mechanisms used to cope with the situations of life.

It is important for nursing professionals to modify their repertoire of orientations to expand nursing care, attempting to create strategies to approach the reality the families experience, assessing what difficulties the mother/family is facing to take effective care of her child, avoiding charges, verifications and prescriptions.

Child health follow-up should be achieved by considering the social and family context. Hence, this follow-up should be a broad and continuous process, guided by the following of child growth and development, with qualified and humanized interventions. In their relation with health services, the families need guidance and support to perform care acts they normally deliver to the children but which they sometimes perceive to be limited, like in situations of breastfeeding difficulties for example, or acute respiratory infections, chronic childhood diseases, obstacles to the stimulation of child and family development, among others. In that process, the families experience the limits of insufficiencies in the relation with their children and the search for sufficiency will lead them to health services and health professionals⁽¹²⁾. Thus, child health nursing can broaden horizons together with the families. The fusion of horizons is not considered as a crossing. Instead, health professionals and care subjects' horizons do not mix, but expand.

These aspects can shape a practical look and way of dealing with practical knowledge in its singularities and particularities. They also permit health care dimensions characterized as contingencies, that is, situations in which nursing and families try and deal with eventuality, uncertainty, unpredictability, with what can happen or not, with aspects and events linked with experiences. This permits decision making without mothers/families and health professionals' a priori attempts to get to know values and routes towards satisfactory human contact, which can generate integration between practical and technical knowledge.

Integrating practical and technical knowledge means attempting to work with the subjects' autonomy and creative powers, but it also means giving sense to the encounter and allowing people to move through situations that put them in positions of solving, of not being confused, of feeling safe, of being connected, allowing them to reestablish themselves in view of the situation and to keep on living.

Thinking about how professionals are delivering care and interacting with mothers/families in a given community implies rethinking relations, actions and commitments. The holistic child health care perspective implies rethinking forms of interacting with the subjects in the health-disease and care process.

FINAL CONSIDERATIONS

Health practices, in health services as well as families and the community, need to be reconsidered and resignified, in the attempt to increase bonding with the population, adherence to health protection and promotion measures, health professionals' effective actions towards families, the construction of accountability plans and health projects.

Child nursing care is guided by understanding the child growth and development process, indissociably imprinting health promotion, disease prevention, health recovery and rehabilitation intervention, in which the children's and families' singularities and qualified and humanized health care are fundamental. In the daily reality of health services, there is a need to pay attention and listen what demands care, putting technical resources at the service of the desired practical success, in line with realities that are contextualized and shared among professionals, families and children.

It is important for nursing professionals to look at daily reality, a practical and not only technical look, so as to deal with the processual nature of health care. This process is not natural. Instead, it is complex and should be permanently reconstructed, enrichened by the integration between technical attainment and practical success and the valuation of practical knowledge. By paying attention to practical knowledge, one can move towards practical success.

This study attempted to take a closer look at these concepts, summarizing its constituent traits with a focus on child health nursing. The concepts highlighted here have neither immediate application nor a pragmatic dimension, but are relevant as a theoretical background, offering possibilities for abstraction and greater understanding about health care issues. It should be highlighted that other spaces for discussion and research can shape the density of these concepts in different health areas and broaden reflections in their epistemological, philosophical and practical dimensions.

Recebido em: 26.6.2008

Aprovado em: 3.3.2009

• 1. Ayres JRCM. O cuidado, os modos de ser (do) humano e as práticas de saúde. Saúde Soc 2004;13(3):16-29.
• 2. Ayres JRCM. Sujeito, intersubjetividade e práticas de saúde. Ciênc Saúde Coletiva 2001; 6(1):63-72.
• 3. Costa AM. Integralidade na atenção e no cuidado à saúde. Saúde Soc 2004; 13(3):5-15.
• 4. Fortes PAC. Ética, direitos dos usuários e políticas de humanização da atenção à saúde. Saúde Soc 2004; 13(3):30-5.
• 5. Rocha SMM, Almeida MCP. O processo de trabalho da enfermagem em saúde coletiva e a interdisciplinaridade. Rev Latino-am Enfermagem 2000; 8(6):96-101.
• 6. Bermejo JC. Salir de la noche: por uma enfermería humanizada. Serie: Humanizar la salud. Santander (España): Editorial Salterrae; 1999.
• 7. Mello DF, Rocha SMM, Scochi CGS, Lima RAG. Brazilian mothers' experiences of home care for their low birth weight infants. Neonatal Network 2002; 21(1):30-4.
• 8. Victora CG, Barros FC. Global child survival initiatives and their relevance to the Latin América and Caribbean Region. Rev Panamericana Salud Publica 2005; 18(3):197-205.
• ⁹
  World Health Organization. Care in normal birth: a practical guide. Maternal and newborn Health, Safe Motherhood, Family and Reproductive Health. Geneva: WHO; 1996.
• 10. Ayres JRCM. Uma concepção hermenêutica de saúde. Physis: Rev Saúde Coletiva 2007; 17(1):43-62.
• 11. Ayres JRCM. Para comprender el sentido práctico de las acciones de salud: contribuciones de la Hermenéutica Filosófica. Salud Colectiva, Buenos Aires 2008; 4(2):159-172.
• 12. Gadamer HG. A idéia da filosofia prática. In: Gadamer HG. Hermenêutica em retrospectiva: hermenêutica e a filosofia prática. Petrópolis: Vozes; 2007. p. 27-39.
• 13. Ayres JRCM. Cuidado e humanização das práticas de saúde. In: Deslandes S, organizadora. Humanização dos cuidados em saúde: conceitos, dilemas e práticas. Rio de Janeiro(RJ): Fiocruz; 2006. p. 49-83.
• 14. Gadamer HG. Experiência corporal e objetivabilidade. In: Gadamer HG. O caráter oculto da saúde. Petrópolis: Vozes; 2006. p.77-90.
• 15. Mello DF, Lima RAG, Scochi CGS. Health follow-up of children in poverty situation: between the routine and eventuality of daily care. Rev Latino-am Enfermagem 2007; 15(especial):820-7.
• 16. Veríssimo MLOR, Sigaud CHS. Assistência de enfermagem à criança com agravos respiratórios. In: Instituto para o Desenvolvimento da Saúde, Universidade de São Paulo, Ministério da Saúde. Manual de enfermagem. Brasília: Ministério da Saúde; 2001.

Publication Dates

• Publication in this collection
  02 Oct 2009
• Date of issue
  Aug 2009

History

• Received
  26 June 2008
• Accepted
  03 Mar 2009