Abstract

Introduction

Social rehabilitation of people with a stoma (surgical communication with the outside for elimination or respiration) encompasses stimulation to face the underlying disease and the new condition, psychoemotional rehabilitation, and facilitation of self-responsibility for care, including family members in the process¹1 Sousa CF, Santos CB. O cuidado de enfermagem em estomaterapia: desenvolvimento de um programa de intervenção. Enferm Foco. 2019; 10(5):161-6.. Such rights of ostomates in Brazil are based on Decree no. 5296 of December 2, 2004, which recognizes them as disabled individuals and ensures social support, quotas, and free access to equipment and adjuvants. This is complemented by Directive no. 400 of November 16, 2009, which regulates specialized and interprofessional care in the Brazilian National Health System (SUS) and a specific Care Network that provides follow-up, assessment, and prevention of health problems²2 Brasil. Decreto-lei nº 5.296 de 2 de dezembro de 2004. Regulamenta as Leis nos 10.048, de 8 de novembro de 2000, que dá prioridade de atendimento às pessoas que especifica, e 10.098, de 19 de dezembro de 2000, que estabelece normas gerais e critérios básicos para a promoção da acessibilidade das pessoas portadoras de deficiência ou com mobilidade reduzida, e dá outras providências. Diário Oficial da União. 03 Dez 2004. Sec. 1, p. 5.^,33 Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Portaria nº 400, de 16 de novembro de 2009 [Internet]. Brasília: Ministério da Saúde; 2009. Disponível em: https://bvsms.saude.gov.br/bvs/saudelegis/sas/2009/prt0400_16_11_2009.html.
https://bvsms.saude.gov.br/bvs/saudelegi... .

Therefore, such users will depend on support offered throughout the treatment for the best prognosis and care, as rehabilitation is a process and, with time, it transcends the themes of ostomy self-care and handling of pouching systems and adjuvants, and culminates in ostomates regaining control of their life and being reinserted in society⁴4 Brasil. Ministério da Saúde. Secretaria de Atenção Especializada em Saúde. Departamento de Atenção Especializada e Temática. Guia de atenção à saúde da pessoa com estomia. Brasília: Ministério da Saúde; 2021.^,55 Sasaki VDM, Teles AADS, Lima MS, Barbosa JCC, Lisboa BB, Sonobe HM. Reabilitação de pessoas com estomia intestinal: revisão integrativa. Rev Enferm UFPE. 2017; 11 Suppl 4:1745-54..

The literature approaches validations and interventions for self-management of digestive ostomy and long-term adaptation, which require cognitive and behavioral efforts⁶6 Krouse RS, Grant M, McCorkle R, Wendel CS, Cobb MD, Tallman NJ, et al. A chronic care ostomy self‐management program for cancer survivors. Psycho‐oncology. 2016; 25(5):574-81. doi: 10.1002/pon.4078.
https://doi.org/10.1002/pon.4078... ^,77 Hueso-Montoro C, Bonill-de-Las-Nieves C, Celdrán-Mañas M, Hernández-Zambrano SM, Amezcua-Martínez M, Morales-Asencio JM. Experiences and coping with the altered body image in digestive stoma patients. Rev Latino Am Enferm. 2016; 24:e2840. doi: 10.1590/1518-8345.1276.2840.
https://doi.org/10.1590/1518-8345.1276.2... . Some examples are the construction and validation of a technology for ostomized women’s self-care of sexual and reproductive health⁸8 Albuquerque AFLL, Pinheiro AKB, Linhares FMP, Guedes TG. Tecnologia para o autocuidado da saúde sexual e reprodutiva de mulheres estomizadas. Rev Bras Enferm. 2016; 69(6):1164-71. doi: 10.1590/0034-7167-2016-0302.
https://doi.org/10.1590/0034-7167-2016-0... ; a virtual learning object on intestinal elimination stoma for undergraduate nursing students and permanent education⁹9 Braga CSR, Andrade EMLR, Luz MHBA, Monteiro AKC, Campo MO, Silva FMS, et al. Construction and validation of a virtual learning object on intestinal elimination stoma. Investig Educ Enferm. 2016; 34(1):120-7. doi: 10.17533/udea.iee.v34n1a14.
https://doi.org/10.17533/udea.iee.v34n1a... ; reinforcement education in ostomy management during hospitalization without the need of many teaching lessons¹⁰10 Seo HW. Effects of the frequency of ostomy management reinforcement education on self‐care knowledge, self‐efficacy, and ability of stoma appliance change among Korean hospitalised ostomates. Int Wound J. 2019; 16 suppl 1:21-8. doi: 10.1111/iwj.13047.
https://doi.org/10.1111/iwj.13047... ; transtheoretical model-based intervention on the self-management of patients with colorectal cancer after ostomy surgery¹¹11 Wen SL, Li J, Wang AN, Lv MM, Li HY, Lu YF, et al. Effects of transtheoretical model‐based intervention on the self‐management of patients with an ostomy: a randomised controlled trial. J Clin Nurs. 2019; 28(9-10):1936-51. doi: 10.1111/jocn.14731.
https://doi.org/10.1111/jocn.14731... ; ostomy self-management training including four elements from the Chronic Care Model in telehealth: 1) identification of cultural resources; 2) promotion of well-being by planning the teaching of self-management; 3) self-management information among peers; and 4) educators in community-based support groups¹²12 Sun V, Ercolano E, McCorkle R, Grant M, Wendel CS, Tallman NJ, et al. Ostomy telehealth for cancer survivors: design of the Ostomy Self-management Training (OSMT) randomized trial. Contemp Clin Trials. 2018; 64:167-72. doi: 10.1016/j.cct.2017.10.008.
https://doi.org/10.1016/j.cct.2017.10.00... . Also grounded on the Chronic Care Model, the chronic care ostomy self-management training is used by oncology nurses⁶6 Krouse RS, Grant M, McCorkle R, Wendel CS, Cobb MD, Tallman NJ, et al. A chronic care ostomy self‐management program for cancer survivors. Psycho‐oncology. 2016; 25(5):574-81. doi: 10.1002/pon.4078.
https://doi.org/10.1002/pon.4078... ^,1313 Ercolano E, Grant M, McCorkle R, Tallman NJ, Cobb MD, Wendel C, et al. Applying the chronic care model to support ostomy self-management: implications for oncology nursing practice. Clin J Oncol Nurs. 2016; 20(3):269-74. doi: 10.1188/16.CJON.20-03AP.
https://doi.org/10.1188/16.CJON.20-03AP... .

The studies mentioned above recognize the importance of professional mediation. However, they propose the hypothesis that the numerous care technologies may not penetrate groups and everyday lives due to the micropolitics of health services. This hypothesis originates the pertinence of learning situated in the micro-social dimension, a concept from Situated Learning Theory, created by Étienne Wenger and Jean Lave, which designates “learning by doing” in social practices within Communities of Practice (CoP). Although it emerged in the social sciences, the correlation between the theory and healthcare was cited in two contexts: in the sharing of practices concerning prenatal care, difficult births and orientations in postpartum visits among Mexican midwives, and in Alcoholics Anonymous groups that reconstruct life histories, mental health, and behavior patterns when individuals become abstainers¹⁴14 Lave J, Wenger E. Situated learning: legitimate peripheral participation. Cambridge: Cambridge University Press; 1991..

In the area of health, CoP is conceptualized as a group that:

However, definitions that include users in the CoP remain scarce. A recent review pointed out the existence of social networks, but no CoP, for people with a stoma¹⁶16 Correa Júnior AJS, Paraizo-Horvath CMS, Russo TMS, Camargo AMS, Teles AAS, Aguiar JC, et al. Redes sociais, aplicativos e vídeos para pessoas com estomia intestinal, traqueostomia e cuidadores: das redes informais para as comunidades de prática. Glob Acad Nurs. 2022; 3(3):e268. doi: 10.5935/2675-5602.20200268.
https://doi.org/10.5935/2675-5602.202002... .

To further explore the theme, we propose, in an introductory fashion, care between peers (significant others) to counterbalance disengagement, aiming at a healthcare CoP, and state that we are against self-responsibility.

Theoretical framework

Cohn¹⁷17 Cohn A. O estudo das políticas de saúde: implicações e fatos. In: Campos GWS, Minayo CS, Akerman M, Drumond Júnior M, Carvalho YM, organizadores. Tratado de Saúde Coletiva. São Paulo: Hucitec; 2006. p. 231-58. criticizes the transfer of responsibility for illness and treatment to the individual. Self-responsibility emerges due to the weakening of the State’s capacity to provide and manage public good and general needs. In addition, the author condemns the strengthening of the transnational market that defends health as a good offered to be consumed as a private need. In the scope of collective mobilization, there are non-governmental organizations (NGOs), philanthropic entities, and communities. Bauman¹⁸18 Bauman Z. Comunidade: a busca por segurança no mundo atual. Rio de Janeiro: Zahar; 2022. states that engagement is triggered by the bonds of a community of interests, which is the opposite of ghettos.

Focusing on the learning process, Wenger theorized that the area of Computer Sciences was able to manage the information process of a CoP, but it needed Anthropology to analyze and explain meanings in the world. Computer Science treated learning as biological - the brain and its electrical impulses in an “organic machine” -, in addition to algorithms that predict human behavior (and its future). Wenger sought to integrate its multidisciplinary model into Anthropology, seen as a teller of stories¹⁹19 Omidvar O, Kislov R. The evolution of the communities of practice approach: toward knowledgeability in a landscape of practice - an interview with Etienne Wenger-Trayner. J Manag Inquiry. 2013; 23(3):266-75. doi: 10.1177/1056492613505908.
https://doi.org/10.1177/1056492613505908... .

To him, discussing problems is the beginning of mutual commitment and qualification, and roles are the point of departure for group concerns and goals. This process is not in a vacuum. It is guided by public policies and healthcare directives²⁰20 Zamprogna KM, Backes VMS, Menegaz JDC, Souza SDSD. Comunidade de prática docente-assistencial: análise do compromisso mútuo, objetivo comum e repertório compartilhado. Acta Scientiarum Educ. 2022; 44:e53705. doi: 10.4025/actascieduc.v44i1.53705.
https://doi.org/10.4025/actascieduc.v44i... and by a repertoire based on practice and negotiation. Implementing communities emerges in a context in which practice frequently does not favor a type of reflection that is grounded on everyday life and gives collaborative answers to problems²¹21 Menegaz JC, Backes VMS, Medina Moya JL. Communities of practice: influences on pedagogical reasoning and action of nursing professors. Invest Educ Enferm. 2018; 36(2). doi: 10.17533/udea.iee.v36n2e02.
https://doi.org/10.17533/udea.iee.v36n2e... .

The three fundamental aspects are the domain, the community, and the practice. Domain is not only about connections; there is an identity involved in adherence to shared competence(s). However, a webpage is not a CoP, as in the latter interactions are more important than online reports of problems or experiences one has when dealing with a problem. Thus, CoP is different from a community of interests²²22 Wenger-Trayner E, Wenger-Trayner B. Comunidades de práctica una breve introducción [Internet]. Proyecto Educación y Nuevas Tecnologías - Área Educación. 2015 [citado 20 Mar 23]. Disponível em: http://www.pent.org.ar/institucional/publicaciones/comunidades-practica-una-breve-introduccion
http://www.pent.org.ar/institucional/pub... ^,2323 Wenger E. Communities of practice and social learning systems. Organization. 2000; 7(2):225-46. doi: 10.1177/135050840072002.
https://doi.org/10.1177/135050840072002... . Some concepts to understand it are²⁴24 Wenger E. Communities of practice and social learning systems: the career of a concept. In: Blackmore C, editor. Social learning systems and communities of practice. London: Springer; 2010. p. 179-98. doi: 10.1007/978-1-84996-133-2_11.
https://doi.org/10.1007/978-1-84996-133-... :

• Engagement: more closely related to a practice - activities, doing things, working alone or together, talking, using and producing artifacts. It enables a participative or non-participative identity;

• Imagination: creates relationships as significant as those derived from engagement. The images of the world locate us, allowing us to reflect on our situation and explore new possibilities. The world provides many imagination tools (one’s interpretation of their participation), like language, stories, maps, visits, photos, TV programs, models, among others;

• Alignment: engagement in practice is rarely effective if it does not have a minimum degree of alignment with the context and coordination. It does not mean submitting to external authority or following a prescription; it is a two-way process of coordinating perspectives and actions;

• Situated activity: as an empirical attribute of the daily activity, it is an answer to those who do not believe in informal, experience-based learning;

• Central participation: it is not a linear movement of skill acquisition; it admits a physical, political or metaphorical center in the community in relation to the individual;

• Complete participation: defines full participation and suggests a closed domain of collective practice with measurable degrees of acquisition for newcomers;

• Full participation: diversity of relationships among members. Full participation is the opposite of peripherality and defines partial participation;

• Peripherality: considering that there may not be only central participation, it is suggested that there are multiple and inclusive ways of engaging. It can also be a common point between two related communities;

• Legitimate peripherality: involves power, specifically in intensive participation, and an empowering position.

Consequently, legitimate peripheral participation is not, in itself, a form of education, a pedagogical strategy or a technique. It constitutes an analytical perspective independent of educational format, context, or educational intentionality. It does not consider that intentional instruction in itself is solely the source or drive of learning; it is always necessary to consider three antagonistic aspects: legitimate versus illegitimate; peripheral versus central; and participation versus non participation¹⁴14 Lave J, Wenger E. Situated learning: legitimate peripheral participation. Cambridge: Cambridge University Press; 1991..

Therefore, the present review aims to discuss situated learning trajectories for social rehabilitation in face-to-face and online Communities of Practice for people with a stoma.

Method

Comprehensive narrative review that is different from systematic reviews in that its selection of data sources is not exhaustive and it has a broad research question, in search of theoretical frameworks and knowledge reformulations²⁵25 Brum CN, Zuge SS, Rangel RF, Freitas HMB, Pieszak GM. Revisão narrativa da literatura: aspectos conceituais e metodológicos na construção do conhecimento da enfermagem. In: Lacerda MR, Costenaro RGS. Metodologia de pesquisa para a enfermagem a saúde: da teoria à prática. Porto Alegre: Moriá; 2015. p. 123-42.. The flexible review plan had seven stages²⁶26 Gil AC. Métodos e técnicas de pesquisa social. 7a ed. São Paulo: Atlas; 2019.: questionings and possible axes for debate; identification of bibliographic sources; reading of the material; selection of excerpts; notes on main points; logical organization of the work; and writing.

The guiding questions were: How is Situated Learning Theory employed for professionals, users, and family members-caregivers in a context of healthcare learning after biographical ruptures? What insights from Situated Learning Theory and face-to-face and online communities of practice, even if theoretical, can be applied to the social rehabilitation and learning of people with a stoma?

The combination of the terms “Situated Learning” AND “Health” in the PUBMED database in an open timeline generated 131 results, with the last upload in the Rayyan web application on November 10, 2022. The exclusion criteria during screening were: not mentioning the health area; approaching exclusively teaching or education of undergraduate students or residents, without focusing on rehabilitation, as the objective is the use of the theory bringing together patient-professional-caregiver; and publications that approached the theory in a precarious way.

A total of 18 theoretical articles and primary studies was identified. It is important to mention that none of the selected international publications had people with a stoma as participants; thus, the collected material was complemented with texts from the enterostomal therapy area and texts by Étienne Wenger. The qualitative analysis was carried out in the following way: textual analysis of the reading unit in a broad temporal frame; thematic analysis in light of the research problem and objective; interpretation verifying the coherence of the central idea; problematization of the literature; synthesis²⁷27 Severino AJ. Diretrizes para a leitura, análise e interpretação do trabalho científico. São Paulo: Cortez; 2007. through a reflection in which the second research problem was addressed.

The order of presentation of the three initial debate axes corresponded to the intercommunicating and non-hierarchical concepts: Domain - recognition of a particular problem of interest to a group, inspiring participation, organization of knowledge, and identities in transition; Community - a critical element of the structure, it summons settings, artifacts, evolving and layered interactions, and recognition of central and peripheral voices; and Practice - requires implementation of language styles, guiding principles, stories, experts, and documents, aiming to achieve situated learning¹⁴14 Lave J, Wenger E. Situated learning: legitimate peripheral participation. Cambridge: Cambridge University Press; 1991.^,2828 Wenger E, McDermott R, Snyder WM. Cultivating communities of practice: a guide to managing knowledge. Boston: Harvard Business Review Press; 2002..

In the fourth axis, we added notes on Civil Society to support the discussion, arguing that communities go beyond business organizations. We defend that expert professionals and “champions of practice” (veterans) perform management by means of multimedia, idealizing the formation of national networks and/or local coalitions²⁸28 Wenger E, McDermott R, Snyder WM. Cultivating communities of practice: a guide to managing knowledge. Boston: Harvard Business Review Press; 2002.. In addition, we applied Bauman’s concepts of ethical and esthetic communities¹⁸18 Bauman Z. Comunidade: a busca por segurança no mundo atual. Rio de Janeiro: Zahar; 2022..

Results and discussion

The publications came from Australia (n=2), United Kingdom (n=3), Denmark (n=3), United States of America (n=4), Spain, Germany, Holland, Taiwan, Sweden, and Norway. There are 08 theoretical studies and 10 primary studies. The primary studies of a quantitative nature were: blog experiment, longitudinal study, stepped wedge trial, longitudinal study with a variable exposure to an intervention, responsive evaluation approach, and cluster randomized trial; the qualitative ones were: phenomenological approach, hermeneutic approach inspired in Gadamer (n= 2), and qualitative study with Facebook data. The 18 publications are described in detail in Dataset²⁹29 Correa Júnior AJS. DATASET - Situated Learning Theory e as comunidades de prática: subsídios para a reabilitação social de pessoas com estomias. Figshare; 2023. doi: 10.6084/m9.figshare.23653755.v2.
https://doi.org/10.6084/m9.figshare.2365... , Figshare: https://doi.org/10.6084/m9.figshare.23653755.v2.

Delimitation of a healthcare community of practice: reified identities and trajectories

Traditional instruction includes³⁰30 Herrington J, Oliver R, Herrington A, Sparrow H. Towards a new tradition of online instruction: using situated learning to design web-based units [Internet]. In: ASCILITE 2000 Conference; 09 – 14 Dez 2000; Coffs Harbour [citado 30 Nov 2022]. Disponível em: https://researchportal.murdoch.edu.au/esploro/outputs/conferencePaper/Towards-a-new-tradition-of-online/991005540687807891
https://researchportal.murdoch.edu.au/es... : the teacher/instructor is the one who most speaks, teaches a whole class of students, time is clocked, the classroom is organized in desks and rows, knowledge is divided into subjects, and physical presence is necessary. By contrast, in online situated learning there would be: 1. Reflection on how knowledge will be used; 2. Access to specialists and process modeling; 3. Multiple roles; 4. Collaborative construction; 5. Articulation; 6. Assessment. Therefore, CoP theory derives from the intersection between the Social and the Learning theories. However, Wenger was more influenced by social scientists like Giddens and Bourdieu than by Learning theorists¹⁹19 Omidvar O, Kislov R. The evolution of the communities of practice approach: toward knowledgeability in a landscape of practice - an interview with Etienne Wenger-Trayner. J Manag Inquiry. 2013; 23(3):266-75. doi: 10.1177/1056492613505908.
https://doi.org/10.1177/1056492613505908... .

CoP is a context to acquire identity using a trajectory, depending on management of knowledge and responsibilities. Wenger calls the interaction regarding identity “learning citizens”, as the person is not an insular and perfect entity¹⁹19 Omidvar O, Kislov R. The evolution of the communities of practice approach: toward knowledgeability in a landscape of practice - an interview with Etienne Wenger-Trayner. J Manag Inquiry. 2013; 23(3):266-75. doi: 10.1177/1056492613505908.
https://doi.org/10.1177/1056492613505908... ; in the community, transfer considers personal knowledge and cognitive theorization³¹31 Billett S. Situated learning: bridging sociocultural and cognitive theorising. Learning and instruction. 1996; 6(3):263-80.^,3232 Pyrko I, Dörfler V, Eden C. Thinking together: what makes communities of practice work? Hum Relat. 2017; 70(4):389-409. doi: 10.1177/0018726716661040.
https://doi.org/10.1177/0018726716661040... . Trajectories and interactions are neither solely mental nor generic like noises; rather, they are attitudes outside the classroom. Therefore, tired students and non-dynamic teachers result in non-significant and non-linear learning³³33 Durning SJ, Artino AR. Situativity theory: a perspective on how participants and the environment can interact: AMEE Guide no. 52. Med Teach. 2011; 33(3):188-99. doi: 10.3109/0142159X.2011.550965.
https://doi.org/10.3109/0142159X.2011.55... .

Finding a network of experts is the gain of the horizontal communication of digital CoPs, which use Information and Communications Technologies (ICTs) and gather interactive discourses outside verticality, in a multi-directional way - before this, a superior entity used to transmit the message and people listened passively. The facilitator will need to stimulate interprofessionality and manage projects, languages, and co-creation of rules³⁴34 Toledo PF, Ferreira IO. Horizontalidad discursiva en comunidades de práctica digitales. Círc Linguíst Apl Comun. 2009; 39:35-55.^,3535 Bindels J, Cox K, Widdershoven G, van Schayck CP, Abma TA. Stimulating program implementation via a Community of Practice: a responsive evaluation of care programs for frail older people in the Netherlands. Eval Program Plann. 2014; 46:115-21. doi: 10.1016/j.evalprogplan.2014.06.001.
https://doi.org/10.1016/j.evalprogplan.2... . A member is designated to give orientations outside the CoP (face-to-face) or in a restricted area of the CoP (online), when there is knowledge that reverberates more around a specific component³⁵35 Bindels J, Cox K, Widdershoven G, van Schayck CP, Abma TA. Stimulating program implementation via a Community of Practice: a responsive evaluation of care programs for frail older people in the Netherlands. Eval Program Plann. 2014; 46:115-21. doi: 10.1016/j.evalprogplan.2014.06.001.
https://doi.org/10.1016/j.evalprogplan.2... .

In the sociocultural perspective, this mutuality enables to revisit beliefs and allows transfer to occur from identifiable factors. In the event learning occurs in an institutional context, the most feasible transfer is to these same spaces, as acquisition circumstances dictate the cognition for this practice. Having said that, forms of orientation for proximal and distal experiences need co-construction and evaluation³¹31 Billett S. Situated learning: bridging sociocultural and cognitive theorising. Learning and instruction. 1996; 6(3):263-80.. The design of the online interface will prioritize the familiar-instructional aspect and the teacher will not be the only source³⁰30 Herrington J, Oliver R, Herrington A, Sparrow H. Towards a new tradition of online instruction: using situated learning to design web-based units [Internet]. In: ASCILITE 2000 Conference; 09 – 14 Dez 2000; Coffs Harbour [citado 30 Nov 2022]. Disponível em: https://researchportal.murdoch.edu.au/esploro/outputs/conferencePaper/Towards-a-new-tradition-of-online/991005540687807891
https://researchportal.murdoch.edu.au/es... .

The participations negotiate the replacement of a stigmatized identity with that of a new woman, new man, mother, father, student, among others. There is a concept that has been little explored in the trajectories: reification - transformation of bad events into material strategies (treatment strategies after a diagnosis or “doing something with what has been given to me” due to the label of chronic condition), generating new reified identities. At this point, there is an exception: stigmatized identities should not be reified, as this hinders the experience of legitimate participation and engagement³⁶36 Murray R, Turner L. Using communities of practice theory to understand the crisis of identity in chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME). Chronic Illn. 2023; 19(1):56-64. doi: 10.1177/17423953211064989.
https://doi.org/10.1177/1742395321106498... .

Thus, CoP helps identities in crisis after biographical ruptures when people are no longer capable of being or doing, and in their incapacity to adopt the new role. This was found in a research on the chronic fatigue syndrome, which revealed professionals’ skepticism concerning symptoms and marginalization inside the community itself, culminating in an illegitimate, disabling and psychosomatic trajectory. Thus, when this reification occurs, participation was useless³⁶36 Murray R, Turner L. Using communities of practice theory to understand the crisis of identity in chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME). Chronic Illn. 2023; 19(1):56-64. doi: 10.1177/17423953211064989.
https://doi.org/10.1177/1742395321106498... .

There is no educational transfer without situated knowledge, artifacts and setting

Legitimate peripheral participation involves cognition situated in an activity distributed in the socio-environmental dimension and conducted by peers who know a little more about the topic, facilitating the evolution of the identity until the modification of the self³³33 Durning SJ, Artino AR. Situativity theory: a perspective on how participants and the environment can interact: AMEE Guide no. 52. Med Teach. 2011; 33(3):188-99. doi: 10.3109/0142159X.2011.550965.
https://doi.org/10.3109/0142159X.2011.55... . With Situated Learning Theory, the organization of the instructions is distributed, for example, over a six-month time continuum: in the first-second months, one weekly instruction, in the third-fourth months, one instruction every two weeks, in the fifth-sixth months, every three weeks³⁷37 Overgaard C, Bøggild H, Hede B, Bagger M, Hartmann LG, Aagaard K. Improving oral health in nursing home residents: a cluster randomized trial of a shared oral care intervention. Community Dent Oral Epidemiol. 2022; 50(2):115-23. doi: 10.1111/cdoe.12638.
https://doi.org/10.1111/cdoe.12638... .

In situativity, situated cognition or sitcog, knowledge and thinking integrate in an evolving way in games, project artifacts or peer writing, having spontaneity without scripting and thinking-action that does not come from one single participant concerning contents³³33 Durning SJ, Artino AR. Situativity theory: a perspective on how participants and the environment can interact: AMEE Guide no. 52. Med Teach. 2011; 33(3):188-99. doi: 10.3109/0142159X.2011.550965.
https://doi.org/10.3109/0142159X.2011.55... . CoPs are characterized by abstraction and transpersonal knowledge (“thinking together”)³²32 Pyrko I, Dörfler V, Eden C. Thinking together: what makes communities of practice work? Hum Relat. 2017; 70(4):389-409. doi: 10.1177/0018726716661040.
https://doi.org/10.1177/0018726716661040... during replication, and it is known that transfer away from where the practice was created is rare, as is transfer from formal to popular education environments. The term knowledge was not approached initially in the theory; however, its role establishes “indwelling” - knowledge added to learning, meaning and identity. Thus, total and peripheral participations cannot be artificial³¹31 Billett S. Situated learning: bridging sociocultural and cognitive theorising. Learning and instruction. 1996; 6(3):263-80..

In interactive landscapes of practice, wisdom demonstrated by transferring knowledge¹⁹19 Omidvar O, Kislov R. The evolution of the communities of practice approach: toward knowledgeability in a landscape of practice - an interview with Etienne Wenger-Trayner. J Manag Inquiry. 2013; 23(3):266-75. doi: 10.1177/1056492613505908.
https://doi.org/10.1177/1056492613505908... does not discard artifacts: devices that amplify human capacities, distributing cognition in educational modules that address actions in order to improve the activities of daily living, self-care, and food and money management. Other examples of artifacts are: computers, psychoeducational materials, exercise books in view of adaptation difficulties, and applied activities, all of them used to the group’s benefit. The existing obstacle is to document and evaluate this moment of adaptation and how to include individuals with relevant experiences and few years of formal education³³33 Durning SJ, Artino AR. Situativity theory: a perspective on how participants and the environment can interact: AMEE Guide no. 52. Med Teach. 2011; 33(3):188-99. doi: 10.3109/0142159X.2011.550965.
https://doi.org/10.3109/0142159X.2011.55... ^,3838 Helfrich CA, Fogg LF. Outcomes of a life skills intervention for homeless adults with mental illness. J Prim Prev. 2007; 28(3-4):313-26. doi: 10.1007/s10935-007-0103-y.
https://doi.org/10.1007/s10935-007-0103-... .

Face-to-face or online barriers are: passive receivers, who always need intermediaries; persistence in using exclusively the traditional pedagogy in cyberspace, even with ICTs; selecting the veteran member who will check the information; individualized communication; negative understanding of the disease; always the same people being present; and a sense of monotony. Thus, refining the topic for discussion and the debated practice is fundamental¹⁵15 Seibert S. The meaning of a healthcare community of practice. Nurs Forum. 2015; 50(2):69-74. doi: 10.1111/nuf.12065.
https://doi.org/10.1111/nuf.12065... ^,3030 Herrington J, Oliver R, Herrington A, Sparrow H. Towards a new tradition of online instruction: using situated learning to design web-based units [Internet]. In: ASCILITE 2000 Conference; 09 – 14 Dez 2000; Coffs Harbour [citado 30 Nov 2022]. Disponível em: https://researchportal.murdoch.edu.au/esploro/outputs/conferencePaper/Towards-a-new-tradition-of-online/991005540687807891
https://researchportal.murdoch.edu.au/es... ^,3434 Toledo PF, Ferreira IO. Horizontalidad discursiva en comunidades de práctica digitales. Círc Linguíst Apl Comun. 2009; 39:35-55.^,3535 Bindels J, Cox K, Widdershoven G, van Schayck CP, Abma TA. Stimulating program implementation via a Community of Practice: a responsive evaluation of care programs for frail older people in the Netherlands. Eval Program Plann. 2014; 46:115-21. doi: 10.1016/j.evalprogplan.2014.06.001.
https://doi.org/10.1016/j.evalprogplan.2... ^,3939 Lee YC, Wu WL. The effects of situated learning and health knowledge involvement on health communications. Reprod Health. 2014; 11:93. doi: 10.1186/1742-4755-11-93.
https://doi.org/10.1186/1742-4755-11-93... . Finally, for educational transfers to occur, professionals must ask themselves: How do users prioritize their participation in different practices? How do they reconcile different regimes of responsibility? What are the mechanisms of knowledge negotiation and obtention of legitimacy?¹⁹19 Omidvar O, Kislov R. The evolution of the communities of practice approach: toward knowledgeability in a landscape of practice - an interview with Etienne Wenger-Trayner. J Manag Inquiry. 2013; 23(3):266-75. doi: 10.1177/1056492613505908.
https://doi.org/10.1177/1056492613505908...

Implementations of healthcare communities of practice: situativity in communication, clinical assessment and rehabilitation

In the search for online medical information, websites and the social media have been pressed to have health professionals as consultants³⁹39 Lee YC, Wu WL. The effects of situated learning and health knowledge involvement on health communications. Reprod Health. 2014; 11:93. doi: 10.1186/1742-4755-11-93.
https://doi.org/10.1186/1742-4755-11-93... . These environments should not be abstract or decontextualized; they should have a responsive evaluation³⁵35 Bindels J, Cox K, Widdershoven G, van Schayck CP, Abma TA. Stimulating program implementation via a Community of Practice: a responsive evaluation of care programs for frail older people in the Netherlands. Eval Program Plann. 2014; 46:115-21. doi: 10.1016/j.evalprogplan.2014.06.001.
https://doi.org/10.1016/j.evalprogplan.2... . To increment them, the collaborative design of Anchored Instruction (audiovisual media, narrative structure and problem-solving) includes:

• Modeling - Construction of models to solve problems⁴⁰40 Pieter A, Fröhlich M, Emrich E, Stark R. Situated health promotion: reflections on implementing situated learning approaches in health promotion. J Prim Care Community Health. 2010; 1(2):93-9. doi: 10.1177/2150131910365161.
  https://doi.org/10.1177/2150131910365161... ;

• Coaching - A facilitator solves the initial steps of the problem⁴⁰40 Pieter A, Fröhlich M, Emrich E, Stark R. Situated health promotion: reflections on implementing situated learning approaches in health promotion. J Prim Care Community Health. 2010; 1(2):93-9. doi: 10.1177/2150131910365161.
  https://doi.org/10.1177/2150131910365161... ;

• Scaffolding - Cooperation for problem-solving, assigning responsibilities⁴⁰40 Pieter A, Fröhlich M, Emrich E, Stark R. Situated health promotion: reflections on implementing situated learning approaches in health promotion. J Prim Care Community Health. 2010; 1(2):93-9. doi: 10.1177/2150131910365161.
  https://doi.org/10.1177/2150131910365161... until a possible central participation is achieved;

• Fading - The facilitator gradually withdraws⁴⁰40 Pieter A, Fröhlich M, Emrich E, Stark R. Situated health promotion: reflections on implementing situated learning approaches in health promotion. J Prim Care Community Health. 2010; 1(2):93-9. doi: 10.1177/2150131910365161.
  https://doi.org/10.1177/2150131910365161... ;

• Articulation - Facilitators make targeted questions and knowledge is stated in answers and in the resolution of the problem⁴⁰40 Pieter A, Fröhlich M, Emrich E, Stark R. Situated health promotion: reflections on implementing situated learning approaches in health promotion. J Prim Care Community Health. 2010; 1(2):93-9. doi: 10.1177/2150131910365161.
  https://doi.org/10.1177/2150131910365161... ;

• Reflection - What was individually retained? What was the strategy to solve problems?⁴⁰40 Pieter A, Fröhlich M, Emrich E, Stark R. Situated health promotion: reflections on implementing situated learning approaches in health promotion. J Prim Care Community Health. 2010; 1(2):93-9. doi: 10.1177/2150131910365161.
  https://doi.org/10.1177/2150131910365161... ;

• Exploration - Students need to keep participating and interacting⁴⁰40 Pieter A, Fröhlich M, Emrich E, Stark R. Situated health promotion: reflections on implementing situated learning approaches in health promotion. J Prim Care Community Health. 2010; 1(2):93-9. doi: 10.1177/2150131910365161.
  https://doi.org/10.1177/2150131910365161... .

Debate-action groups with artifacts³³33 Durning SJ, Artino AR. Situativity theory: a perspective on how participants and the environment can interact: AMEE Guide no. 52. Med Teach. 2011; 33(3):188-99. doi: 10.3109/0142159X.2011.550965.
https://doi.org/10.3109/0142159X.2011.55... , blogs or platforms with texts about health problems using alerts of different severities are propositions³⁹39 Lee YC, Wu WL. The effects of situated learning and health knowledge involvement on health communications. Reprod Health. 2014; 11:93. doi: 10.1186/1742-4755-11-93.
https://doi.org/10.1186/1742-4755-11-93... . Sharing how life has been going through knowledge related to colostomy/ileostomy and prevention of complications provides the opportunity to share self-care diaries in instant messaging groups, allowing the program to adjust according to the diaries. There are specific times for video call responses. The team reminds patients of days and times of follow-up appointments, explains about rectal cancer treatment, and posts health tips, funny texts, and inspirational videos⁴¹41 Huang Q, Zhuang Y, Ye X, Li M, Liu Z, Li J, et al. The effect of online training-based continuous nursing care for rectal cancer-patients undergoing permanent colostomy. Am J Transl Res. 2021; 13(4):3084-92..

Face-to-face in the groups, the “icebreaker” moment uses colorful stickers for patients to write a question or a comment on what was said. Positive remarks³⁵35 Bindels J, Cox K, Widdershoven G, van Schayck CP, Abma TA. Stimulating program implementation via a Community of Practice: a responsive evaluation of care programs for frail older people in the Netherlands. Eval Program Plann. 2014; 46:115-21. doi: 10.1016/j.evalprogplan.2014.06.001.
https://doi.org/10.1016/j.evalprogplan.2... and directive dialog³⁴34 Toledo PF, Ferreira IO. Horizontalidad discursiva en comunidades de práctica digitales. Círc Linguíst Apl Comun. 2009; 39:35-55. are crucial. These rehabilitation strategies through bonds are extremely necessary, as lack of support leads to refusal to attend follow-up appointments. Thus, implementations enable to screen cases, learn about difficulties related to small practices, conceive and manage how contents will be taught, perform activities with assessments of effectivity, and provide presentations open to comments³⁰30 Herrington J, Oliver R, Herrington A, Sparrow H. Towards a new tradition of online instruction: using situated learning to design web-based units [Internet]. In: ASCILITE 2000 Conference; 09 – 14 Dez 2000; Coffs Harbour [citado 30 Nov 2022]. Disponível em: https://researchportal.murdoch.edu.au/esploro/outputs/conferencePaper/Towards-a-new-tradition-of-online/991005540687807891
https://researchportal.murdoch.edu.au/es... ^,3535 Bindels J, Cox K, Widdershoven G, van Schayck CP, Abma TA. Stimulating program implementation via a Community of Practice: a responsive evaluation of care programs for frail older people in the Netherlands. Eval Program Plann. 2014; 46:115-21. doi: 10.1016/j.evalprogplan.2014.06.001.
https://doi.org/10.1016/j.evalprogplan.2... ^,4242 Lopes APAT, Decesaro MN. The adjustments experienced by persons with an ostomy: an integrative review of the literature. Ostomy Wound Manage. 2014; 60(10):34-42. .

Wikis, forums and blogs (informal networks) for CoPs help through “one to many” and “many to many” communication, using a visible alert activated whenever someone has a problem and providing a set of informative links¹⁵15 Seibert S. The meaning of a healthcare community of practice. Nurs Forum. 2015; 50(2):69-74. doi: 10.1111/nuf.12065.
https://doi.org/10.1111/nuf.12065... ^,3434 Toledo PF, Ferreira IO. Horizontalidad discursiva en comunidades de práctica digitales. Círc Linguíst Apl Comun. 2009; 39:35-55.. Depending on this and on the inspirational design, some contexts increase or reduce capacities to reach new horizons¹⁴14 Lave J, Wenger E. Situated learning: legitimate peripheral participation. Cambridge: Cambridge University Press; 1991.^,4343 Rosenberg L, Nygård L. Learning and knowing technology as lived experience in people with Alzheimer’s disease: a phenomenological study. Aging Ment Health. 2017; 21(12):1272-9. doi: 10.1080/13607863.2016.1222347.
https://doi.org/10.1080/13607863.2016.12... .

Giving neuro-physiological and neuro-psychological orientations as short instructions has helped elderly individuals with hypotonic lower limbs, uncoordinated movements and reduced balance to solve problems like disorientation, physical and verbal aggressiveness, dysphagia and aphasia. In the physiotherapeutic context of traumatic brain injury, it has encouraged hygiene, bandages, coughing exercises, and tooth brushing, respecting personal limitations and fatigue, as these individuals will have different skills in the stage of adherence to routines, acquiring (or not) full participation. This rehabilitation/neuro-rehabilitation lists alterations, evaluating environmental stimuli, independence, and trajectory through interprofessional tests⁴⁴44 Aadal L, Kirkevold M. Integrating situated learning theory and neuropsychological research to facilitate patient participation and learning in traumatic brain injury rehabilitation patients. Brain Inj. 2011; 25(7-8):717-28. doi: 10.3109/02699052.2011.580314.
https://doi.org/10.3109/02699052.2011.58... ^,4545 Aadal L, Kirkevold M. A model for neurorehabilitation after severe traumatic brain injury: facilitating patient participation and learning. Adv Nurs Sci. 2011; 34(1):E1-E17. doi: 10.1097/ANS.0b013e318209b01a.
https://doi.org/10.1097/ANS.0b013e318209... .

Positive clinical implications, like people with dementia handling electronic artifacts independently, clearly reveal an environmental adaptation deriving from usual practices⁴⁶46 Jentoft R, Holthe T, Arntzen C. The use of assistive technology in the everyday lives of young people living with dementia and their caregivers. Can a simple remote control make a difference? Int Psychogeriatr. 2014; 26(12):2011-21. doi: 10.1017/S1041610214001069.
https://doi.org/10.1017/S104161021400106... or, in the case of a clinical domain for those who had a transient ischemic attack, content on opportune care. In this example, participation in Meet chats updates members on artifacts, like a website, and cases are discussed with veteran members, when questions are asked so that engagement becomes more tangible. Subsequently, a chat can provide a quick assessment of practices and symptoms in kickoffs (meeting with interested parties defining the elements of the case) and/or hubs (spaces to work with projects)⁴⁷47 Penney LS, Homoya BJ, Damush TM, Rattray NA, Miech EJ, Myers LJ, et al. Seeding structures for a community of practice focused on transient ischemic attack (tia): implementing across disciplines and waves. J Gen Intern Med. 2021; 36(2):313-21. doi: 10.1007/s11606-020-06135-z.
https://doi.org/10.1007/s11606-020-06135... .

Finally, we present some myths regarding implementations of CoPs: not all of them are informal; self-organization is rarely seen; they are not centered exclusively on acquisition of knowledge and problem-solving; they do not substitute work networks. It is assured that the domain will guarantee that they are obtaining something in return²²22 Wenger-Trayner E, Wenger-Trayner B. Comunidades de práctica una breve introducción [Internet]. Proyecto Educación y Nuevas Tecnologías - Área Educación. 2015 [citado 20 Mar 23]. Disponível em: http://www.pent.org.ar/institucional/publicaciones/comunidades-practica-una-breve-introduccion
http://www.pent.org.ar/institucional/pub... .

Possibilities for the social rehabilitation of ostomates with the subsidy of communities of practice and ethical communities

According to the literature, social rehabilitation has established a trajectory guided by Situated Learning depending on the reception of the Care Network, research initiatives, and material support. However, in Brazil, realistically speaking, the bond in Primary Care seems to be weak. This is due to the need of its professionals’ participation in qualification courses and to lack of research on lines of care that perform micro-social actions inducing such communities or situativity, in order to provide comprehensive oncological care and ostomy care⁴⁸48 Nascentes CC, Moreira MC, Oliveira NVD, Palasson RR, Ghelman LG, Souza MHN. Rede social no cuidado à pessoa estomizada por câncer colorretal. Rev Enferm UFPE. 2019; 13:e239569. doi: 10.5205/1981-8963.2019.239569.
https://doi.org/10.5205/1981-8963.2019.2... .

In this axis, we adopt, for healthcare communities, the concepts of ethical communities (those that seek long-term commitments) and esthetic communities (fleeting and spontaneous). A dilemma for CoPs is the establishment of common interests - a cause they defend. Without this, bonds do not last long (esthetic), causing occupation of increasingly restricted public spaces. Contestation and social learning directed towards a cause allow for a critical appropriation of reality and, perhaps, resolutions (ethics). In turn, demobilization - the predominant theme - does not allow for engagement in participatory culture¹⁸18 Bauman Z. Comunidade: a busca por segurança no mundo atual. Rio de Janeiro: Zahar; 2022.^,4949 Miwa M, Ventura C. O (des)engajamento social na modernidade líquida: sobre participação social em saúde. Saude Debate. 2020; 44(127):1246-54. doi: 10.1590/0103-1104202012722.
https://doi.org/10.1590/0103-11042020127... .

Decree no. 5296 of December 2, 2004, on accessibility for people with disabilities or reduced mobility, addresses accessibility as a right to citizenship and conceptualizes ostomy as a physical disability. Regarding communication with the significant others, chapter III of Article 8 approaches the overcoming of difficulties in accessing information²2 Brasil. Decreto-lei nº 5.296 de 2 de dezembro de 2004. Regulamenta as Leis nos 10.048, de 8 de novembro de 2000, que dá prioridade de atendimento às pessoas que especifica, e 10.098, de 19 de dezembro de 2000, que estabelece normas gerais e critérios básicos para a promoção da acessibilidade das pessoas portadoras de deficiência ou com mobilidade reduzida, e dá outras providências. Diário Oficial da União. 03 Dez 2004. Sec. 1, p. 5.. To solve the problem, practice settings based on the 4G network of Android mobile phones would focus on remote diagnostic impressions about complications, providing appropriate orientations. This would imply the upload of stoma images and instantaneous communication between patients and doctors. This information would be transmitted in the 4G diagnosis network in which the specialist physician logs in, downloads and unzip files like medical records and images in the mobile phone. A technical professional would be in charge of managing users’ information⁵⁰50 Xu X, Cao Y, Luan X. Application of 4G wireless network-based system for remote diagnosis and nursing of stomal complications. Int J Clin Exp Med. 2014; 7(11):4554-61..

As we explained here, the need of intervention programs is an obstacle. Appendix 1 of Directive 400/2009 addresses individual activities of the Care Services for Ostomates 1 and 2 and lists actions of nursing, medical, and social work appointments, as well as group activities³3 Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Portaria nº 400, de 16 de novembro de 2009 [Internet]. Brasília: Ministério da Saúde; 2009. Disponível em: https://bvsms.saude.gov.br/bvs/saudelegis/sas/2009/prt0400_16_11_2009.html.
https://bvsms.saude.gov.br/bvs/saudelegi... , which are related to Situated Learning Theory and operating groups²⁸28 Wenger E, McDermott R, Snyder WM. Cultivating communities of practice: a guide to managing knowledge. Boston: Harvard Business Review Press; 2002.. During rehabilitation, autonomy must start to be developed in the hospital and, more than this, in a self-management program if the underlying disease persists⁵5 Sasaki VDM, Teles AADS, Lima MS, Barbosa JCC, Lisboa BB, Sonobe HM. Reabilitação de pessoas com estomia intestinal: revisão integrativa. Rev Enferm UFPE. 2017; 11 Suppl 4:1745-54.. Coordinated instructions in Specialized Care would evaluate progress, quality of life and psychological status, reducing complications after discharge⁴¹41 Huang Q, Zhuang Y, Ye X, Li M, Liu Z, Li J, et al. The effect of online training-based continuous nursing care for rectal cancer-patients undergoing permanent colostomy. Am J Transl Res. 2021; 13(4):3084-92..

However, we draw a distinction here. Participatory culture requires commitments in order to persist in liquid and pernicious contexts like those of capitalism. Limitation of individual freedom in choices, actions and codes has eroded the notion of collectivity. Bearing in mind that Primary Care is the field of full social participation and the macro-social setting of mass individualization causes disintegration⁴⁹49 Miwa M, Ventura C. O (des)engajamento social na modernidade líquida: sobre participação social em saúde. Saude Debate. 2020; 44(127):1246-54. doi: 10.1590/0103-1104202012722.
https://doi.org/10.1590/0103-11042020127... , in evolving interactions and group reifications, learning care practices in micro-social settings would vivify social participation.

Wenger¹⁴14 Lave J, Wenger E. Situated learning: legitimate peripheral participation. Cambridge: Cambridge University Press; 1991.^,2828 Wenger E, McDermott R, Snyder WM. Cultivating communities of practice: a guide to managing knowledge. Boston: Harvard Business Review Press; 2002. defends mobilization in social organizations. Therefore, in a healthcare CoP, referring users to treat clinical problems, compare techniques and debate the challenges of the service is connected with a structure of mutual understanding³⁵35 Bindels J, Cox K, Widdershoven G, van Schayck CP, Abma TA. Stimulating program implementation via a Community of Practice: a responsive evaluation of care programs for frail older people in the Netherlands. Eval Program Plann. 2014; 46:115-21. doi: 10.1016/j.evalprogplan.2014.06.001.
https://doi.org/10.1016/j.evalprogplan.2... that deals with subjective demands in relation to themselves and to an informal and formal support network in rehabilitation/adaptation⁴²42 Lopes APAT, Decesaro MN. The adjustments experienced by persons with an ostomy: an integrative review of the literature. Ostomy Wound Manage. 2014; 60(10):34-42. ^,5151 Mota MS, Gomes GC, Petuco VM, Heck RM, Barros EJL, Gomes VLO. Facilitators of the transition process for the self-care of the person with stoma: subsidies for nursing. Rev Esc Enferm USP. 2015; 49(1):82-8. doi: 10.1590/S0080-623420150000100011.
https://doi.org/10.1590/S0080-6234201500... . To be successful, not only the health system but also family members⁵²52 Nam KH, Kim HY, Kim JH, Kang KN, Na SY, Han BH. Effects of social support and self‐efficacy on the psychosocial adjustment of Korean ostomy patients. Int Wound J. 2019; 16 suppl 1:13-20. doi: 10.1111/iwj.13038.
https://doi.org/10.1111/iwj.13038... must participate in the understanding of the normal peristomal pattern, in conversations about new concerns, and in the perception of body control⁴²42 Lopes APAT, Decesaro MN. The adjustments experienced by persons with an ostomy: an integrative review of the literature. Ostomy Wound Manage. 2014; 60(10):34-42. ^,5252 Nam KH, Kim HY, Kim JH, Kang KN, Na SY, Han BH. Effects of social support and self‐efficacy on the psychosocial adjustment of Korean ostomy patients. Int Wound J. 2019; 16 suppl 1:13-20. doi: 10.1111/iwj.13038.
https://doi.org/10.1111/iwj.13038... .

The Care Services for Ostomized People level II are considered the theoretical point of departure for the rehabilitation of people with a stoma in CoPs within the SUS, due to the completeness of their technical and care structure and to their specialized interdisciplinary nature. Such services are responsible for the permanent education of the healthcare network teams³3 Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Portaria nº 400, de 16 de novembro de 2009 [Internet]. Brasília: Ministério da Saúde; 2009. Disponível em: https://bvsms.saude.gov.br/bvs/saudelegis/sas/2009/prt0400_16_11_2009.html.
https://bvsms.saude.gov.br/bvs/saudelegi... . Care for Ostomized People I offers supported self-care, prevents complications, and provides equipment and adjuvants, while Care for Ostomized People II offers, in addition to everything that is performed in the Care Services for Ostomized People I, professional qualification. An online CoP would gather the social actors from services I and II and, perhaps, offer qualifications in its private spaces for professionals from the other levels of care, like Primary Care and hospital units that assist people with peristomal complications.

Concerning rehabilitation, Category 2 is responsible for: III) inclusion of people with a stoma in the family and in society; IV) planning of quantitative and qualitative acquisition and supply of pouching systems and adjuvants; V) permanent education in the network points for referral and counter-referral; and, finally, VI) qualification in specialized techniques for professionals from hospital units and health teams of the Service of Category 1, which would be facilitated in the CoP.

Decree no. 5296 of December 2, 2004, in its Article 8, addresses technical aid concerning “products, instruments, equipment or technology for the functional improvement of people with disabilities or reduced mobility, promoting personal autonomy, total or assisted”²2 Brasil. Decreto-lei nº 5.296 de 2 de dezembro de 2004. Regulamenta as Leis nos 10.048, de 8 de novembro de 2000, que dá prioridade de atendimento às pessoas que especifica, e 10.098, de 19 de dezembro de 2000, que estabelece normas gerais e critérios básicos para a promoção da acessibilidade das pessoas portadoras de deficiência ou com mobilidade reduzida, e dá outras providências. Diário Oficial da União. 03 Dez 2004. Sec. 1, p. 5.. It is worth thinking about the social control that would be performed if this information were in the private space of the online CoP, providing transparency for the service indicators²⁸28 Wenger E, McDermott R, Snyder WM. Cultivating communities of practice: a guide to managing knowledge. Boston: Harvard Business Review Press; 2002.. In the educational aspect, a systematization of the compensatory rehabilitation of altered or lost skills would be implemented. Short texts approaching conditions that limit or potentialize learning would be provided, as well as activities, content, materials, and spaces where they can report what has changed in their life⁴⁵45 Aadal L, Kirkevold M. A model for neurorehabilitation after severe traumatic brain injury: facilitating patient participation and learning. Adv Nurs Sci. 2011; 34(1):E1-E17. doi: 10.1097/ANS.0b013e318209b01a.
https://doi.org/10.1097/ANS.0b013e318209... and talk about anxieties or spirituality. Furthermore, information on receipt of pouching systems and adjuvants free of charge from the SUS⁵¹51 Mota MS, Gomes GC, Petuco VM, Heck RM, Barros EJL, Gomes VLO. Facilitators of the transition process for the self-care of the person with stoma: subsidies for nursing. Rev Esc Enferm USP. 2015; 49(1):82-8. doi: 10.1590/S0080-623420150000100011.
https://doi.org/10.1590/S0080-6234201500... would be supplied. All of this is tacit and professional knowledge that generates indwelling³²32 Pyrko I, Dörfler V, Eden C. Thinking together: what makes communities of practice work? Hum Relat. 2017; 70(4):389-409. doi: 10.1177/0018726716661040.
https://doi.org/10.1177/0018726716661040... .

In addition, communication via blogs, web 2.0, videologs, wikis, forums, podcasts, and other feedback channels³⁴34 Toledo PF, Ferreira IO. Horizontalidad discursiva en comunidades de práctica digitales. Círc Linguíst Apl Comun. 2009; 39:35-55. shows that CoPs do not have only esthetic-technological commitments, but are also connected with the potential for struggle, social contestation⁴⁹49 Miwa M, Ventura C. O (des)engajamento social na modernidade líquida: sobre participação social em saúde. Saude Debate. 2020; 44(127):1246-54. doi: 10.1590/0103-1104202012722.
https://doi.org/10.1590/0103-11042020127... , and situativity.

The limitations of the evidences described here were: the articles were international, with care network arrangements and professional interventions that are different from the Brazilian arrangement (in Brazil, Primary Care is the front door and the matrix support); non-utilization of the descriptor “ostomy” due to the previous recognition of lack of studies; non-inclusion of studies indexed in Latin American databases; and limited access to ICTs by people with a stoma in the case of online CoPs.

On the other hand, the strong point of this study is the possibility, still unexplored, of transferring evidences from online and face-to-face CoPs to the Program of Care for Ostomates. Figure 1 reports family members-caregivers as one of the driving forces, together with the “champions of practice”, and suppliers of artifacts or knowledge as senior components²⁸28 Wenger E, McDermott R, Snyder WM. Cultivating communities of practice: a guide to managing knowledge. Boston: Harvard Business Review Press; 2002..

Final remarks

It is possible to conclude that health services and professionals would benefit from the longitudinal interprofessional design that prioritizes the experience of veterans, the trajectory of newcomers, and the facilitation of specialists. Situated Learning Theory is one of the solutions for transfer of knowledge in health education concerning rehabilitation, as it engenders a social infrastructure for the expansion of capacities. This theoretical proposal, which synthesizes studies of different natures and from different countries in the area of social rehabilitation, advocates community arrangement and social participation, proposing that services I and II of the Healthcare Program for Ostomates in the scope of SUS should not be limited to fragmented appointments and product dispensing.

Social rehabilitation and the possible establishment of self-care are a chain of meanings connected with occupation of identities, reifications, and expectations. Therefore, “the walking path” from periphery to full participation says a lot about the identity of the person in recovery, transition, adaptation, and adjustment. Face-to-face and online situated approaches would only reverberate by means of a community-based, citizen participation in the SUS, bearing in mind the cohesion difficulties of Support Groups, professionals, managers, and Local Health Councils. In addition, we conclude that the fluidity of relationships and of the globalized political space produces fruitful interactions, but it is a context that will need to be confronted by apparatuses that produce life and subjectivities.

References

Publication Dates

History