ABSTRACT

This qualitative integrated single-case study analyzed the role of nursing professionals in implementing the National Policy for the Integral Health of the Black Population in quilombola communities, based on the Feminist Ethics approach. Data collection took place between February and June 2018 by means of interviews conducted with nurses from the Family Health Strategy working in quilombola communities in the Metropolitan Region of Belo Horizonte, Minas Gerais, Brazil. The data underwent Content Analysis, via ATLAS.ti software, version 8. Results show that nursing professionals contributed to implementing the PNSIPN, acting on the following categories: “bonding”, “community nurse” and “acknowledgment of community specificities”. Such aspects are important to implement the National Policy for the Integral Health of the Black Population in the community.

Keywords:
Nursing; Feminist Ethics; Family Health Strategy, African Continental Ancestry Group; Minority Group; Public Nondiscrimination Policies

Introduction

The practice of nurses in the Family Health Strategy (ESF) is consolidated in a dialogical and interactional way between teams and users. It is connected to a reflective practice that can acknowledge individuals, families and collectivities and transform social reality (Corrêa; Acioli; Tinoco, 2018CORRÊA, V. A. F.; ACIOLI, S.; TINOCO, T. F. O cuidado do enfermeiro na Estratégia Saúde da Família: práticas e fundamentação teórica. Revista Brasileira de Enfermagem, Brasília, DF, v. 71, n. 6, p. 2767-2774, 2018. DOI: 10.1590/0034-7167-2018-0383
https://doi.org/10.1590/0034-7167-2018-0... ). The concept of practice used in this study is based on the epistemological perspective of feminist ethics, the object of which are the relations created in the intersection of minority groups (Walker, 2007WALKER, M. U. Moral understandings: a feminist study in ethics. Oxford: Oxford University Press, 2007.).

The practice, from the perspective of feminist ethics, takes place in a collaborative manner among the subjects involved. It is based on the shared and negotiated construction of responsibilities and the acknowledgment of inequalities and cultural diversity. Its foundations are the ethical behaviors arising from the subjects’ experiences encompassing normative, theoretical, political, empirical, ethical and moral knowledge (Walker, 2007WALKER, M. U. Moral understandings: a feminist study in ethics. Oxford: Oxford University Press, 2007.). Therefore, considering this concept of practice applied to the practice of ESF nursing implies the assumption that care is centered on the relationships between subjects and, as a result, that it can transform their ways of life (Ferraccioli; Acioli, 2017FERRACCIOLI, P.; ACIOLI, S. As diferentes dimensões do cuidado na prática realizada por enfermeiros no âmbito da atenção básica. Revista de Pesquisa: Cuidado é fundamental online, Rio de Janeiro, v. 9, n. 1, p. 28-36, 2017. DOI: 10.9789/2175-5361.2017.v9i1.28-36
https://doi.org/10.9789/2175-5361.2017.v... ).

For the practice of ESF nurses to conform to this adopted construct, nurses must be brought closer to the society and culture of the assigned population, and they must develop the ability to listen carefully and when patients check in, so that the patients feel confident and safe to expose their doubts, fears and anxieties (Corrêa; Acioli; Tinoco, 2018CORRÊA, V. A. F.; ACIOLI, S.; TINOCO, T. F. O cuidado do enfermeiro na Estratégia Saúde da Família: práticas e fundamentação teórica. Revista Brasileira de Enfermagem, Brasília, DF, v. 71, n. 6, p. 2767-2774, 2018. DOI: 10.1590/0034-7167-2018-0383
https://doi.org/10.1590/0034-7167-2018-0... ). In this relationship, practice based on collaboration and cooperation will find the space to materialize.

When entering the universe of historical and cultural specificities of the Brazilian territory, we are faced with health inequities and cultural diversity which, among other aspects, are important challenges for the consolidation of nursing practice. In this perspective, the specificities of quilombola communities stand out, as they are made up mostly of groups descended from the African continent who organize themselves collectively in demarcated territories (Brasil, 2017BRASIL. Ministério da Saúde. Política Nacional de Saúde Integral da População Negra: uma política do SUS. 3. ed. Brasília, DF: 2017. Disponível em: <Disponível em: https://bit.ly/2Vo0SVF >. Acesso em: 20 out. 2020.
https://bit.ly/2Vo0SVF... ).

The work of nurses in overcoming the ethnic-racial inequities experienced by quilombola communities must be supported by the National Policy for the Integral Health of the Black Population (PNSIPN). Launched in 2009, the PNSIPN provides for the elaboration and implementation of non-discrimination mechanisms and strategies (Brazil, 2017BRASIL. Ministério da Saúde. Política Nacional de Saúde Integral da População Negra: uma política do SUS. 3. ed. Brasília, DF: 2017. Disponível em: <Disponível em: https://bit.ly/2Vo0SVF >. Acesso em: 20 out. 2020.
https://bit.ly/2Vo0SVF... ). However, a study shows that there are weaknesses in the implementation of PNSIPN due to a lack of awareness - on the part of healthcare workers and the community - of its existence (Franchi et al., 2018FRANCHI, E. P. L. P. et al. A formação de profissionais de saúde no cuidado às comunidades quilombolas: um relato de experiência. Revista Brasileira de Medicina de Família e Comunidade, Rio de Janeiro, v. 13, n. 40, p. 1-11, 2018. DOI: 10.5712/rbmfc13(40)1620
https://doi.org/10.5712/rbmfc13(40)1620... ) and to practices inconsistent with the plan’s guidelines (Brasil, 2017BRASIL. Ministério da Saúde. Política Nacional de Saúde Integral da População Negra: uma política do SUS. 3. ed. Brasília, DF: 2017. Disponível em: <Disponível em: https://bit.ly/2Vo0SVF >. Acesso em: 20 out. 2020.
https://bit.ly/2Vo0SVF... ).

For the purposes of this study, it is assumed that the practice of ESF nurses can minimize these weaknesses when it acknowledges the cultural and historical diversity that makes up society.

Given what was described above, the guiding question of the study was: how does nursing practice contribute to the implementation of public health policies for the black population? The objective of this study was to analyze the contributions of nursing practice to the implementation of the National Policy for the Integral Health of the Black Population in quilombola communities, through the perspective of feminist ethics.

Method

This is a qualitative, single integrated case study. This approach allows the understanding of subjective and complex aspects of daily experiences based on empirical findings, with an interpretive perspective of the worldview and its manifestation (Minayo, 2017MINAYO, M. C. S. Cientificidade, generalização e divulgação de estudos qualitativos. Ciência & Saúde Coletiva, Rio de Janeiro, v. 22, n. 1, p. 16-17, 2017. DOI: 10.1590/1413-81232017221.30302016
https://doi.org/10.1590/1413-81232017221... ; Yin, 2017YIN, R. K. Case study research and applications: design and methods. Thousand Oaks: Sage publications, 2017.).

The case study used is the practice of ESF nurses in the context of quilombola communities. The quilombola communities represented each integrated subunit of analysis, which allows the triangulation of information and the deepening and understanding of different realities on the same object. The theory of feminist ethics, by Margaret Urban Walker, was used as an analytical perspective of the case in question. This theoretical proposition presents key questions capable of analyzing complex and contemporary empirical results, which provide the basis for an analytical generalization by allowing theoretical breakthroughs (Yin, 2017YIN, R. K. Case study research and applications: design and methods. Thousand Oaks: Sage publications, 2017.). The study was designed by following the checklist for qualitative studies based on RATS guidelines (Clark, 2003CLARK, J. P. How to peer review a qualitative manuscript. In: JEFFERSON, T.; GODLEE, F. (Org.). Peer Review in Health Sciences. 2. ed. London: BJM Books, 2003, p. 219-235. Disponível em: <Disponível em: https://bit.ly/3k1wo5Z >. Acesso em: 11 maio 2021.
https://bit.ly/3k1wo5Z... ).

The study setting consisted of seven ESF assigned to quilombola communities certified by Fundação Cultural Palmares (FCP) (Brasil, 2018BRASIL. Ministério da Cultura. Fundação Cultural Palmares. Certidões expedidas às comunidades remanescentes de quilombos (CRQs) atualizada até a Portaria nº. 88/2019, publicada no D. O. U. de 13/05/2019. Brasília, DF, 2018. Disponível em: <Disponível em: https://bit.ly/2VbXqNB >. Acesso em: 20 out. 2020.
https://bit.ly/2VbXqNB... ), located in the Belo Horizonte Metropolitan Area (RMBH), Minas Gerais, Brazil. The participants in this study were seven nurses from the ESF team working in the quilombola communities in the RMBH. The criterion for inclusion of participants was having worked in ESF for at least six months.

Data collection happened from February to June 2018 through an individual interview guided by a semi-structured script. The interview was conducted by an outside researcher with no ties to the service. The questions addressed knowledge about the community, public policies aimed at serving the black population, actions developed in the ESF and the challenges and comforts of daily life. To conduct the interviews, the nurses were contacted by telephone and, once they had accepted to participate in the study, the day, time and place of their choosing was scheduled. The interviews, 30 minutes long on average, were recorded and transcribed. At the interview, the objectives, risks and benefits of the research were explained, and all the participants read and signed the Informed Consent Form (ICF).

The empirical data collected from the nurses’ testimonies underwent content analysis following the three chronological poles, namely: pre-analysis; exploration of the material and treatment of the results; inference and interpretation (Bardin, 2011BARDIN L. Análise de conteúdo. Lisboa: Edições 70, 2011.). This analysis was initially performed by subunits and then the information was triangulated in order to promote integration between the case in question. The analysis was supported by the Atlas.ti ® version 8 software, with which the codes were grouped into the following theme categories “bonding”, “community nurse” and “acknowledgment of community specificities”. The operational tool Atlas.ti ® Software provided agility and security for treating and organizing data, allowing indexing, search and theorization (Brito et al., 2017BRITO, M. J. M. et al. Potentialities of Atlas.ti for data analysis in qualitative research in nursing. In: COSTA, A. P. et al. Computer supported qualitative research. Cham: Springer, 2017. p. 75-84. DOI: 10.1007/978-3-319-43271-7_7
https://doi.org/10.1007/978-3-319-43271-... ).

The study complied with the formal requirements of Resolution N. 466/12 by National Health Council. It was approved by the Research Ethics Committee of Universidade Federal de Minas Gerais and authorized by the Health Departments of the respective towns. The participants had all of their rights preserved and their freedom to participate, or refuse to, guaranteed, as well as their right to withdraw their consent in the course of the study by free express informed manifestation. To ensure anonymity, the interviews were given the designation “ENF” and assigned a random number from 1 to 7.

Result

The results showed contributions of nursing practice to the implementation of the PNSIPN. They are presented under the following categories: bonding; community nurse and acknowledgment of community specificities. The categories will be presented in a continuous and connected way since nursing practice is configured as transversal and relational, based on the assumptions of feminist ethics. Regarding bonding, the study found the need to strengthen the relationship with the community in order to find ways of implementing the PNSIPN. The category community nurse permeates the relationships built and the nurses’ appreciation of the culture. Finally, the category “acknowledgement of community specificities” highlights the need for nurses to be closer to the community to strengthen healthcare as a potential way of transforming living conditions and raising political and civil awareness among the population for their social rights.

The ties with the population are pointed out by ENF6 as an important strategy for proposing actions consistent with the principles of the ESF and the PNSIPN, expanding user access and helping users to reflect on their health and eventual illness.

One of the ways of creating and strengthening the bonds is the community nurse, when he acknowledges and appreciates the culture and ways of life of the population assigned to the ESF. About that, ENF7 reports that the health team promotes themed events at the clinic to approach the social inequities experienced by the quilombola community.

These events, held by the nurses of the ESF, are spaces for propagation of the culture and other specificities of that population. The effective engagement of the nurse in close proximity to the community shows their commitment and responsibility with minority groups and the shared construction of actions among them, promoting the discussion of racism and the health of the black population, minimizing ethnic-racial inequities, as advocated by the PNSIPN.

The relationship between nurses and the community stands out in the statements by ENF5 and ENF7, who point out that the relationship produced by the encounter between them promotes the reception and, as a result, the response to needs.

The nurse’s acknowledgement of the community creates an understanding of the experienced reality and leads their ethical and moral behavior when dealing with the fragile aspects of minority groups.

Nursing practice was highlighted by ENF3 and ENF6, with emphasis on its potential to transform the quilombola community. For the participants, the changes in the behavior and ways of life of the population regarding their health concerns are related to the relationship of trust established with the nurse working in the community.

The conformation of nursing practice centered on the individual and the collective allows him to promote the transformation of the lifestyles of these communities, because he can visualize the needs of the others and search for effective answers.

It should be stressed that the needs of the community are not restricted to health issues. Therefore, nursing should be based on the acknowledgement of the specificities of the community so that the political and civil awareness of the population can be developed, as mentioned by ENF2. He points out that the nurse is regarded as an important reference for guidance on issues related to the population’s rights and how they can access them, transcending the scope of healthcare.

The results showed the responsibility and potential of the nurse’s practice as a political action with the power to transform the social reality of the quilombola community with important contributions toward implementing the PNSIPN.

Discussion

In the context of public policies in Brazil, the PNSIPN inserts actions aimed at promoting the health of the black population, focusing on their specificities and vulnerabilities. With its transversal character in fighting ethnic and racial discrimination across the public health services delivered by the SUS, the PNSIPN seeks to address the health needs of the black population and to ensure full care by expanding the access of this population group to quality health services (Brazil, 2017BRASIL. Ministério da Saúde. Política Nacional de Saúde Integral da População Negra: uma política do SUS. 3. ed. Brasília, DF: 2017. Disponível em: <Disponível em: https://bit.ly/2Vo0SVF >. Acesso em: 20 out. 2020.
https://bit.ly/2Vo0SVF... ).

The implementation of PNSIPN is essential, not only to fight discrimination in SUS services, but also to ensure that the rights of the black population have effective reach, considering the historical struggles of that population for respect for their civil rights and needs (Gomes et al., 2017GOMES, I. C. R. et al. Implementação da política nacional de atenção integral à saúde da população negra na Bahia. Revista Baiana de Enfermagem, Salvador, v. 31, n. 2, 2017. Disponível em: <Disponível em: https://bit.ly/3hqX6U1 >. Acesso em: 20 out. 2020.
https://bit.ly/3hqX6U1... ). From the perspective of feminist ethics, fighting inequities is intrinsically related to criticism and social change that can be promoted by subjects (Walker, 2007WALKER, M. U. Moral understandings: a feminist study in ethics. Oxford: Oxford University Press, 2007.). About that, the results of this study showed that the nurse acknowledges the needs of the population and takes co-responsibility for actions that guarantee the rights of the black population.

Considering that implementing the PNSIPN requires the social commitment of nurses, it is crucial that that they bond with the population in order to really effect the care actions recommended by the PNSIPN, with emphasis on promotion of healthcare, which stands out as a structuring axis for their ties with the community. In this perspective, there is a possibility to build the practice under the auspices of feminist ethics, with emphasis on cooperation and negotiation, in an intense process of (re)cognitions to effect the sharing of knowledge and responsibilities among social actors in a given context (Walker, 2007WALKER, M. U. Moral understandings: a feminist study in ethics. Oxford: Oxford University Press, 2007.). The results showed that the relationship created with the population can improve their adherence to the propositions of care, which are built and rebuilt in collaboration on a daily basis.

The nurse’s practice must, therefore, be guided by patient/family/community-centered care and based on principles of humanization such as active listening, which allows an encounter with the nurse (Oliveira et al., 2018OLIVEIRA, M. J. S. et al. A escuta ativa como estratégia de humanização da assistência em saúde. Saúde e Desenvolvimento Humano, Canoas, v. 6, n. 2, p. 33-38, 2018. DOI: http://dx.doi.org/10.18316/sdh.v6i2.4732
http://dx.doi.org/10.18316/sdh.v6i2.4732... ). This study found that this encounter strengthens the bond, promoting reception and developing the moral responsibility of the nurse, in tune with the real needs of the community.

The moral responsibility of the nurse occurs when they can grasp the social and moral context of a group and can understand their values and ways of living, thereby producing responsibilities for what they apprehend (Walker, 2007WALKER, M. U. Moral understandings: a feminist study in ethics. Oxford: Oxford University Press, 2007.). In this sense, the nurse’s practice demands reflections on the complexity of social and health issues, considering the diversity of society in present times (Schveitzer; Zoboli; Vieira, 2016SCHVEITZER, M. C.; ZOBOLI, E. L. C. P.; VIEIRA, M. M. S. Nursing challenges for universal health coverage: a systematic review. Revista Latino-Americana de Enfermagem, Ribeirão Preto, v. 24, 2016. DOI: 10.1590/1518-8345.0933.2676
https://doi.org/10.1590/1518-8345.0933.2... ). Also, nurses need to bring back their condition as subjects/citizens to develop their potential to transform the reality of quilombola communities. In this way, they must share their practice with the community to make it a protagonist of their own health, and the relationship built between them produces reception.

Reception, in this sense, was noticed in the results of the study as a way of expanding access and appreciating the population. It is a way of improving the relationship between healthcare workers and users that transcends the mere system of work organization, providing autonomy for subjects through dialogue and qualified listening (Schveitzer; Zoboli; Vieira, 2016SCHVEITZER, M. C.; ZOBOLI, E. L. C. P.; VIEIRA, M. M. S. Nursing challenges for universal health coverage: a systematic review. Revista Latino-Americana de Enfermagem, Ribeirão Preto, v. 24, 2016. DOI: 10.1590/1518-8345.0933.2676
https://doi.org/10.1590/1518-8345.0933.2... ). From the perspective of feminist ethics, the practice is guided by morality, which entails acknowledging the subjects of minority groups in their social context, promoting autonomy and moral responsibility through their social experience (Walker, 2007WALKER, M. U. Moral understandings: a feminist study in ethics. Oxford: Oxford University Press, 2007.). This social context is permeated by injustices that deprive society of humanity, making it challenge for healthcare workers to effect practices relevant to various social groups (Walker, 2007WALKER, M. U. Moral understandings: a feminist study in ethics. Oxford: Oxford University Press, 2007.).

The injustices generate situations of vulnerability experienced by this population group, such as oppression, curtailment of their rights, and structural racism. It is important that nurses incorporate reception into their practice the as an active listening device, a strategy to access the healthcare needs which extrapolate the demands expressed by the users (Melo; Cecílio; Andreazza, 2017MELO, S. M.; CECÍLIO, L. C. O; ANDREAZZA, R. Nem sempre sim, nem sempre não: os encontros entre trabalhadores e usuários em uma unidade de saúde. Saúde em Debate, Rio de Janeiro, v. 41, n. 112, p. 195-207, 2017. DOI: 10.1590/0103-1104201711216
https://doi.org/10.1590/0103-11042017112... ; Ayres; Castellanos; Baptista, 2018AYRES, J. R.; CASTELLANOS, M. E. P; BAPTISTA, T. W. F. Interview with José Ricardo Ayres. Saúde e Sociedade, São Paulo, v. 27, n. 1, p. 51-60, 2018. DOI: 10.1590/S0104-12902018000002
https://doi.org/10.1590/S0104-1290201800... ). In feminist ethics, acknowledging the condition of vulnerability and inequity of a specific population and their cultural diversity and specificities of the social context are crucial aspects for overcoming exclusionary practices (Walker, 2007WALKER, M. U. Moral understandings: a feminist study in ethics. Oxford: Oxford University Press, 2007.).

The results highlighted the importance of the recognition by nurses that the shortcomings and challenges of quilombola communities are potential devices for overcoming them. Nurses are, therefore, expected to carry out ongoing actions to bring about their own transformation and that of the social reality (Corrêa; Acioli; Tinoco, 2018CORRÊA, V. A. F.; ACIOLI, S.; TINOCO, T. F. O cuidado do enfermeiro na Estratégia Saúde da Família: práticas e fundamentação teórica. Revista Brasileira de Enfermagem, Brasília, DF, v. 71, n. 6, p. 2767-2774, 2018. DOI: 10.1590/0034-7167-2018-0383
https://doi.org/10.1590/0034-7167-2018-0... ; Ferreira; Périco; Dias, 2018FERREIRA, S. R. S.; PÉRICO, L. A. D.; DIAS, V. R. F. G. The complexity of the work of nurses in Primary Health Care. Revista Brasileira de Enfermagem, Brasília, DF, v. 71, p. 704-709, 2018. DOI: 10.1590/0034-7167-2017-0471
https://doi.org/10.1590/0034-7167-2017-0... ). As an example of innovative and reality-transforming actions, participants reported that themed events were held at health clinics focusing on the quilombola community. Holding events and cultural spaces like these is consistent with the objectives of the PNSIPN, given the need for commitment in fighting the socioeconomic, cultural and ethnic-racial inequities that affect the Brazilian black population (Brazil, 2017BRASIL. Ministério da Saúde. Política Nacional de Saúde Integral da População Negra: uma política do SUS. 3. ed. Brasília, DF: 2017. Disponível em: <Disponível em: https://bit.ly/2Vo0SVF >. Acesso em: 20 out. 2020.
https://bit.ly/2Vo0SVF... ). The importance of practices that extrapolate pragmatic actions defined vertically and give broader responses to the real demands of the population are particularly important (Corrêa; Acioli; Tinoco, 2018CORRÊA, V. A. F.; ACIOLI, S.; TINOCO, T. F. O cuidado do enfermeiro na Estratégia Saúde da Família: práticas e fundamentação teórica. Revista Brasileira de Enfermagem, Brasília, DF, v. 71, n. 6, p. 2767-2774, 2018. DOI: 10.1590/0034-7167-2018-0383
https://doi.org/10.1590/0034-7167-2018-0... ).

This study contributes to the appreciation of nursing in the field of science by allowing a reflection on the contributions of nursing practice to minority groups regarding the acknowledgement of their singularities and social commitment, especially to quilombola communities. Moreover, the contribution is made by instigating nurses about the importance of breaking barriers to promote equity, in addition to paying attention to a socio-political stance that implies the implementation of essential policies for the population, giving the profession visibility in the eyes of society.

It can be inferred that the practice of nurses is a means of implementing policies such as the PNSIPN, in the sense that it brings elements that transcend the biomedical model and expands the notion of care to issues involving the inequities experienced by this population. It is, therefore, the political stance taken by nurses, which implies the ability to articulate the different kinds of knowledge and responsibilities and use one’s own judgment to respond to the needs of the society, thereby helping to strengthen the profession (Melo; Cecílio; Andreazza, 2017MELO, S. M.; CECÍLIO, L. C. O; ANDREAZZA, R. Nem sempre sim, nem sempre não: os encontros entre trabalhadores e usuários em uma unidade de saúde. Saúde em Debate, Rio de Janeiro, v. 41, n. 112, p. 195-207, 2017. DOI: 10.1590/0103-1104201711216
https://doi.org/10.1590/0103-11042017112... ).

The limitations of the study are based on the geographical limit and the use to bibliographical reference limited to feminist ethics. The geographical limit chosen was Belo Horizonte the Metropolitan Area. We suggest that further studies be carried out in other areas. As a recommendation, it would be interesting to conduct an ethnographic study to better understand the specificities of the community and the development of nursing practice in the ESF. Regarding the theoretical limitation, the concept of practice in the theory of feminist ethics requires caution of researchers when adopting this construct for data analysis, since it is a specific practice carried out within the context of minority groups, which requires collaboration and mutual responsibility between the subjects, and not just a series of activities to be performed.

Final considerations

This study showed that by putting into effect a collaborative practice and mutual responsibility, nurses contribute to the implementation of the National Policy for the Integral Health of the Black Population. We stress that the methodological design was adequate and helped understand the objective.

The theoretical assumption of feminist ethics used was adequate and showed the importance of delivering nursing practice for minority groups according to the precepts of feminist ethics. Such precepts indicate that the practice is based on moral responsibility, shared and negotiated among the subjects, who should acknowledge the inequities and cultural diversity existing in minority groups.

The results showed that the practice founded on the interrelationship with the community to create ties, acknowledge and appreciate the culture and history, enable political and civil awareness, and provide reception for the PNSIPN to be effectively implemented. In addition, these results provide subsidies to assist in the design of new policies by discussing aspects of micropolitics that need to be taken into account to that end.

The implementation and effecting of PNSIPN is designed to respond to the nuances of daily life by engaging nurses in understanding the social and historical context of the inequalities rooted in quilombola communities in the search to promote and materialize an equitable health practice.

References

Publication Dates

History