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Enfermería: Cuidados Humanizados

versão impressa ISSN 1688-8375versão On-line ISSN 2393-6606

Enfermería (Montevideo) vol.8 no.1 Montevideo jun. 2019 

Artículos originales

Nursing professional practice in reproductive health: an ethnographic approach

Frediminda Vargas Cárdenas1

Flor A. Sanmiguel2 

1Hospital Central tipo III Dr. Plácido Daniel Rodríguez Rivero. Valencia, Venezuela.

2Unidad de Investigación de Salud Reproductiva. Valencia, Venezuela. Universidad de Carabobo. Venezuela


The objective of the study was to discover the meanings of cultural nursing care for a group of nurses of the Maternal and Child Clinical Unit of a public hospital of Venezuela. Its methodological proposal is of a qualitative nature under the phenomenological approach. Focused ethnography and the ethnoendermal method proposed by Leininger were chosen, using the ethnographic analysis of Spradley for the processing of the data. The participants were six nurses who work in the maternal clinical unit of Dr. Placido Daniel Rodríguez Central Hospital in San Felipe, Venezuela. The expressions and experiences provided by them allowed to describe the study object through in-depth interviews. Based on the analysis of the data, two domains emerged from this process: "The Practice of Cultural Nursing is the Way of Making Care an Art”, as well as, "Knowing the Culture is the Way to Provide Congruent Human Care”. These preliminary contributions reveal nursing actions that help to promote the concept, as well as tools that allow nurses to apply culturally appropriate care to pregnant and puerperal women and newborns in this context. It is concluded that the nurse, in the provision of care process, combines her knowledge with the art of caring, respecting the beliefs and values ​of the the users admitted to this public hospital

Keywords: Nursing Care; Reproductive Health. Human Care; Ethnography


El objetivo del estudio fue descubrir los significados del cuidado de enfermería cultural de un grupo de enfermeras de la Unidad Clínica Materno Infantil de un hospital público de Venezuela. La propuesta metodológica es de naturaleza cualitativa bajo el enfoque fenomenológico. Se escogió la etnografía focalizada, y el método de etnoenfermería propuesto por Leininger, utilizando el análisis etnográfico de Spradley para el procesamiento de los datos. Las participantes fueron seis enfermeras que laboran en la unidad clínica materna en Venezuela. Las expresiones y experiencias suministradas por las profesionales de enfermería permitieron que surgieran esencias que describieron el fenómeno de estudio a través de las entrevistas a profundidad. Con base en el análisis de los datos, emergieron de este proceso dos dominios: “la Práctica de Enfermería Cultural, es el Modo de Hacer Arte del Cuidado”, así como también, “Conociendo la Cultura, es el Modo de brindar Cuidados Humano Congruente”. Estos aportes preliminares encontrados develan acciones de enfermería que ayudan a promover, así como también herramientas que les permiten a las enfermeras aplicar cuidados culturalmente adecuados a las embarazadas, puérperas y recién nacidos en este contexto. Se concluye que la enfermera en la prestación del cuidado engloba los conocimientos con el arte de cuidar, respetando sus creencias y valores a las usuarias ingresadas en el hospital público en Salud reproductiva

Palabras clave: Atención de Enfermería; Salud Reproductiva. Cuidado Humano; Etnografía


O objectivo do estudo era descobrir os significados da cultura de cuidados de enfermagem de um grupo de enfermeiras na clínica Maternal and Child Unidade de uma abordagem metodológica Hospital Público Venezuela.Cuya é qualitativa sob a abordagem fenomenológica. A etnografia focalizada e o método etnoendérmico proposto por Leininger foi escolhido. Usando a análise etnográfica de Spradley para o processamento dos dados. Os participantes eram 06 enfermeiros que trabalham em unidade clínica humana do Hospital Central Dr. Plácido Daniel Rodriguez de San Felipe, Venezuela. Expressões e experiências proporcionadas pelos enfermeiros autorizados a surgir estudo essências descrito o fenômeno por meio de entrevistas em profundidade, com base na análise de domínios de dados surgiu desse processo: '' Practice La Cultural Enfermagem é o caminho para tornar os cuidados de arte, bem como, '' Conociendo Cultura é a forma de prestação de cuidados Congruent Humano. Estas contribuições preliminares encontrados desvendar ações de enfermagem que ajudam a promover, bem como ferramentas que lhes permitam aplicar enfermeiros culturalmente competentes para grávidas, pós-parto e ao recém-nascido neste contexto. Conclui-se que a enfermeira na prestação de cuidados abrange o conhecimento com a arte de cuidar, respeitando suas crenças e valores para os usuários internados no hospital público de Saúde Reprodutiva

Palavras chave: Cuidados de Enfermagem; Saúde Reprodutiva; Cuidado Humano; Etnografia


We live in a society impregnated with a versatile character, where the existing complex cultural relationship requires considering the perspective of the nursing professional, of humanized care, allowing the discovery of the cultural aspects of the people, their practices and values. When nursing care is considered, we can reach our patients using the nursing practice as a therapeutic activity only, but when these activities are directed to pregnant women they must also be educational, that is, they must be taught to take care of themselves and the newborn while in the institution and also at home.

The care was always based on the need to preserve the health and to give continuity to life. During many years the care given was not of the best quality; persons helped other persons just to ensure that his/her life would go on1. Later the practice of nursing professionals in the mother-child units was improved in order to contribute not only with disciplinary knowledge but also seeking to find foundations from the needs and expectations of the users, with a view to achieving a warm and welcoming human care both for the mother and the newborn.

For the woman and her family, pregnancy constitutes an experience of life and one of the most important events in life, during which they develop behaviors and perform care practices for themselves and the unborn child in order to continue living, to maintain their health, to treat their diseases and to preserve their well being2. The behaviors and care that women receive in the prenatal stage depend on the social structure and the ethnohistorical and environmental context, that is, on the culture in which they grow and live. Leininger argued that culture was the broadest, most comprehensive, holistic and universal aspect of human beings and predicted that care was imbedded in culture. Both had to be understood to discover the needs of patient care from a cross-cultural perspective3.

This study shows the need for interaction between the nursing professional and the patients, who enter the mother-child units to provide them with care in the orientation and accompaniment expecting the arrival of a new being. Today, nurses are committed to professional practice in relation to patients, families or communities; they are responsible for offering specific care depending on the needs that people require in diverse health experiences. The practice focuses on caring for the person (individual, family, group, community) who, in continuous interaction with their environment, experience health needs4.

The context of the subjects of the study is framed in the population of the State of Yaracuy, Venezuela, in a public health institution where health care services are provided for pregnant women, post-partum women and newborns. This unit includes users from different geographical areas; I have been able to see in my personal and professional experience how the nurses have limitations in the attention of the users due to their own beliefs and values, their lack of talents, as well as the myths and beliefs in relation to their professional practice.

Among the studies that support this research, one was found in the City of Trujillo, Venezuela, entitled "Cultural Practices of Care for the Trujillan Diabetic", which aimed to learn about care practices based on the cultural framework of these patients in the Hospital "Dr. Juan Motezuma Ginnari "of the Venezuelan Institute of Social Security, Trujillo. The care practices based on the cultural health framework of these patients, based on their beliefs and values, revealed patterns of cultural care that serve as guidelines for care practices given by health professionals, as suggested by Madeleine Leininger. Acquiring cultural competence to provide culturally congruent and sensitive care is a task in which nursing professionals must engage5.

In the city of Havana, another research was found that supports this study entitled "The Cultural Care in Nursing, Necessity and Relevance". The purpose of this research was to reflect on the importance and relevance of cultural care in nursing practices. This article increased the understanding of nursing systems in Cuba, which undoubtedly strengthens the role of nurses in clinical practice. Values, spiritual beliefs and cultural elements cannot be absent from the nursing practice, where cultural knowledge is an indispensable pattern in care systems6.


This study was conducted in the City of San Felipe, Yaracuy State, Venezuela. The data was taken in a public hospital between March 2016 and April 2018. The design of this study was done using the qualitative approach, which captures this subject in a comprehensive manner: it is of utmost importance the whole environment in a holistic way. It is currently in the process of elaboration, applying the focused ethnographic method and the ethno-nursing method proposed by Leininger(7, 8).

The inclusion criteria were based on those nursing professionals who identified themselves with the topic and were sensitized to the objectives of the study: an active professional nurse, performing care functions belonging to the mother-child clinical unit, with an average of more than five years in the institution, belonging to the Fixed Staff of the Ministry of Health, providing direct care to users and newborns, who agree to participate voluntarily and sign the Informed Consent form. It began with the reading and delivery of this form, which was read and accepted. Exclusion criteria: administrative professionals, teachers, multidisciplinary teams or those who do not wish to participate in this study. Ethnography was approached, as Spradley points out, an oriented topical ethnography because it focuses on one aspect of life9. The Ethnographic Analysis of Spradley was used for information processing.

It is important to point out that in all the stages of this investigation, a document named Informed Consent was used which, according to the Code of Ethics for Life of the Venezuelan State, is an agreement resulting from a consensus among actors that voluntarily decide to participate in the achievement of certain scientific goals10. The main objective of the Informed Consent is to safeguard the rights of research subjects or those affected by it. Those who participated in the research had the right to be informed that they were going to be studied, as well as the right to know the nature of the research and the possible consequences of the studies in which they are involved11.

The data collection was obtained through recordings for approximately three hours with each of the six participant nursing professionals, directly in the work unit. Before starting, hospital and palliative care institutions were informed as well as the board of directors of the institution and the nursing department. Formal ethical endorsements were obtained; then weekly tours were made in the care units, as well as the planning control of the professionals in turn and the census of the users in the maternity unit, which allowed to arrange the recorded interviews in the time and place proposed by the actors.

Participant observation was observed in the study: the observer participates only by recording, not being an active member of the group studied. The researcher can observe particular units, but cannot work directly as part of the labor force12.

During the research process the observations and conversations with the actors were recorded. The interviews were structured, focused on the situations generated in the individualized care for the pregnant, puerperal and newborn users in the unit until their discharge. Previously the actors were informed about the purpose of the meeting and reminded that it was an investigative work. Afterwards, they freely agreed to participate, signed and authorized the recording of the conversation. The direct care-nursing professionals interviewed reported, in their own words, facts about the care of their patients and what that experience meant to them13.

The collection of the information was completed following the criterion of saturation of the data, when redundancy is reached and no new information emerges14. The data collection and analysis processes were carried out simultaneously, carefully reading the initial information collected from different sources; the interviews and notes were sorted, selected and re-read, segmenting paragraph by paragraph and significant units, identifying codes or keywords.

This method identified four fields in which the collected information are grouped: a) Domain analysis, b) Taxonomic analysis, c) Analysis of meaning components and d) Discovery of cultural issues. Its domain structure is made up of the elements "Inclusive Term". Each inclusive term implies two or more single terms included and also the semantic relationship that links an inclusive term with all the terms included. After the first phase of the analysis, the data collection, the second phase consisted in the transcription of interviews and descriptions of the notes, defining inclusive terms, semantic relations and domains and writing them down them in the left margin of the sheets of the transcripts. During this second phase, the key informants were asked to indicate the sequence of the domains and, according to their vision, to better indicate ​​how the behavior of the nursing professionals in these care units was related to their practices.

The third phase of the analysis is building the taxonomies. The taxonomic analysis is a procedure that uses a taxonomy (a set of organized categories, based on a semantic relationship) as an organizational tool. The steps of the recommended process for taxonomy analysis are: 1. Select a domain for taxonomic analysis. 2. Find similarities based on the same semantic relationship. 3. Look for additional included terms.

The fourth phase is related to the discovery of cultural issues, what people believe and accept as true and valid with more or less generality, taking into account that any cognitive principle is a cultural topic, tacit or explicit, that is repeated in numerous domains and that serves as a relationship between subsystems of cultural significance. The coded data was recorded, grouped and fed with the new codes until a stable group of domains was established to organize the information. Work began on those that seemed fundamental to the analysis; we sought to clarify their significance and established relationships with other domains. A model of interpretation was generated and a process of verification with the theory was initiated; finally it was considered that the results of this study reached the level of interpretation.

Criteria of accuracy

The methodological rigor was carried out according to commonly used criteria to evaluate the scientific quality of a qualitative study and therefore its methodological rigor: -The credibility: training, skills, competencies, discussion of interpretations, investigative rigor of the author and tutor of the thesis during the realization of the field work; observations, interviews and the focus group to determine the congruence between the results. -The auditability: the interviews with the participants were kept in electronic media by the investigators, doing a reliable transcription of the caregiver’s voices15,16,17. Transferability or applicability: the scenarios and characteristics of the care of pregnant and puerperal women and newborns in the unit were described, together with the research report, written in an understandable language so that more researchers can use them in other contexts. -Dependability: systematic process that included reflective awareness of one's own and others' perspectives, impartiality in constructions, descriptions, representations and values that support the findings15,16,17. The results tried to be a reliable description of the perspective of the direct care professionals who work in the Mother-Child Clinical Unit. If the study finally shows that, then this entire rigor has confirmability18.

Ethical considerations

Three levels of control were established19,20. Level of universal principles of ethics: reflection on the conservation of universal ethical principles: Beneficence, Autonomy, Justice and Respect. Universal ethical standards set out the ethical guidelines on experimentation with human beings, the Nuremberg Code of 1947, the Universal Declaration of Human Rights of 1948, Standards of the International Council of Nurses and of the World Health Organization. In terms of science and ethics we sought the revision of updated and classic bibliography and the recognition of the authors in which the elements of the study were based19.

Ethical review committees: the work was submitted to the institutional endorsements, regarding the university educational institution (Ethics Committee of the University Research Headquarters of Carabobo- Venezuela) so that it would be understood, judged and ensured that it was done according to the principles and rigor of ethics, the use of informed consent and the balance of risks and benefits. Finally, permission to access the institutions was obtained, with the commitment to return the results of the research and proposals once the study was completed. During the process, progress reports were sent to the Research and Ethics Committee of the hospital, with care unit identified when required. The educational institution public was also informed of both the semiannual advances and the final report of the results.

Findings and interpretation of preliminary dadta

The participants in this study, six direct care-nursing professionals who work in the mother-child unit with pregnant and puerperal women and newborn, were females between 21 and 50 years old. Their educational level: between TSU, graduates, a specialist and a graduate professional, with different ideologies and religions. Their socioeconomic situation: they resided in urbanizations near the city, belonging to average social strata. Their sources of income were variable; some were simultaneously caretakers and workers, receiving a salary; others subsisted on money from other private (clinical) jobs. The conditions to provide care: some had a seniority of five years working in the unit in direct care, having started at 21 years of age; others were professionals with more than ten years of seniority. The time of availability for the care, in all cases, was a 12-hour night shift, with minimum rest times. Some had fixed positions in the Ministry of Popular Power for Health and regional contracts.

The hospital as a cultural scenario is a public institution of high complexity in the level of medical care, with great use of technology and little privacy for patients and families, in the Mother-child units: specifically the Maternity Unit "A", a physical space in where the nurses fulfill their professional activities with the goal of offering quality care to the users, newborns and their families in an integral way, 24 hours a day, 365 days a year. The care provided has the purpose of promoting and preserving health, working with a large multi-disciplinary team to help each other, and to schedule activities for the user. This unit has 60 hospital beds, including 4 private groups.

The practice of Cultural Nursing is the way of doing Art of Care

The main practices performed referred by the nursing professionals start when pregnant, puerperal and newborn users enter the mother-child unit: caring, performing cures, providing not only physical care but also emotional, spiritual and psychological, individualized care.

Caring is a human activity defined as a relationship and a process whose objective goes beyond the disease21. For nursing, care is considered as the essence of the discipline that involves not only the recipient, but also the nurse as a transmitter22. For the nursing professional that works in a children's unit, giving care is an art. For the professionals interviewed, the nursing practices:

I believe that caring is the knowledge that we bring academically, applying the appropriate procedural techniques, so that the patient sees what I am doing to cover her needs so she can go home without complications

Considero que el cuidar es el conocimiento que traemos académicamente, aplicando las técnicas de procedimiento adecuadas, para que la paciente vea lo que estoy haciéndole y así cubra sus necesidades y pueda egresar a su hogar sin complicaciones (Rubí, Nurse I).

For the interviewee, caring consists of having knowledge, in the way of doing things, to feel what she is doing; visualizes that the person must be satisfied and perceive that she is being taken of with love; the techniques are necessary, but even more the involvement with the users is what is really important. The nurses visualize that all these actions are performed with art, with the purpose that the patient can see it and appreciate it.

For other interviewees:

The care given to the puerperal women, during their treatment, the newborn care, perianal hygiene and cures, among others, applying the right techniques, and that the important thing is that they are carried out to avoid infections and complications. They come looking for this adequate attention, but also to be treated as human beings.

Los cuidados que se les dan a las puérperas, durante su tratamiento, los cuidados del recién nacido, higiene perianal, curas, entre otros, aplicando técnicas correspondientes a las prácticas, y que lo importante es que se realicen para evitar infecciones y complicaciones. En vista que ellas vienen buscando esta atención adecuada, pero también ser tratada como ser humano (Esmeralda. Enfer. II).

For her, caring applying the techniques in the procedures is important, but the most important thing is the nurse-patient relationship. In the maternal units the patients present physical alterations, dependence, contractions, post-partum pains, and expect the nurse to attend to their needs. In this perspective, she considers the importance of the knowledge that the nurse should have of the techniques. As Boff expresses, care means sleeplessness, solicitude, diligence, zeal, attention, and good treatment. We are facing a fundamental attitude where the person focuses on the other with care and solicitude. The care has two basic meanings linked together, the first, the request, the care, the attention to the other; the second, concern, because the person in their care feels involved and emotionally linked to the other23.

When an interviewee was asked what is the art of caring, she told us:

That each person is different, therefore I must individualize the care, to know what she needs, to provide not only physical but emotional, spiritual and psychological care, provide care that will help in her life process.

Que cada usuaria es diferente a otra, por lo tanto, debo individualizar el cuidado, saber que necesidades tiene, brindar cuidados no solo físicos sino emocionales, espirituales y psicológicos, brindarle cuidados que lo ayuden a su proceso de vida (Escarlata Nursing Esp).

The process of caring for a person can only be optimal if it is individual, because each person is unique. The interviewees have no doubts about individual care; that based on that individuality they perceive the art of caring based on the needs of the patient from a holistic conception, considering care in its physical, emotional and spiritual dimension. It is impossible to care for a group, because each human being has its own reality24.

Knowing Culture is the Way to Provide Congruent Human Care

Cultural care in nursing is an opportune and relevant study field and practice of the profession. This allows the nursing professional to perform a comprehensive analysis of the individual. The main objective of the nursing process is to build a structure that can be covered individualizing the needs of the patient, the family and the community; the diversity and universality of the care in Leininger's theory supports the importance of revaluing cultural patterns, of looking at care from a cultural perspective, of considering the cultural dimension aspects of relevance in nursing care. According to the expressions of the nurses interviewed, they stated that in order to carry out a cross-cultural care it is necessary to know about the culture of the person that they are looking after. They say:

We offer a timely and safe care that consists of trying to get close to the mother since the moment she enters the unit, to meet them and help them in that stage of their lives in whatever they need.

Brindamos un cuidado oportuno y seguro que consiste en tratar de acercarnos a la madre desde el momento que ellas ingresan en la unidad para conocerlas y ayudarlas en esa etapa de su vida en lo que necesitan (Rubí, Nurse I).

We nurses, must first know where she comes from, its ethnicity, religion, and thus know who we are addressing to make it easier to give care to these patients during their stay so we can meet their needs.

Nosotras las profesionales de enfermería, debemos primero conocer de dónde proviene, su etnia, religión, ya sea de la usuaria, gestantes, y puérpera y así conocer a quiénes nos estamos dirigiendo para que sea más fácil dar el cuidado a estas pacientes durante su estadía por lo tanto ellas puedan solventar sus necesidades (Esmeralda, Nurse II).

Through the expressions of the nurses and informants it is clear that for them the meaning of cross-culturally caring, as Boff mentions that truly involves an interrelation between two persons, with differences and similarities, with the idea of helping and being helped23. These expressions show us that for the nursing professional it is necessary to approach the person, in this case the mother, in order to know her and help her from the moment they enter these units, since they come in search of help in this new stage, which is to give life.

Another informant tells us:

The culture that the users bring influence the way they think and do things; some prepare medicines in their homes that speed up the labor before arriving in the maternal institutions, such as herbs, creams or ointments prepared by their relatives.

Las culturas que traen las usuarias influyen en la manera de que ellas piensan y hacen las cosas, es decir, ellas en sus hogares preparan medicamentos que agilicen el trabajo de parto antes de llegar a las instituciones maternas como son tomar hierbas o colocarse cremas o ungüentos preparadas por sus familiares (Perlas, Nurse III).

This shows us that culture influences the health of people; that is of utmost importance since the author Leininger tells us that to provide transcultural care the first requirement is to know that culture plays an important role in the life of people25.


Individualized, congruent and timely care practices should be provided by the direct care nursing professionals, with specific knowledge for the care of the users who enter the maternity unit. The changes experienced by pregnant and puerperal women during the process are different from patient to patient. The need to develop specific knowledge for care in these maternal units remains latent in the academic, scientific and healthcare environment.

The study presents some limitations that must be taken into account in the interpretation of the results. It is a qualitative study in very sensitive topics and moments for the nursing professionals who work in these units. In this research the participants were only women, something that could influence the study since the literature reports that care is an aspect attributed to gender.

Although during the stages of the research process of the present study the ethical requirements were fulfilled to obtain the endorsements of the Ethics Committees and the Institutional Scientific Technical Committees of the health institution and the educational institution, there were difficulties and delays in the various fields where the research was conducted; there were delays in the answers, refusals on the part of the management to do the field work, demands of having to link to the academic study, all which delayed obtaining the information.


Facilitating culturally coherent care practices at the beginning of life is a way to recover a humanized health care practice, seeking a close relationship between the beliefs of the nursing professionals and those receiving care in an effective, satisfactory and consistent manner.

The care practices carried out by nursing professionals in these units require specialists in the area or a training to provide these specific cares, because the care provided will depend on their beliefs when facing users with different cultures. Actions remain oriented towards the biomedical model, centered on the users, privileging only the physical or biological aspects, with the omission of other fundamental human dimensions in a vision of integrative care: mental, cognitive, emotional, social and spiritual aspects, in a specific and fragmentary practice of care. It is recommended an integral vision, and, even better, care from a perspective of the total, holistic human being, where their capacities and deficiencies are considered to understand it.

It was also possible to observe the nurses influencing in the art of the professional care of pregnant women, postpartum women and newborns in the mother-child units, besides knowing about the patient´s culture. The practical principles recognized by science give the nurse a better capacity to care with art, because the art of caring is based on the skillful and humanistic application of scientific knowledge. In this sense, nurses perceive the art of caring based on the needs of patients from a holistic conception, considering care in its physical, emotional and spiritual dimension; therefore, knowing the culture of the patients provide an opportune to give individualized care.

These preliminary statements support what was expressed by Leininger: "the patients propose their points of view as bases for the actions of the nurses". That is, if nurses are to give a cross-cultural care then they must take into account their culture, first of all, subject to what they know, what they think, to adapt or modify their care during the exercise of their practice and the education received during their professional training.

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Received: April 20, 2018; Accepted: December 15, 2019

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