192 AQUICHAN - ISSN 1657-5997 José Siles1 María del Carmen Solano-Ruiz2 Genival Fernández de Freitas3 Taka Oguisso4 Political Systems and the Perspective on Nursing Education during the Spanish Transition (from the Franco Regime to Democracy). A Contribution based on Nursing History 1 Doctor en historia. Licenciado en pedagogía y diplomado en Enfermería, Catedrático de la E.U. de Enfermería, Departamento de Enfermería, Universidad de Alicante, España. jose.siles@ua.es 2 Doctora en cultura de los cuidados. Licenciada en Antropología Social y Cultural. Enfermera. Profesora titular de Enfermería de la Universidad de Alicante, España. carmen.solano@ua.es 3 Doctor en enfermería. Licenciado en Enfermería y en Derecho. Profesor titular. Escuela de Enfermería Universidad de Sao Paulo, Brasil. genivalf@usp.br 4 Doctora en Derecho. Licenciada en Enfermería. Profesora titular. Escuela de Enfermería de la Universidad de São Paulo, Brasil. takaoguisso@vol.com.br Recibido: 20 de julio de 2010 Aceptado: 27 de octubre de 2010 ABSTRACT The aim of this study is to describe the changes in nursing education during the process prior to and after the establishment of demo- cracy in Spain. It begins with the hypothesis that differences in social and political organization influenced the way the system of nursing education evolved, keeping it in line with neopositivistic schemes and exclusively technical approaches up until the advent of democracy. The evolution of a specific profile for nursing within the educational system has been shaped by the relationship between the systems of social and political organization in Spain. To examine the insertion of subjects such as the anthropology of healthcare into education programs for Spanish nursing, one must consider the cultural, intercultural and transcultural factors that are key to understanding the changes in nursing education that allowed for the adoption of a holistic approach in the curricula.Until the arrival of democracy in 1977, Spanish nursing education was solely technical in nature and the role of nurses was limited to the tasks and procedures defined by the bureaucratic thinking characteristic of the rational-technological paradigm. Consequently, during the long period prior to democracy, nur- sing in Spain was under the influence of neopositivistic and technical thinking, which had its effect on educational curricula. The addition of humanities and anthropology to the curricula, which facilitated a holistic approach, occurred once nursing became a field of study at the university level in 1977, a period that coincided with the beginnings of democracy in Spain. KEY WORDS Nursing, care, nursing history, political systems, Spain. (Source: DeCs, BIREME). AÑO 10 - VOL. 10 Nº 3 - CHÍA, COLOMBIA - DICIEMBRE 2010 l 192-203 193 Political systems and the perspective on nursing education during the spanish transition ... l José Siles, María del Carmen Solano-Ruiz, Genival Fernández de Freitas, Taka Oguisso Sistemas políticos y perspectiva de la educación de enfermería en la transición española (del franquismo a la democracia). Una contribución desde la historia de la enfermería RESUMEN El objetivo del estudio consiste en describir los cambios que afectan a enfermería dentro del sistema educativo durante el proceso pre- vio y posterior al establecimiento de la democracia en España. Se parte de la siguiente hipótesis: las diferencias en la organización social y política influenciaron la evolución de la enfermería española manteniéndola dentro de los esquemas del neopositivismo y los enfoques exclusivamente técnicos hasta la llegada de la democracia. La relación entre los sistemas de organización social y política en España ha determinado la evolución de un perfil específico de enfermería en el sistema educativo. Para comprender la integración de asignaturas como la antropología del los cuidados en los programas educativos de la enfermería española hay que se considerar los factores cultura- les, interculturales y transculturales que constituyen las claves para el entendimiento de los cambios en la educación enfermera haciendo posible la adopción de una perspectiva holística en los currículos. Hasta la llegada del sistema democrático en 1977, la educación en la Enfermería española fue solamente de naturaleza técnica y los roles de las enfermeras se limitaban al cumplimiento de tareas y proce- dimientos definidos por el pensamiento burocrático característico del paradigma racional tecnológico. Conclusiones: Durante el largo período predemocrático la enfermería española estuvo bajo la influencia del pensamiento neopositivista y técnico, lo cual se plasmaba en los currículos educativos. La integración en los currículos de materias humanísticas y antropológicas que facilitaban el enfoque holístico se produjo tras la integración de la enfermería en la Universidad en 1977 coincidiendo con los inicios de la democracia en España. PALABRAS CLAVE Enfermería, cuidado, historia de la enfermería, sistemas políticos, España. (Fuente: DeCs, BIREME). 194 AÑO 10 - VOL. 10 Nº 3 - CHÍA, COLOMBIA - DICIEMBRE 2010 AQUICHAN - ISSN 1657-5997 Sistemas políticos e perspectiva de ensino da enfermagem na transição espanhola (do regime de Franco à democracia). Uma contribuição da história da enfermagem RESUMO Objetivo: descrever as mudanças que afetam a enfermagem no sistema de ensino durante o período pré e pós-estabelecimento da democracia na Espanha. A hipótese de partida é: as diferenças na organização social e política influenciaram a evolução da enfermagem espanhola mantendo-a dentro do positivismo e das abordagens puramente técnicas até a chegada da democracia. A relação entre os sistemas de organização social e política em Espanha determinou o desenvolvimento de um perfil específico da enfermagem no sistema de ensino. Para compreender a integração de disciplinas como a antropologia do cuidado nos programas de educação da enfermagem espanhola é necessário considerar factores culturais, interculturaisl e transculturais fundamentais para a compreensão das mudanças no ensino de enfermagem. Isso permites a adoção de uma perspectiva holística nos currículos. Até o advento da democracia em 1977, o en- sino da enfermagem na Espanha era apenas de natureza técnica e os papéis dos enfermeiros eram limitados ao cumprimento de tarefas e procedimentos definidos pelo pensamento burocrático característico do paradigma racional da tecnologia. Conclusões: durante o longo período pré-democrático, a enfermagem espanhola esteve sob a influência do pensamento técnico neo-positivista, que foi incorporado nos currículos educacionais. A integração de matérias humanísticas e antropológicas no currículo, que facilitou a abordagem holística, chegou depois a integração da enfermagem na universidade em 1977, o qual coincide com o início da democracia em Espanha. PALAVRAS-CHAVE Enfermagem, cuidado, história da enfermagem, sistemas políticos, Espanha. (Fonte: DeCs, BIREME). 195 Political systems and the perspective on nursing education during the spanish transition ... l José Siles, María del Carmen Solano-Ruiz, Genival Fernández de Freitas, Taka Oguisso Introduction Power differences in a society are linked to diversities in the evolution of education and educational strategies. The essential and existential dimensions of education are in- fluenced by power relationships in society. The aim of this study is to describe the changes in nursing education during the process prior to and following the establishment of democ- racy in Spain. It work begins with the hypothesis that the differences in social and political organization influenced the way the system of nursing education evolved, keeping it in line with neopositivistic schemes and exclusively technical approaches up until the advent of democracy. The relationship between the systems of social and political organization in Spain has shaped the evolution of a specific profile for nursing within the educational system. To examine the insertion of subjects such as the anthropology of healthcare into education programs for the Spanish nursing, one must consider the cultural, intercultural and transcultural factors that are key to understanding the changes in nursing education that allowed for the adoption of a holistic approach in the curricula. Background The nature of power and ideology, their link to education, and the strategies devel- oped for their perpetuation have influenced the way the education system has been struc- tured (1,2). Furthermore, the transmission mechanisms for learning have been influenced strongly by power and politics (3, 4, and 5). Integrating Political Involvement and Nursing Education emphasizes the need for nurses to develop health policy skills. Education sys- tems also are influenced by religious political power (6, 7). In Spain, literature concerning the influence of political power on education is scarce (8, 9). A number of authors identi- fied the false neutrality of scientific paradigms and the hierarchical and authoritarian bu- reaucratization of disciplines (10). Other works analyze the dogma in scientific production and deal with the subject of power and its relationship to science within the specific scope of nursing (11, 12, 13, 14, 15, and 16). Historical and anthropological work on Spanish nursing was begun in the 80’s. The first publication on the anthropology of healthcare appeared in the 90´s. As the decade progressed, the anthropological view of nursing in Spain continued to evolve. These publications dealt with specific topics such as pregnancy, nurses’ image in the media during the Spanish Civil War, and mental health (17- 18). Methodology This historical study was conducted in two parts. The first involved a historical study of Spanish nursing education under the social, labour and scientific conditions that existed before (1939-1976) and after (1977-1998) the arrival of a democratic system. The rational- technological, hermeneutic and socio-critical paradigms were used to analyze the features of the period prior to and after democracy was established. It work begins with the hypothesis that the differences in social and political organization influenced the way the system of nursing education evolved, keeping it in line with neopositivistic schemes and exclusively technical approaches up until the advent of democracy. 196 AÑO 10 - VOL. 10 Nº 3 - CHÍA, COLOMBIA - DICIEMBRE 2010 AQUICHAN - ISSN 1657-5997 The second historical study involved a bibliographic review focused primarily on journals and monographs on Spanish nursing education. The more relevant peri- odical publications were reviewed, such as Rol, Enfermería Clínica, Index and Cultura de los Cuidados. The Spanish database CUIDEN (published by the Index Founda- tion) also was used, as was cuidatge (Uni- versidad Rovira y Virgil), and the ISBN da- tabase published by the Ministry of Culture. Results After the end of the Spanish Civil War in 1939, nurses returned to their old ac- tivities and traditional values, abandoning a great many of the achievements secured during the II Republic. The number of reli- gious leaders and their impact on nursing and nursing education increased. In fact, religious leaders regained the influence lost before and during the Spanish Civil War. Nursing returned to a working situ- ation directly related to a gender-depen- dant distribution of tasks and regained its condition as a predominantly female pro- fession. Sección Femenina (The Women’s Division) was founded in 1933; directly dependent on the Falange, its members specialised in the task of assistance. In 1936, Winter Aid was founded; its primary function was care of the wounded and sick in military hospitals. Consequently, it became necessary to endow these or- ganizations with the most basic and indis- pensable knowledge. In 1937, Social Aid was founded and its first by-laws estab- lished three delegations: Education, Social Aid and Hospitals. The future directors of nursing schools were selected from among the most outstanding students. In 1942, Traditionalist Spanish Falange Nurses was constituted in four sections. A high degree of ideological and re- ligious indoctrination was customary. Because of the unavoidable requirement of being a member of Sección Femenina in order to study nursing or to become a teacher, an important part of education for teachers and nurses was dedicated to religion and prayer. Ibáñez Martín was the Minister of Education from 1939 to 1951, a period characterised by immobility and religious and ideological predominance (Falange) in primary, secondary and uni- versity education. The Beginning of the Technocratic Period The shift from education based on reli- gious and political ideas to education that was more technocratic and utilitarian took place when Ruiz Giménez was in charge of the Ministry of Education. At this opening stage, secondary edu- cation continued to polarize the education- al system. In 1953, two levels (elementary and higher) were established in second- ary school. At the elementary secondary- school level, one could begin to study for a short degree, i.e. nursing. During Ruiz Giménez’s time, studies for practicantes (interns) and nursing were combined. Ul- timately, this period led to the creation of the Degree of Technical Health Assistant (A.T.S.) in 1955. In this context of techno- logical medicine and technocratic scientific development, nursing was regarded solely as an auxiliary profession subordinate to the figure of the physician. Technocracy, with its limitations, influ- enced nursing progress by hindering the secularisation of hospital workers (Tables 1 and 2). However, to understand this pro- cess of technification within the context Nursing returned to a working situation directly related to a gender-dependant distribution of tasks and regained its condition as a predominantly female profession. 197 Political systems and the perspective on nursing education during the spanish transition ... l José Siles, María del Carmen Solano-Ruiz, Genival Fernández de Freitas, Taka Oguisso of nursing, it is important to bear in mind one of the most decisive factors in the de- velopment of the health system. Parallel to the improvements in education, tech- nocrats favoured a politically-influenced development of hospitals and encouraged the construction of healthcare facilities through several development plans imple- mented during the Franco regime (i.e. the First and Second Development Plans). The Role of Nursing According to the Rational-Technological Paradigm: Nurse: Executor of techniques and sub- ordinate to other professionals. (...) Patient as a “passive recipient” of pro- cedures and educational advice Nursing dependent on research in other disciplines. Later, with publication of the Laws on Hospital Regulation (1962), the number of hospitals tripled to more than one hundred, and the number of hospital assistants came to approximately 70,000 by 1970. In 1953, the total number of people with social secu- rity surpassed 29%; in 1968, the proportion of Spanish state beneficiaries who were in- sured was 72%. The same developmental movement influenced nursing education, in- asmuch as a considerable effort was made to endow new and previously existing hospi- tals with a technically trained nursing staff and to substitute or recycle the religious staff (nuns) working as nurses at health centres. This was an extremely important period in nursing history, because it was when the foundation for the leap towards a professional situation was laid. Parallel to this, the education system improved while Lora Tamayo was head of the Ministry of Education. He extended the compulsory school age to 14 years (1964) and made a “Bachiller Superior” (Upper Secondary) de- gree a mandatory prerequisite for studying to become a teacher (Magisterial). During those years, a person’s profession was de- termined largely by their gender. Male A.T.S. picked up where the old practicantes left off (most were men). These professionals obtained their de- TABLE 1 MORAL DIMENSION OF THE PRACTICE “The rational technological reduces the practi- cal activity to a mere instrumental one, to the analysis of the resources adapted for certain aims, avoiding the moral and ethical problem of the objetives in every professional initiative that tries to solve human problems (…)” Source: Habermas J. Ciencia y técnica como ideología. Madrid: Tecnos; 2007 “The rational-technological regime reduces practical activity to merely an in- strumental role and to the analysis of re- sources adapted for certain aims. It avoids the moral and ethical problems of the ob- jectives in every professional initiative that attempts to resolve human problems (...)“ TABLE 2 NURSING ROL FROM RATIONAL TECHNOLOGICAL PARADIGM l Neutrality and objectivity of science. l Nurse: executor of techniques and subordina- ted to other professionals. External controller of the health process. l Patient as" receiving passive object " of proce- dures and educative advice. l Concept of health: empty /negative(no symp- toms) nursing dependending of the investiga- tion of other disciplines. l Standardized, experimental scientific produc- tion with statistical instruments. Source: Epistemología y enfermería: por una fundamentación científica y profesional de la disciplina. Enfermería Clínica. En- fermería Clínica 1997; 7: 188-94. “The rational- technological regime reduces practical activity to merely an instrumental role and to the analysis of resources adapted for certain aims. It avoids the moral and ethical problems of the objectives in every professional initiative that attempts to resolve human problems (...)”. 198 AÑO 10 - VOL. 10 Nº 3 - CHÍA, COLOMBIA - DICIEMBRE 2010 AQUICHAN - ISSN 1657-5997 grees from medical schools where they received a fundamentally theoretical edu- cation with a technical orientation. As to their destination, they worked essentially in local healthcare settings and the old A.P.D. (Atención Publica Domiciliaria- Pub- lic Home Care). Female A.T.S. were educated in schools integrated into hospitals, receiv- ing mostly practical training, although the technological aspect was emphasized. The increase in this type of personnel was closely linked to the development of health institutions. The curricula during the 60’s and 70’s included subjects that had little to do with the needs of the profession and were con- cerned more with religious and ideologi- cal matters (religion, the development of a nationalistic spirit and - in the schools for women - subjects related to house man- agement and domestic tasks). However, these matters were deliberately ignored in many schools, thanks to the good will of a number of professors (Table 3). A Historical Fact: The Option of University Integration In 1968, Villar Palasi took over as head of the Ministry of Education and Science. Soon after, in 1970, a decisive law for the future of nursing would result in nursing becoming a field of study at the university level. This legislation represented an at- tempt to answer the propositions estab- lished by Moyano´s hundred-year-old law (1857), which continued to persist in the Spanish education system and particu- larly in Spanish nursing, which was being moulded professionally and academically by it. The General Education Act provid- ed for diploma studies at the university level. In this context, nurses were able to choose between vocational training, and studies for a university degree. In Feb- ruary 1976, the Comisión Interministerial (Cross-Ministerial Commission) was con- stituted to reform A.T.S. studies. It was comprised of representatives from a num- ber of official agencies (Dirección General Table 3. Distribution of Contents in “Nursing Study Programs” - Spain, 1 First Course Second Course Third Course Religion Professional Ethics Functional Anatomy Biology-Histology Microbiology General Hygiene General Pathology Building a National Spirit Physical Education Practice Religion Professional Ethics Pathology and Prescription Surgical Pathology General Psychology History of the Profession Building a National Spirit Physical Education Practice Religion Professional Ethics Surgical Specialities Medical/Surgical Causalities Hygiene and Prevention Obstetrics and Genecology Newborns-Infants Social Medicine Differential Psychology Physical Education Practice Source: (Siles, 1999): Study Programs In 1968, Villar Palasi took over as head of the Ministry of Education and Science. Soon after, in 1970, a decisive law for the future of nursing would result in nursing becoming a field of study at the university level. 199 Political systems and the perspective on nursing education during the spanish transition ... l José Siles, María del Carmen Solano-Ruiz, Genival Fernández de Freitas, Taka Oguisso de Sanidad, Ministerio de Educación y Ciencia, Instituto Nacional de Previsión, Sindicato de Actividades Sanitarias and the three branches of the Consejo Gen- eral de A.T.S.), in addition to two doctors and two nurses as advisory members. To justify their decision to include studies at the university level, the experts used the European Council guidelines on the activi- ties of nurses responsible for general care (77/453/CEE). The strain imposed by the work force, mainly from the hospital sec- tor, and the pressure brought to bear by professionals who were part of the pro- vincial A.T.S. associations brought them all together to form a National Co-ordinat- ing Committee, ultimately achieving the addition of nursing at the university level. A Bachelor’s Degree in Nursing (as at the University of Alicante) became a reality during the 1998-99 academic year, after a long struggle and with the hope that this experience would serve as model and be implemented nationwide. Historical Evolution of Studies in Spain to Become “Practicantes,” Midwives, Nurses (1942-43 / 1955- 56) and A.T.S. (1956- 57/1976-77) After World War II and as a conse- quence of the international isolation that totalitarian Spain experienced, the trans- formation regarding authoritarianism was slow, but irreversible. Between the course” in 1942-43 to the one in 1955-56, a total of 57, 496 students were enrolled (Table 4). The course in 1951-52 had the highest enrolment. Course/year Schools Total Males % Males Females % Females Degrees 1942-43 1943-44 1944-45 1945-46 1946-47 1947-48 1948-49 1949-50 1950-51 1951-52 1952-53 1953-54 1954-55 1955-56 10 10 10 10 10 10 10 10 10 10 10 10 10 10 2241 2277 2716 2835 3031 4052 5727 6240 6354 6733 4874 5745 3588 1113 1758 1791 2029 2081 2168 2797 3872 4305 4723 4970 3307 3823 2263 752 78,4 78,7 74,7 73,4 71,5 69,0 67,6 69,0 74,7 73,8 67,8 66,5 63,1 67,6 483 486 687 754 863 1255 1855 1935 1601 1763 1567 1922 1325 361 21,6 21,3 25,3 26,6 28,5 31,0 32,4 31,0 25,3 26,2 32,2 33,5 36,9 32,4 822 1245 717 872 1016 1850 1541 1850 2128 2121 2108 1751 1844 1493 Table 4. Distribution of Men and Women in the Nursing Course between 1942 and 1956. Spain, 1957 Midwives This period witnessed a clear evolu- tion in midwifery studies. With unification of the curricula and the creation of the title and profession of Technical Health Assis- tant (A.T.S.), midwifery was established Source: Anuario Nacional de Estadística, 1957: 801. as an A.T.S. specialty. During this aca- demic period, a total of 12.567 students were enrolled (897 per course) (Table 5). The following table shows the total number of students enrolled to study mid- wifery during the period between 1942 and 1956. Table 5. Total Number of Nursing Students Studying Midwifery between 1942 and 1956. Spain, 1957 Course Schools Total Degrees 1942-43 1943-44 1944-45 1945-46 1946-47 1947-48 1948-49 1949-50 1950-51 1951-52 1952-53 1953-54 1954-55 1955-56 Source: Anuario Nacional de Estadística, 1957: 801. 10 10 10 10 10 10 10 10 10 10 10 10 10 10 432 469 572 731 760 779 1038 1117 1333 1326 1008 1133 1171 698 122 152 190 243 233 329 316 537 379 456 406 385 385 382 200 AÑO 10 - VOL. 10 Nº 3 - CHÍA, COLOMBIA - DICIEMBRE 2010 AQUICHAN - ISSN 1657-5997 Nurses Nursing studies began in 1915 and reached their peak of development during the II Republic, when there was a massive influx of women. Between 1942-43/1955- 56, a total of 49,816 students were en- rolled (3,558 per course) (Table 6). The following table shows the number of students enrolled between 1942 and 1956. The University Stage and Nursing Graduates The democratic transition in Spain was important to improving academic teach- ing. In 1989-90, 20,228 students were enrolled and 5,973 degrees were granted by a total of 31 university schools, three of them private. The following table shows the universities and the total number of nursing students enrolled in Spain during the period from 1989 to 1990 (Table 7). The Origin of Nursing Research in Spain Híades is the first Spanish journal dedi- cated exclusively to the history of nursing. It first appeared in August 1994, encouraged by the efforts of the Andalusian Group for Research on Nursing History (GAIHE). The first issue of Cultura de los Cuidados ap- peared in August 1997. This journal is char- acterized by a zeal for the development of humanistic nursing in four fundamental ar- eas: phenomenology, anthropology, history and theory, and nursing ideas and princi- ples pursuant to the hermeneutic and socio- critical paradigms (Tables 8 y 9). Moreover, the first Spanish association of history and the anthropology of healthcare was estab- lished as a result of this publication. 1942-43 1943-44 1944-45 1945-46 1946-47 1947-48 1948-49 1949-50 1950-51 1951-52 1952-53 1953-54 1954-55 1955-56 10 10 10 10 10 10 10 10 10 10 10 10 10 10 869 1217 1891 1749 2024 2811 4274 5277 6464 7066 11586 2805 496 1242(2) 186 419 229 440 620 755 773 1656 1478 1912 2352 3069 1699 930 Course Schools Female Students(1) Degrees Source: Anuario Nacional de Estadística, 1957: 801. (1) External and “official” students. (2) Included 237 males (A.T.S. students). In Spain, the A.T.S were known as “Technical Health Assistants”. Table 7. Universities and Total Number of Nursing Students in Spain during 1989 1990. Spain, 1992 Public and private universities Public universities Alcala Henares Alicante Baleares Autonoma Barcelona Barcelona Cantabria Cadiz Castilla La Mancha Cordoba Coruña Extremadura Granada La Laguna Leon Universities Enrolment Females Degrees Total Students 20228 19064 130 198 164 340 1342 190 561 658 252 189 855 1354 289 179 17036 15931 117 165 143 316 1197 157 371 567 187 168 696 1040 225 168 5973 5537 37 55 42 101 357 63 135 280 74 - 259 512 148 41 Table 6. Distribution of Female Students Enrolled in the Nursing Course during 1942-1956, Spain, 1957 201 Political systems and the perspective on nursing education during the spanish transition ... l José Siles, María del Carmen Solano-Ruiz, Genival Fernández de Freitas, Taka Oguisso Source: Anuario Estadístico de 1992, INE, Madrid: 571 l Possibility of admitting the subjective dimen- sion in research. l Nurse works like agent of comprehensive and interactive communication l Patient exerts the roll of subject signaller of his state and expectations l The health concept is processed interactively l Scientific knowledge: Phenomenology, sym- bolic interactionism, anthropology, lifes his- tories, etc. TABLE 8 HERMENEUTIC PARADIGM Source: Siles J. Epistemología y enfermería: por una fundamentación científica y profesional de la disciplina. Enfermería Clínica. Enfermería Clínica 1997; 7: 188-94. Table 7. Universities and Total Number of Nursing Students in Spain during 1989 1990. Spain, 1992 Universities Enrolment Females Degrees Total Students Madrid (Autonoma Madrid (Complutense) Malaga Murcia Oviedo Pais Vasco Las Palmas Salamanca Santiago Sevilla Valencia Valladolid Vigo Zaragoza Private universities Navarra Pontificia de Comillas Pontificia de Salamanca 257 966 567 372 524 1220 214 547 590 682 1127 928 373 1125 642 257 265 233 788 434 307 457 1086 166 482 506 525 901 841 311 1003 642 208 255 97 488 137 109 138 367 50 133 290 146 286 236 - 249 173 - 83 Continue. l Necessity of developing the historical cons- cience. l Interpret subjectively nurse as agent of change. l The patient acts like subject involved in the control and dynamics of his process of health l Positive concept of health: reelaboration of the same one on the part of the subject. l Constructed knowledge dialectically critical investigation, study of contexts and consi- deration of the subjet-patient (anthropology, history, critical sociology). TABLE 9 SOCIOCRITICAL PARADIGM Source: Siles J. Epistemología y enfermería: por una fundamentación científica y profesional de la disciplina. Enfermería Clínica. Enfermería Clínica 1997; 7: 188-94. 202 AÑO 10 - VOL. 10 Nº 3 - CHÍA, COLOMBIA - DICIEMBRE 2010 AQUICHAN - ISSN 1657-5997 Hermeneutic Paradigm: - Possibility of permitting a subjective dimension in research. - The nurse functions as an agent for comprehensive and interactive com- munication. - The patient is a subject who signals his/ her state of health and expectations. Socio-critical Paradigm: - Need to develop a historical conscience. - Subjectively interprets the nurse’s role as an agent of change. - Patients behave as subjects involved in the control and dynamics of their health process. - Positive concept of health: Reworking of that concept on the part of the subject. - Constructed knowledge, dialectically critical research, study of contexts, and consideration of the subject-patient (an- thropology, history, critical sociology). Among other results, this study found only one Spanish journal that dedicates a section to the anthropology of healthcare (Cultura de los Cuidados in 1997); while another publication often includes articles on the subject (Index, in 1988). The other journals consulted only occasionally con- tain articles on the anthropology of health- care. The characteristics of the articles published in Cultura de los Cuidados and Index point to an evident change of para- digm. Thus, three different periods can be distinguished, given the political system at the time and the characteristics of Span- ish nursing education. The first stage is dominated by the ra- tional-technological paradigm (Figure I). It coincides with the authoritarian period (1855-1977) when nurses were not re- garded as independent professionals, but as physicians’ assistants with no scien- tific knowledge. During this period, nurses performed only simple tasks, with the pa- tient as the recipient. In other words, it is possible to say that the moral dimension of nursing practice was not taken into ac- count during that time. The hermeneutic paradigm pertains to a shorter period, which began when nurs- ing became a field of study for a univer- sity degree (coinciding with the beginning of the democratic transition in 1977) and lasted up until enactment of the General Health Act in 1986. During that period, the nurse became an interpreter of the pa- tient’s situation, as it was the nurse who had a command of know-how, communi- cation skills and psychology, and a his- torical, sociological and anthropological education. Yet, nurses were unable apply all of this in practice, because the labour system was not structured for university- trained nurses. Finally, the phase when the socio- critical paradigm began coincides with enactment of the General Health Act and continues to this day. In this phase, nurses are agents of socio-health change and their knowledge can be applied in practice, since the General Health Act recognizes them as university-trained health professionals. Conclusions During the long pre-democratic pe- riod, Spanish nursing was governed by positivistic logic and a technical approach, which influenced educational curricula. The addition of humanistic and anthropo- logical subjects to the curricula facilitated a holistic approach and occurred in 1997, when nursing became a field of study at the university level. This coincided with the onset of democracy in Spain. The variability of the political and so- cial system has had a strong influence on the adoption of nursing paradigms in edu- cation, and on development of the anthro- pology of healthcare. The false neutrality of the scientific paradigms and the hierar- chical and authoritarian bureaucratization of the disciplines are evident, particularly on the part of specialists in the so-called emerging, new or developing disciplines, which is the case of nursing education. Practicantes, midwives and nurses suffered an educational system in which ideology, political indoctrination and re- ligious ideas played a paramount role. With the arrival of democracy in Spain, nursing finally became a field of study for a university degree 1977. This did away with the nurse’s image as a mere tech- nician. After being incorporated into the university curriculum, nursing began an evolution that culminated with adoption of the hermeneutic and socio-political paradigms. Historical, sociological and anthro- pological research acquired a prominent role (in curricula) following the adoption of approaches endorsed by the herme- neutic and socio-political paradigms. 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