Editor's note : Re-published archive article (cf. Crescendo no.7, May 2022 "La France à Istanbul, une présence durable")
Health is a state of complete physical, psychological and social well-being and is not merely the absence of disease or infirmity. The concept of global health introduced by the World Health Organization (WHO) in 1948 defines a turning point in the conceptions of health because it attaches as much importance to the psychological and social dimensions as to the physical ones. Global health is an expansive vision of health since it is defined by a multidimensional positive state and no longer by the mere absence of disease. However, this first WHO model of global health was often criticized later, particularly in paramedical circles, because it is too romantic and, above all, too static. Therefore, as understood today by health professionals, global health covers a much broader and more dynamic vision of health, conceived as a sort of capital to be managed involving a personal approach by the individual. Who becomes the primary responsibility and craftsman of his health?
A professional challenge
Nurses have played a significant role in promoting the holistic health model. Over the past twenty years, the professional field of nursing has been primarily inhabited by the aspiration to create a specific professional identity both about doctors and about other paramedical and social professions. It was necessary to free oneself from the negative identity of the doctor’s performer by founding « the autonomy of nursing concerning other knowledge, » particularly medical. In the United States and Canada, nursing theorists have developed conceptual frameworks to circumscribe the specific scope of the profession. As a result, the whole current research in nursing has been formed. This work of redefinition takes place in the vast movement that leads nurses « from vocation to profession ». The notion of Global Health (biopsychosocial approach) has thus become a critical value, an essential reference in the professions of the medico-social sector, as well as the ideological foundation of nursing practice. However, it remains to ask what use we make of it and its effects at different levels on the « field. » The following analysis is based on interactive research conducted with two groups of school nurses and based on the collective analysis of practice.
As conceived by health professionals, we now know that global health does not necessarily correspond to the representations and concrete experiences of users of a health service or a care system.
A professional ideology
Suppose the notion of global health inhabits all health professionals. In that case, this takes on a particular understanding for nurses in public health because they are more directly confronted with the living environment of users. This does not mean that this concern does not exist in the hospital environment. Still, it is often relegated to the background, the front of the stage being occupied by the disease and its symptoms and urgency and technicality. In the non-hospital sector and particularly in the school environment, the social and psychological dimensions are, on the contrary, very present. School nurses are faced with situations where they check the interdependence of these different factors (bio-psycho-social) every day. Closed to a broader vision of health, it is not surprising that they constantly refer to the notion of global health. This notion also obviously plays the role of a professional ideology whose function is threefold: to orient, legitimize, organize and divide the action.
But the difficulty arises because professionals find it challenging to define global health in an « operational » way, to specify its content and contours once applied to concrete situations. This is why this notion often appears without limit. The school nurses taking part in the research gladly say they « do everything » and draw inspiration from the model of certain Nordic and Anglo-Saxon countries where the public health nurse enjoys accurate social recognition. But, as if to ward off a lack of affirmation of professional identity, a desire for omnipotence emerges that the participants are not aware of but which is sometimes perceived as such by the other participants. The « encompassing » dimension of this ideology could also conflict with the values and interests of different groups, particularly pupils and their parents.
Between the relative and the absolute
During an exercise, the participants of one of the research groups were asked to define in three keywords what expresses for them the essence of their work in the school environment. References to optimal well-being and quality of life came out strongly, reflecting high ambition in the targeted objectives. The first WHO definition of health (state of complete well-being) still seems to permeate nurses’ professional unconscious largely. From this observation, the reflection focused on the difference between « idealities and realities » (5) and the distinction between relative and absolute norms. If we take the term optimal in its complete sense of the « best ideally possible, » the work is endless because the state of well-being is not.
Never perfect. But for optimal, taken in its relative sense, also means the « best realistically possible, » taking into account the circumstances and the inherent limits of the situation. But unfortunately, the best state of health, hygiene, or well-being realistically possible in many cases is somewhat limited compared to what one might ideally wish. It would, therefore, sometimes be beneficial to replace the term optimal with relatively satisfactory or acceptable and to correct the « universalizing » definitions of health (WHO style) by introducing social and cultural considerations, namely the concrete living conditions of the people.
For health professionals, there is a distinction between the level of outstanding values and standards that guide action on the one hand and the relative standards that are the yardstick by which one can realistically measure its results. On the other hand, without this precaution, practitioners risk abuse of power in the name of an absolute and all-powerful standard and professional dissatisfaction, guilt, and depression because the objective is unrealistic or out of reach. A professional tool such as the process of care can help stay within the limits of practical intervention.
Hyphen or bone of contention?
During the interactive research, the participants wanted to reflect on the difficulties encountered in multidisciplinary collaborations, particularly with psychologists and social workers working in schools. Therefore, we organized a meeting session with people representing the various professions in question but not working in the same establishments, with a view to sociological intervention: the function of these meetings is twofold: on the one hand, they include the actors in a social relationship, and the discourses are thus ‘in situation’ on the other hand, they create a critical distance because the actors experience the gap that exists between their representations and the relationships in which they are inscribed ».
This session highlighted some of the issues at work in situations of multidisciplinary collaboration in the medico-social sector. It emerges that in this context, the notion of global health, far from playing a « facilitating » role by bringing everyone to an agreement, tends to create confusion in the definition of territories and professional identities. As a result, issues passed over in silence.
Indeed, the members of the psychosocial team share with the nurses the particularity of having a helping relationship profession. Although the intervention of each one is more particularly interested in an aspect of the problem encountered, which he approaches with specific tools, these various professionals are nevertheless all aware that the life of the child and his difficulties do not stop the process. They know to what extent these different elements are interdependent and cannot help but consider the whole. This is perhaps, even more the case for nurses trained to think of health as a global entity and who are often the first to intervene with a student in difficulty. They must then obligatorily concern themselves with these various aspects and intervene on several fronts simultaneously. As soon as we touch on the medico-social field (whether physical or mental health), the borders are blurred, the territories overlap, and the limits are difficult to establish. The three professions in question have in common that the relationship with the user is of paramount importance. While only psychologists make strictly therapeutic use of it, social workers like public health nurses are trained in conducting interviews and consider the relationship with the client as the privileged channel of their intervention, the very condition of its success. This relationship is very often the source of social and affective gratifications that maintain professionals’ motivation and contribute to their subjective satisfaction at work. It is a considerable stake but which is never declared as such.
Psychologists legitimize their fear of competition by warning against « wild » therapeutic approaches practiced by « laypeople, » and the others wish more than anything to safeguard this gratifying aspect of the practice « for the good of the child and his comprehensive support. » School nurses are thus considered as doubly threatening by other professionals: they have the formidable privilege of being institutionally legitimized to see all children for systematic screening, and part of their activity is also centered on the person, the follow-up, and the support for confident children leading them to establish a special relationship with them. Moreover, claiming a global approach more than others gives their partners the impression that their « professional territory » and, therefore, their « hold » is limitless. Indeed, « to claim the specificity of being the professional of the synthesis and therefore of the coordination of the other professions, is to expose oneself to rivalry with these other professions which willingly affirm the same claims. » The question of professional identities is at the heart of the problem. The solution inevitably involves a clear definition of these identities, skills, specific professional methods, and their respective limits.
A lucid and efficient global approach
Ideally, the option of multidisciplinary collaboration is legitimized by the idea that it theoretically seems to be the most appropriate operating choice to collectively respond to complex situations and the multidimensional needs of users. The notion of global health can contribute to effective and satisfying multidisciplinary collaboration. It is a broad concept to allow the various professionals to find a specific place in a collective approach. It is, therefore, a question of managing the areas of articulation as well as possible; consultation and the definition of common objectives are the first steps. Then come the methods of teamwork. There are different ways to update priorities and objectives on the ground. For example, the group can delegate the intervention to a practitioner who already knows the person or family concerned and can establish a privileged relationship with them. The other team members can offer him a form of supervision, especially when certain aspects of care are at the border of various professional approaches. Or, some members of the team may decide to receive a family together to broaden and diversify the view of their situation.
Much remains to be invented to overcome often very rigid professional and organizational divides concerning the ambitious perspective of broader health. The relevance and effectiveness of the concept of global health necessarily involve a reflection on its possibilities and limits. It emerges once stripped of its ideological and potentially totalitarian dimensions. It continues to represent a fruitful conceptual tool for medico-social work.
Editor's note :Special thanks to Ms. Cécile Guinard for her support on this article.