Meaning of the Systematization of Nursing Care for nurse managers

Abstracts

OBJECTIVE:

To understand the meaning that the nurse managers attributed to the nursing process, developed in their daily work.

METHODS:

The phenomenological method was used, referencing the structure of the situated phenomenon. The subjects were thirteen nurses, managers of a university hospital. The analysis included transcription and readings of depositions aimed at the essence, by means of thematization, interpretation and synthesis of the phenomenon.

RESULTS:

The thematic categories were: human resources in achieving the systematization of nursing care; their relevance to the work of the nurse, difficulties in its implementation; qualification for its realization.

CONCLUSION:

The meaning that nurse managers attribute to the systematization of nursing care are related to the legal aspects of professional practice, teamwork, and to the adequate scheduling of human resources.

Nursing care; Practice management; Nursing process; Nursing staff; Qualitative research; Education; nursing; continuing

OBJETIVO:

Compreender o significado que os enfermeiros gerentes atribuem à sistematização da assistência de enfermagem, desenvolvido em seu cotidiano de trabalho.

MÉTODOS:

Método fenomenológico, referencial da estrutura do fenômeno situado. Os sujeitos foram treze enfermeiros, gerentes de um hospital universitário. A análise incluiu transcrição e leituras dos depoimentos visando a essência por meio da tematização, interpretação e a síntese do fenômeno.

RESULTADOS:

As categorias temáticas foram: recursos humanos na realização da sistematização da assistência de enfermagem; sua relevância para o trabalho do enfermeiro; dificuldades na sua implementação; capacitação para a sua realização.

CONCLUSÃO:

O significado que os enfermeiros gerentes atribuem à sistematização da assistência de enfermagem relacionam-se aos aspectos legais da prática profissional, ao trabalho em equipe, ao dimensionamento adequado de recursos humanos.

Cuidados de enfermagem; Gerenciamento de prática profissional; Processos de enfermagem; Recursos humanos de enfermagem; Pesquisa qualitativa; Educação continuada em enfermagem

Introduction

The systematization of nursing care (SNC) is characterized by a set of interrelated actions whose purpose is the care provided by the nursing staff.^{( 1 )} It can be understood as the organization of the necessary conditions for the completion of the nursing process.^{( 2 )}

The nursing process is constituted in action filled with meanings, it is possible for it to be used by nurses as a methodology for provision of care; however, challenges are presented by its implementation.^{( 3 )}

Nursing utilizes the SNC as a model of the working process that enables nurses to systematize assistance and direct care, contributing to the safety of the user and the professionals in the health system.^{( 4 )}

In the undergraduate experience, nursing students experience a practice that prioritizes the need to master science and construct knowledge sustained by theories to support systematic, comprehensive and individualized care, to the detriment of professional donation, historically arising from a charitable vision of care.

The SNC is a scientific instrument that provides to the nurse the planning and systematization of his actions. As a method in the process of nursing work, it brings increased visibility to his actions.^{( 5 )}

Its utilization in daily nursing enables better planning of care and ensures accountability together with the patient being attended. It permits the diagnosis of the needs of the patient, making the adequate prescription of care and it can guide decision-making experienced by the nurse as a nursing team leader, promoting the autonomy of the profession.^{( 6 )}

Thus, the daily activities of the nurse are quite diversified and complaints of overwork are not uncommon, requiring the prioritization of some activities over others. Thus, the nurse tends to privilege or move away from activities that do not appear to be as relevant. Given the importance of systematization in the current context of the nurse and considering the broad discourse of literature about the subject and even our personal questions, our concerns are configured into the question: How is the implementation of the systematization of nursing care demonstrated to unit nurse managers?

The theme is relevant to nursing practice, seeing as the perspective approach enables reflections about the process of management work in nursing. We hope to contribute to the evaluation of professional practice of nurse managers, restore the importance of the implementation of systematization of nursing care in the management of care and support the educational process in the development of this theme.

Therefore, the objective of this study was to understand the meanings that nurse managers attribute to the systematization of nursing care implemented in their daily work.

Methods

This research was conducted based on the phenomenological framework, considered a philosophy and a method of research. A pathway to understanding the life experience of individuals and the meaning they attach to their experiences.^{( 7 )}

This study is based on the method of situated phenomenology, which has the following steps: description, reduction and comprehension.^{( 8 , 9 )}

The description includes three elements: perception, conscience and the subject. At first we sought to hear testimony about how the subjects perceived the systematization of nursing care in their daily work. Then, the phenomenological reduction selected which fragments of the description were considered essential. Third, the phenomenological comprehension revealed the meaning of what is essential in the description and in the reduction, enabling the understanding of the phenomenon of systematization of nursing care in the daily work of nurse managers. Based on this meaning, the synthesis of significant units was performed, allowing the construction of thematic categories.

The region of inquiry, of a philosophical nature, consisted of interrogating the situation experienced by nurses, unit managers of a university hospital, regarding the systematization of nursing care.

The peculiarity of the work of these managers is that they are the only nurses in their work units, performing management and care activities. The units in which managers worked consisted of medical and surgical units in a hospital organization.

The hospital, the setting of the study, had 415 beds (general and specialty) and 52 ICU beds for care, mostly in the tertiary level of the Sistema Único de Saúde (Unified Health System - SUS).

At the time of data collection, the nursing department had 60 nurses, an insufficient quantity to enable more than one nurse in the medical unit and surgical unit.

We listened to a total of 13 nurses, a number defined by theoretical data saturation. Audio-recorded interviews were conducted, with the consent of the subjects, to which the research question was proposed: As a nurse manager, what is the significance of the systematization of nursing care in your daily work?

The first stage consisted of an ideographic analysis, individual analysis of discourses. These were numbered I to XIII, transcribed, read attentively and units of meaning were identified for comprehension of the essentiality of each statement. In the second instance, a Nomotetic analysis was conducted, which involves the generality to capture and reveal the phenomenon through the themes and subthemes, interpreting statements, seeking the similarities, differences and idiosyncrasies, and using as a theoretical framework of analysis, the literature about the topic in nursing management and systematization of nursing care. The last step, the realization of the synthesis, integrated this essentiality and possibility to know the structure of the phenomenon: meanings attributed to the systematization of nursing care by unit nurse managers.

The study was developed attending to the national and international standards of ethics in research involving human beings.

Results

Four themes were constructed: human resources in achieving the systematization of nursing care; its relevance to the work of the nurse; difficulties in its implementation; the capacity for its realization.

The category reveals that human resources are essential to implementation of the systematization of nursing care. At the institution, these resources are represented by higher education professionals, nurses, technicians and nursing assistants, active in care process. Technicians and nursing assistants participate in the systematization of nursing care, working in direct patient care, executing the prescriptions of the nurse, recording annotations about the care provided and executing activities delegated by the nurse.

The subjects considered the systematization of nursing care of grand importance for the care and, even if it was not completely implemented, attributed to that same responsibility in providing quality care to patients. They perceived that they had distanced themselves from the activities directly related to the patient, for assuming activities related to the administration of the unit.

They also expressed dissatisfaction regarding human resources, as those who concentrated on scarcity of these resources in the institution, especially nurses, who need to develop actions of management and care competence, knowing that the activities required for unit management demand time in their work. In their daily lives, they need to participate in several meetings, develop staffing schedules, reports, among other things that keep them away from care activities.

One of the major difficulties for the implementation of the systematization of nursing care is human resources. A majority of the subjects also revealed that it is impossible to implement its use for all patients and, therefore, they have to prioritize those who they believe needs it most.

They cannot conduct the systematization of nursing care with all patients because of a lack of nurses, they are unable to record the care provided. The records of the systematization used in the institution are sometimes not completed, considering that there is not enough time due to the excessive activities of the professional and the shortage of nurses in the work unit. Proper numbers of nurses would enable the adequate conduct of clinical and managerial activities.

There is a paradox in the conception of the role of the nurse. While most understand that, being unique and responsible for the unit, her primary function is management, others, although they acknowledge that there are problems related to the shortage of human resources, prefer to move away from management activities, dedicating themselves to care, in order to harm patients.

There are nursing attendants designated for providing care. Many of these professionals already have formal qualifications as a nursing assistant, but are registered and are paid salaries of attendants. This situation constitutes an aggrivation that hinders the implementation of the systematization of nursing care.

In this category it can be observed that the systematization of nursing care is one of the main tools for the planning of care and development of clinical competence of the nurse.

In this sense, the study subjects considered systematization of nursing care relevant to daily professional practice, by conferring another dimension to the care. It provided specific care for patients, allowing the monitoring of the evolution of their clinical status from admission to discharge.

The testimonies revealed that there was a demand for management of the technical service of nursing for the implementation of the systematization of nursing care in the units. The printed forms were established, but there were difficulties in extending these to all patients. Although there was an organizational need to establish priorities, it should not be addressed only to the most severely ill patients, because those with less complex needs would be underserved.

The nurses revealed that the systematization of nursing care provided a holistic view, allowing quality, comprehensive care, allowing a better assessment of the patient for the detection of problems and important pathologies. They attribute importance to perceiving the satisfaction of patients that are considered in their singularity.

Among other things of importance, the organization of work of the nursing team was highlighted. For the subjects, systematization directs the care, nursing work and its entire team, and, thus is constituted in legal support of the work of the nurse. In order to practice the profession, the nursing staff needs to be supported according to the ethical and legal precepts and protected from iniquities. However, the record of activity does not always occur.

Some testimonies revealed that the nurses received institutional support for the implemention of the systematization of nursing care, through standardized form in all sectors. It is believed that this standardization determines a form of professional commitment towards systematization.

One statement also revealed that the systematization of nursing care allowed the appreciation of the professional and, therefore, it was possible for the nurse to show her technical expertise.

Nursing is faced with many challenges that contribute to the deviation from systematization of nursing care.

Nurses have many clinical and managerial responsibilities. They are responsible for activities that should not be their expertise, which departs from systematization, because they are the only one in the unit. The other members of the nursing team are also overloaded, suffering from the lack of human resources. This factor leads them to reorganize the work on their own, returning to functional care with resistance to comprehensive actions, pushing away, therefore, the proposal of holistic care.

One discourse mentioned the issue of disrespect for comprehensive care, resulting from the division of tasks. The environment for medication preparation has space for only one person and only one team member was designated for the administration of medications, which refers to a functional form of care.

Moreover, a high turnover of patients, in some units of the hospital, was perceived by the nurses in the study as detrimental to the implementation of the systematization of nursing care and the patient care records.

A statement highlighted the high incidence of interruptions in the work of the nurse, which was characterized as another difficulty in performing the systematization of nursing care. Professionals, students, patients and families had free access to the hospital and, thus, it was common that patients and families interrupt the work of nurses to request information. A solution for this case would be to monitor the movement of people in the wards.

Activities to be developed are numerous and there is only one nurse to to be responsible for them, making it hard to bring them together. The health care expertise covers care in an integrated way, including the care of family members, agents and active participants in this process. For another nurse, care for the family members was part of the managerial competence and not of care.

Another discourse expressed that the medical prescription was used to structure the nursing prescription, including more specific medical care in order to facilitate the work of the nursing team.

The nurses' statements showed the difficulty of implementation, in its entirety, of the systematization of nursing care because of difficulty faced at the institution. For this reason, there were professional frustrations.

Nurses perceived qualification to be a crucial element. According to their statements, the systematization of nursing care needed to be taught by competent persons. The lack of knowledge for its preparation makes some nurses transcribes the medical prescription into the nursing prescription, for example.

Some subjects also referred to the trainees, those taking courses of specialization, among other learners, as facilitators of work and implementation of the systematization of nursing care. They stated that sharing nursing actions with learners provides better patient care.

Discussion

The primary limitations of the study referred to the small number of participants, which do not allow a generalization of the research results, and the amplitude of the studied phenomenon. However, qualitative research proposes profound analysis and discussion of the results, of a located context, in a comprehensive perspective.

The study contributes to the practice of nursing, as it pointed out that to implement the systematization of nursing care, integrated and coordinated work of the nursing staff is necessary along with the development of clinical competence of the nurse. The challenges were related to the overload of the nurse who developed clinical and managerial actions. The educational process was considered fundamental for the application of systematization of nursing care.

The systematization of nursing care has its legal aspect and is inserted in the process of nursing work in order to provide autonomy and visibility to the profession.^{( 10 )}

The knowledge provided by systematization of nursing care is crucial for solidifying professional autonomy. Nurses have their care competency, acting to fulfill themselves, and their managerial expertise, working in management within a technical scope, a hospital, in the team, in human resources, decision making, leadership, continuous education, communication, among others. However, they have been removed from the object of the work - care - and even more have realized and assumed activities related to management of material and personnel resources.^{( 5 , 11 , 12 )}

In that sense, the nurse becomes an invisible professional in the representativeness of the healthcare team, because he focused his attention on administration of the hospital services and not in care management. With this loss of professional identity, the implementation of the systematization of nursing care ends up being underestimated.^{( 13 )}

A different approach in the literature, also found in this study, is the lack of knowledge as a factor that hinders the process of implementation of the systematization of nursing care, as it is associated with the fragmented practice of the phases of the nursing process, with the lack of a theoretical-philosophical reference and with the difficulty of detaching themselves from the biomedical / Cartesian model.^{( 14 )}

So, it is important that nurses understand systematization of nursing care, not as a quick recipe, but as a method that can contribute to the care. A well-structured program of continuous education becomes necessary for staff to understand, aiming systematization as a scientific methodology for conducting nursing activities.^{( 15 )}

A great number of patients overburden the work of the nursing staff. For this reason, it is important that managers of nursing services are qualified to manage, allocate and control human resources in health institutions.^{( 16 )}

As already explained, there are some challenges integrating the path of constructing the systematization of nursing care in organizations: knowledge, the number of nurses in service, their involvement with the process, the valuation on the part of the administration of the institution, as well as indicators of outcome of care. At the same time, this process requires the scientific basis, knowledge, skills and attitudes ruled in the ethical commitment, responsibility and in assuming care of the other.^{( 4 )}

Experience and knowledge are skills used by nurses in order to achieve quality care. Thus, the practical knowledge associated with the theoretical support, promotes a more fundamental care.

The implantation / implementation of the systematization of nursing care requires working with strategies resulting from an elaborate plan that allows staff participation, construction of instruments and implementation of steps based on nursing theories.^{( 4 )}

A further point is that the nursing process improves the quality of nursing records, favoring the evaluation of care and directing the actions of assistance. It provides a better quality of care by the possibility of systematic and individualized assessment and contributes to the continuity of care, giving satisfaction, professional recognition and a nurse-user bond. It enables decision-making and guides the reasoning of the nurse in managing the dimension of the process of nursing care.^{( 4 , 16 )}

It is emphasized that the nurse manager is the professional responsible for coordinating the work of the nursing staff. This work involves actions of direct and indirect care, enabling the development of a differentiated professional practice, thus highlighting the plurality of actions of nurses in the managerial dimension of their work process.^{( 15 )}

Conclusion

The meanings attributed by nurse managers to systematization of nursing care were related to legal aspects of professional practice, teamwork, proper scheduling of human resources. The unveiled challenges refer to resistance to implementation, workload of the nursing staff, shortage of human resources, excessive number of patients, and the dichotomy between the management and care functions.

Acknowledgements

To FAPESP, Fundação de Apoio à Pesquisa de São Paulo (Foundation for Research Support of São Paulo), which supported the scientific initiation scholarship of the author, process 2008/00755-3.

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• Collaborations Penedo RM, Spiri WC contributed in the design, research development, data interpretation, writing, relevant critical review of the intellectual content and final approval of the version to be published.

Publication Dates

• Publication in this collection
  2014

History

• Received
  16 Dec 2013
• Accepted
  11 Feb 2014