Nurses' work process in an emergency hospital service

Proceso de trabajo de enfermería en un servicio de hospital de emergencia

ABSTRACT

Objectives:

to analyze the nurses' work process in an Emergency Hospital Service.

Methods:

a qualitative, exploratory and descriptive research conducted with 17 nurses from the emergency service of a high complexity hospital in southern Brazil. Data were collected through interviews, focus group and document analysis. Data analysis followed the thematic content analysis framework.

Results:

four categories emerged: Work environment characteristics; Assistance dimension; Management dimension; Care management.

Final Considerations:

the nurses' work process in Emergency Hospital Service is characterized by the peculiarities of the setting, with centrality in care and care management aiming at quality care and safety to patients.

Descriptors:
Emergency Nursing; Emergency Service, Hospital; Nurse's Role; Professional Practice; Health Management

RESUMEN

Objetivos:

analizar el proceso de trabajo de las enfermeras en un Servicio de Urgencia em Hospital.

Métodos:

investigación cualitativa, exploratoria y descriptiva realizada con 17 enfermeras del servicio de emergencia de un hospital de alta complejidad en el sur de Brasil. Los datos fueron recolectados a través de entrevistas, grupos focales y análisis de documentos. El análisis de datos siguió el marco de análisis de contenido temático.

Resultados:

surgieron cuatro categorías: Características del ambiente de trabajo; Dimensión del cuidado; Dimensión gerencial; Gestión de la atención.

Consideraciones Finales:

el proceso de trabajo de las enfermeras en el Servicio de Urgencia en Hospital se caracteriza por las peculiaridades del escenario, centrado en la atención y la gestión de la atención con el objetivo de una atención de calidad y seguridad para los pacientes.

Descriptores:
Enfermería de Urgencia; Servicio de Urgencia en Hospital; Práctica Profesional; Rol de la Enfermera; Gestión en Salud

RESUMO

Objetivos:

analisar o processo de trabalho do enfermeiro em um serviço hospitalar de emergência.

Métodos:

pesquisa qualitativa, exploratória e descritiva, realizada com 17 enfermeiros do serviço de emergência de um hospital de alta complexidade da região Sul do Brasil. Os dados foram coletados por meio de entrevistas, grupo focal e análise documental. A análise de dados seguiu o referencial da análise de conteúdo temática.

Resultados:

emergiram quatro categorias: Características do ambiente de trabalho; Dimensão assistencial; Dimensão gerencial; Gerenciamento do cuidado.

Considerações Finais:

o processo de trabalho do enfermeiro no serviço hospitalar de emergência caracteriza-se pelas peculiaridades do cenário, com centralidade na assistência e no gerenciamento do cuidado visando um cuidado de qualidade e segurança aos pacientes.

Descritores:
Enfermagem em Emergência; Serviço Hospitalar de Emergência; Prática Profissional; Papel do Profissional de Enfermagem; Gestão em Saúde

INTRODUCTION

The Emergency Hospital Service (EHS) is a complex setting in Brazilian health care and worldwide. Despite the increasing implementation of care protocols and policies, the care provided by EHS still has weaknesses, especially due to the lack of back-up beds and the continuing demand for care that characterizes these care settings. These characteristics impact the permanence of patients with continuous care needs - those whose emergency and stabilization care has already been remedied - to occupy beds for acute care and observation^(1-2).

The provision of service to a growing and continuous demand of patients gives different characteristics to the work process of nurses at EHS and, consequently, demands a differentiated performance of this professional⁽²⁾. Emergency service nurses need to develop their work process with attitudes that highlight knowledge, technical skills, care management and team leadership in order to optimize resources and develop activities in the shortest possible time⁽³⁾.

From the theoretical-conceptual point of view, the work process is the intervention made on an object by the human being in order to modify it. The two main work processes of nurses are caring and managing. The care process involves the various agents of the nursing team, with the object of caring for the individual, family and community, whose purpose is to promote, maintain and restore health. The work process to manage in nursing has as its object the care agents and the resources employed to assist and the purpose of coordinating nursing care with the sole agent being the nurse⁽⁴⁾.

Care management is intertwined in the various work processes that make up the daily work of nurses. The dialectical relationship between managing and caring, almost as opposite meanings of their terms, complement and unite giving rise to a new, dynamic, situational and systemic meaning that articulates management and care knowledge⁽⁵⁾.

Despite advances in understanding the articulation and complementarity between the nurses' work processes, it is important that nurses reflect on their work constantly to overcome difficulties and adopt critical-reflexive attitudes, especially in critical care settings. In this sense, research on aspects related to the work process are essential and relevant at all times, allowing discussion of different approaches and adding new perspectives to knowledge has already been described in the literature⁽⁶⁾. Therefore, this study aims to answer the following question: how does the nurses' work process happen at EHS?

OBJECTIVES

To analyze the work process of nurses in an EHS.

METHODS

Ethical aspects

The study was approved by the Research Ethics Committee of the reference institution, under Opinion 69091217.2.0000.5346. All participants signed an informed consent after being properly informed about the research. To guarantee participants anonymity, the statements were identified by the letter I, followed by the order number of the interview. For the focus group, the acronym FG was used, followed by the group's order number.

Theoretical-methodological framework and Type of study

The present study is configured as a qualitative, exploratory and descriptive research, elaborated according to COREQ precepts for qualitative research.

Methodological procedures

Study setting

A study conducted at EHS of a high complexity hospital in the countryside of a state in southern Brazil. The service meets the referenced demand of 32 municipalities in the central region of the state, in the areas of medical, surgical and traumatology care.

Data source

Seventeen nurses from a universe of 20 participated in the study, who met the selection criteria: minimum performance of one year in the unit. Exclusion criteria were defined as absence from work during the period of data collection.

In addition, documents were also used as a data source, such as the unit's statistical bulletin provided by the institution's statistical service (DOC 1) and the daily census of patients in the sector (DOC 2).

Collection and organization of data

The work dynamics, as well as the complexity and variety of actions developed at EHS led to the need for multiple looks at the object of study, leading to the selection of data triangulation to analyze the data⁽⁷⁾. Thus, the data were obtained through open interviews, focus group (FG) and documentary data. The data collection took place between August and November 2017.

Work steps

Participants were sensitized about the importance of research and invited to participate in the research during work shift. Initially, individual interviews were conducted with participants in a private room at the institution. The interviews were conducted by three duly trained volunteers with experience in the data collection technique. The interview script had a sociodemographic questionnaire, followed by the guiding question “Tell me about your day-to-day in the emergency service, how is your work process?”.

The interviews were recorded on audio recording devices and lasted an average of 37 minutes and were later transcribed. A preliminary analysis was carried out in order to elect the most recurrent and in-depth topics. These topics were used as focus group trigger themes. Thus, the FG aimed to generate consensus or divergence from the interaction between participants in order to explore the main facets that make up the work process of nurses at EHS.

Four FG were held with three to seven participants and an average duration of 60 minutes. The groups took place in a private room, at a previously scheduled time with the nurses, being led by an animator and three observers, who underwent previous training. The themes from the preliminary analysis were introduced to the groups through a central question.

The first FG had as theme fire extinguishing and the multiple tasks involved in the emergency nurse's PT, in FG2 the theme addressed was the nurses' PT and their instruments. FG3, on the other hand, addressed professional autonomy, barriers to PT, and coping strategies. The difficulty in bringing the professionals together for the meetings meant that they occurred with the minimum number of participants. However, the last group, which had a larger number of professionals (seven), was performed as a validation group, so the results of the previous groups were exposed and validated.

The documentary data aimed to configure the characteristics of the study environment and the other variables to understand the dimension of the nurse's work process in the emergency service, such as flow and patient profile. Documentary data collection occurred continuously during the field research process.

Data analysis

Data were subjected to thematic content analysis, based on the following steps: (1) pre-analysis, with reading of all material for data organization purposes; (2) exploration of the material, to grasp the central ideas by reordering the data in order to group those that had relationship with each other; (3) final analysis, with articulation between data and interpretation of results in order to answer the research question and achieve the study objectives⁽⁸⁾.

RESULTS

Participants were predominantly female (n=10) and mean age 38 years. The average time of profession was 12 years, with an average of 4.9 years of experience in the emergency sector. Regarding professional qualification, most participants had specialization (n=14), with emphasis on the area of urgency and emergency (n=5). Two participants had a degree as the highest level of education and one had a master's degree completed.

From the analysis of the characteristics of the nurse's work process at EHS, the following categories were obtained: Work environment characteristics; Care dimension; Management dimension and Care management.

Work environment characterictics

The work environment of the emergency service stands out for the need for patients to remain in the sector due to the low outflow and/or referral to inpatient units. This makes the work process of nurses involve both patient care in emergency conditions and care for patients whose acute needs have already been ceased, which generates different levels of care complexity for the nursing team. Inpatients care often implies greater time off in activities dissonant to the purpose of emergency work, which results in increased workload of nurses.

In my opinion, it would be an emergency and observation emergency room, so the hospitalization part should already be defined if it goes to the floor, goes to the ICU, goes to the block, where it goes, as we know it is not so the reality here, the observations end up in the hallway outside the emergency room. (I12)

There is a lot here that we end up assuming and becomes our responsibility, cases that I see that would not be for us, would be for inpatient units, but because of high demand, overcrowding, stay with us, so end up being left inmates here and this overloads the staff. (I4)

EHS nurses understand the purpose of their work process centered on caring for patients with borderline life situations, that is, in urgent and emergency situations. Thus, the permanence of inpatients who require continuous care entails loss of identity in the sector. The nurses' statements, below, exemplify the above:

One thing here in the ER is the Braden Scale, I don't agree because how am I going to do a Braden scale and assess the patient every day, schedule him if he's on a stretcher? Sometimes they charge you something that you have to do, I don't think it has to be done just for doing it, but sometimes in our reality I think it's a little bit missing, if you assess each sector, the reality of each care. (I8)

[…] that the emergency was really to deal with critical and immediate cases such as accidents, such as life-threatening complications and that there should not be inpatients here for more than 24, 48 hours, for longer term care, I think the Emergency Room loses its identity a bit with that. (I4)

The documents consulted during data collection corroborate the low reported outflow and the relationship between the volume of inpatients and those arriving at the service. During the study period, EHS maintained a daily average of 52 inpatients. The average of emergency consultations was 30, from which only four patients remained under observation (DOC1, DOC2). From the demand perspective, nurses understand that the patient who arrives at the unit really needs urgent care, because the complexity is consistent with the EHS. Fact that establishes the high demand in the sector as something inherent to the service.

Overcrowding…in three years that I am here I have never seen the emergency room empty, the reality is even because, if you see, there are several municipalities that depend on the hospital, so they depend on us, so will come here when it is more complex so I have no problem about that being full. (I14)

Thus, the context of EHS is characterized by overcrowding. However, this characteristic is understood as inherent in the work environment due to the complexity of the patients. Thus, nurses seek to adapt the dimensions of their work process considering this specificity.

Assistance dimension

EHS nurses are directly involved in patient care due to the clinical severity and complexity of the care provided. From this perspective, care is considered complex and dynamic, including technical-operational and evaluative aspects, permeated by the characteristics of the environment and determined by the clinical profile of the patients. There are some examples of speech below:

It is a differentiated, complex and dynamic sector, because in addition to your work as a nurse, both the procedures that are the competencies of the nurse, probing, the assessment and care with the most serious patient, [...] there is the fact that patients on stretchers, which can sometimes get worse and you have to be always watching and seeing, I believe it is a different work from other units. (I5)

We end up being much more assistance, in the sense that you observe the patient much more than doing the bureaucratic part [...] we already pass in the corridor looking at the faces, because we know, we even know the patient who it's stopping [...]. (I6)

Of this number of patients and the volume of tasks, teamwork stands out as a strategy to achieve the intended purposes in the sector. In this sense, the nurse has an articulating role and performs actions of different levels of complexity, in order to provide adequate care to patients.

You always have to work together, the characteristic of the emergency team is like this, because sometimes you are there in the emergency room you have two patients, in a moment the ambulance calls and says: we are taking five patients, so the team has to work united and not differentiated [...] we end up doing all the activities together. [...] Transport patient to X-ray and tomography, helps staff to see vital signs and hygienics, because it's a huge demand, sometimes has 70 patients for nine nursing technicians, it's impossible for staff to handle it without the nurse getting involved in care [...]. (I3)

I think everyone can see the emergency room as a different place, that you have to be the difference and make this team mediation, the medical [...] team, nurses, technicians, and multidisciplinary teams, the nurse is right in the middle. center because you have to know everything that is happening all the time [...]. (I2)

In the institutional records, there was an average of 4.5 patients on mechanical ventilation per day. In some shifts, there were 10 intubated patients (DOC2). Thus, nursing care in the EHS becomes a different point as it involves several demands, either due to the complexity and care needs of patients, or the workload.

Management dimension

The management dimension of the nurse's work process in the EHS focuses mainly on the need for environment organization and care in order to provide adequate care to patients. In this sense, decision-making appears as an important instrument for defining the order in which care will be carried out and/or prioritized, as well as the realization of other emergency demands, whether administrative or assistance.

Scales, the forecast of staff, material and the medication of the patients, we have to take care of the folders and justifications, go after the doctors, the medication for the technicians is our responsibility, the receipt of blood byproducts, the bandages, aspirations, oral hygiene, punctures, checklists, taking and seeking patients in the block, the baths, the polls, the evolutions, but that's what our daily life is all about. (I8)

We hardly can get in and do a routine, I will suddenly start by visiting [...] you start something and give it a break and you have to go there, drop what you were doing and go there and sometimes just go to the trouble, emergency, trouble and ask here and ask there, you are doing, you cannot even sometimes do what you proposed to you that day, nor the procedures. (FG1)

Nurses are concerned with organizing the work environment through planning, which requires the ability to match available resources to patients' needs. These are assessed by clinical criteria and unexpected demands, based on the “whole view” and unforeseen mediated management.

We receive the patient in the emergency room, if he is going to be hospitalized, you have to see everything, you have to receive the patient, providing care for puncture, probes, diet, stretcher, place to stay [...]. Does he need oxygen? So let's go down the hallway where there's oxygen to see if there's a place. If it's full you have to take someone out and think where you are going to take it and it steals you a lot of time and I find it very laborious [...]. (FG1)

You arrive, make a plan on the shift change, what you have to do on the shift, but many things that you didn't expect come up, so there are a lot of unforeseen things here that hinder your management, which changes your management. (I4)

You have to have the vision of the whole to organize, coordinate, delegate whatever you can [...]. (FG4)

To plan, coordinate and perform care, nurses use the initial assessment from the shift change as a parameter to list and order their activities, as well as other team members. In this context, the relocation of patients from the assessment of clinical status was highlighted, which confers autonomy in the work process of nurses and contributes to the organization of the sector.

I take the duty, write down the events, the issues, leave everything a little separate to discern well, then make my action plan like “such a priority, such a thing”. (I9)

We have a shift change routine where you get the patient information and make an initial assessment of how the customers who were already in the service, try to analyze the issue of infrastructure, materials. (I6)

The emergency room is not to admit anyone, it is for free flow, it is to arrive and stabilize, assist and remove the patient from there, we have the autonomy to relocate the patients here from the beds, remove, put a grave, an intubate. The nurse does have autonomy to come and organize the environment, take the patient who is better from the physical space, we do not get the patient out of bed we take the physical space brings the serious that is in mechanical ventilation inside, [...] organization, management, where we will allocate all these patients is the nurse who does it. (I3)

We have autonomy, this issue on service organization, sector, to assess the most serious yes, we have autonomy. (I5)

During the study period, shifts were recorded with up to 72 patients admitted to the EHS. However, the place has 20 observation boxes and three isolations. The pits rarely remained vacant from one shift to the next, and patients were always accommodated in the corridors, a space called by participants “stretchers” (DOC1, DOC2).

Care management

In the context of the work process of nurses at EHS, nursing care management involves activities performed by nurses to provide care, provide support for planning, performing and organizing work, articulating care and management in their work practice. The activities that promote this articulation involve human resources management, assistance delivery, decision-making and provision of material and infrastructure resources, which were named by participants through the expression “put out fire”.

When we take the duty, it is basically putting out the fire, this is missing, that is missing, the medication has to be taken from the pharmacy, the HU (extra medication request), there is the patient who has to go there to see, the other is without the medicine, the other is without the prescription, has exam to take, was missing it. So, we arrive and try to organize the remaining issues first, so you can start to see, assess the patients, do your things, make bandages, see the patients intubated. (I15)

You have a huge variety of patient cases, so you will put out a fire, because one day there is an employee missing, then you get ready to give care, then there is a stop, then there are more patients, then you have to transfer patients, then you have to be organizing, assessing who is more serious or less serious and everything else too, you do not have a work process already defined, I call it fire extinguishing, you are there to meet the most urgent causes. (FG1)

Thus, the work process is effective through the constant articulation between the management and the care dimensions, merging and materializing in care management, focusing on the immediate resolution of patients' needs or unit problems. The term “put out fire” allows us to infer decision-making as a process of prioritization of tasks, in a sector contextualized by the unpredictability, the immediacy and intensity of care needs and interruptions in care delivery. Characteristics abstracted by sector demand, concretized in the speeches due to complications, in which the dichotomy continuous care versus emergency care stands out.

There is no time, it is a kind of extinguishing fire, it is just doing “have a probe in that”, “aspire that”, “bandage that”, “pass that one here”, “look for that one”. (FG2)

Sometimes you program yourself so you leave care activities already listed, but sometimes you can't follow that because there are so many complications that happen. (I12)

Sometimes you are in a rush, in a call, in an emergency, in a stop, but at the same time there is someone calling you, it is familiar asking you something. (I11)

Care is interspersed with the different management and care priorities, emerging “care in parentheses” exemplified in the following statement.

Yesterday I had to see the NO (Nothing Orally) There were some surgeries that were canceled and the patients were in NO, when I was talking to the secretary the technique came to pass me that I had a patient who was very, very hypertensive he was heart disease and had no prescribed medication, ok what I did? I wrote a note to the secretary saying everything I wanted and went to see the patient, saw the patient talked to the doctor, and went back to the secretary to see the operating room staff. So, I go (pause) it's like parentheses are created within a service you know? When you have a speech that you are writing and you want to (pause) create a parenthesis, it's an action in parentheses! If I were to give a concrete example. (I7)

Thus, the term “put out fire” reveals intermittent caution in the face of multiple work process tasks. This makes nurses use decision-making as a strategy to manage care in the face of the several concurrent and/or sequential tasks that arise from the various simultaneous priorities present in the EHS.

DISCUSSION

The participants' profile consisted of experienced professionals, contrasting with their short time working in the sector, partly explained by the holding of a large competition about three years before the research was conducted. The profile showed a slight predominance of females, with high level of education. The profiles of emergency service nurses generally differ from other settings, with the male population having more experience and advanced qualifications predominating. However, this variation has a cultural influence, so that in underdeveloped countries there is a predominance of women and with less qualifications⁽⁹⁾.

The environment of EHS is marked by overcrowding and patient permanence even after the need for acute care ceases, which generates a large number of patients with continuous care demands with different levels of complexity⁽¹⁰⁾. The permanence of inpatients is a reality in the internationally described EHS that increases the nursing workload, compromising the quality of nursing care and patient safety^(11-15).

Inpatient care compromises care for patients with emergency demands, since tasks related to continuous care require more time from nurses. A study conducted at a trauma care center showed that the greater the number of patients under the care of a single nurse, the longer the time for assessment and diagnosis, influencing emergency service performance and patient outcomes⁽¹⁶⁾. Similarly, nurses reported difficulties in providing care to patients with prolonged stay in Swedish hospital emergencies, as it is a service that is not designed, equipped or structured for this purpose⁽¹²⁾.

The clash between continuous care and emergency care leads nurses to face a loss of identity. Emergency nurses expect to serve patients in life-limiting demands. However, as your work process is taken care of by continuous care, you lose the clarity of roles and work identity and, consequently, control of your environment^(13,17).

The service receives a large number of patients requiring intensive care, which is consistent with the level of complexity of the EHS. On the other hand, it is known that the inappropriate use of high complexity services is seen as a frustration⁽¹⁰⁾ and a source of overload for the team, which may make it difficult to treat the most severe patients⁽¹⁸⁾. In this sense, the emergency service environment shapes the work process of nurses, in which the high and differentiated demand, which involves emergency care and continuous care, implies multiple tasks management, increased workload and, many times. sometimes loss of professional identity.

The unpredictability, complexity of care and high demand make nurses coordinate the team by dividing tasks and delegating activities, which requires clinical sector competence and mastery. Thus, teamwork is emerging as an important means of achieving adequate care in the EHS. The team adapts to the environment of high demand, stress and unpredictability by developing the ability to come together and manage time to save lives⁽¹⁰⁾. Thus, good emergency care happens when each member works as a team, performing their task expertly and quickly^(19-20).

It is also inferred that EHS nurses occupy all emergency spaces, taking care, especially in critical situations, of care and actions necessary for the continuity of care. Thus, nurses are so involved in patient care that they share care tasks with nursing technicians, maintaining in their practice management associated with care, distancing themselves from manage-care dichotomy⁽¹⁹⁾.

Nurses also stand out for their role in care management through the planning, execution and coordination of different tasks in emergency care and inpatient care. To this end, it makes use of prioritization from the comprehensive assessment of care needs as an instrument of its work process. Due to the severity of patients, nurses develop a wide range of specific clinical competences in this area⁽²¹⁾, and also perform bureaucratic activities for the continuity of care by the multidisciplinary team⁽¹⁷⁾.

High demand and intense characteristic of the work lead nurses to maintain space organization to attend to new emergencies. A previous study has shown this dubiousness, where EHS frontline nurses are divided between care for patients who are already in service and those who will come, maintaining a veiled function of being accessible while controlling patient flow⁽²²⁾.

Adaptation to this environment generates the need for planning and organization of actions by prioritizing those patients with signs and symptoms of worsening⁽²³⁾. Thus, the definition of priorities constitutes an adaptation to the environment, in which nurses rank their activities and those of the team when planning care. In this sense, EHS is a complex and adaptive system in which individual and collective behavior are transformed, adapted and organized at the microscopic level forming macroscopic networks⁽²⁴⁾.

One of the skills developed by the nurses in this study is decision-making, based on a global look at the needs of inpatients to list priorities. Patient care according to the severity of the condition, and priority-based tasks are inherent, this principle stems from the idea that in emergency care for critically ill patients, time is crucial to saving lives⁽¹⁰⁾.

In this sense, studies that describe the peculiarities and difficulties of the emergency setting, demonstrate its relevance in providing knowledge that empowers nurses to make a decision and a more autonomous practice⁽¹⁷⁾. The autonomy of nurses was emphasized by defining the priority in patient allocation and care planning. Nurses emerge as responsible for the organization, management and assessment of patient care, which gives greater professional value⁽²⁵⁾.

The emergency is a dynamic environment and involves a “momentary fit in a fluid environment”, where the assessment of severity and anticipation of needs form the basis of its management in order to manage the use of available spaces and create new spaces. Thus, emergency space is an elastic system in which material and human resources can be reorganized to meet the needs of patients⁽²⁶⁾.

Acute situations care is the main purpose of EHS. In this sense, nurses live in constant waiting and feel responsible for preparing the environment for this service. A study conducted with nurses from various countries about their experiences in disasters reports this expectation, in which after the warning of the disaster, one of the feelings involved is the anticipation, in which they organize the environment, moving unaffected patients to free space⁽²⁷⁾.

The emergency presents itself as an unpredictable sector, with uncontrolled workload and information intensity. Adding complex tasks where time is critical, nurses' work is prone to disruption. This situation requires multiple simultaneous tasks management, which combined with interruptions, is seen as inherent in the EHS⁽²⁾.

The term used by participants to represent multiple tasks management was “put out fire”. Their varied jobs have given rise to various interpretations. Much more than simply prioritizing, he describes the stumbling block and interruptions in the work process generated by the diverse industry demands that exposes not only the unpredictable characteristic of the work process but also the intense pace of work.

Another finding refers to the classification of nursing care as “intermittent”, as nurses need to deal with interruptions, emerging “care in parentheses”, which when interrupted the professional breaks his/her care into several moments and may or may not resume it. The cognitive load required by a task influences the impact of disruptions in care delivery, human memory has limitations that make it difficult to simultaneously assimilate multiple information inputs⁽²⁸⁾. However, a study conducted at the emergency department of a hospital in Sweden⁽²⁾ found multitasking as an attractive industry requirement, i.e., starting a new task without completing the last one. It was even justified by nurses as something natural, inherent in emergency work.

In the results presented, emerged all the basic competences presented in a matrix and a profile of professional competence of nurses in Brazilian emergencies created and validated recently. Therefore, it is emphasized that nurses' skills to work at EHS involve focus on care performance, teamwork, leadership, humanization, interpersonal relationship, results orientation and proactivity. Through these skills, nurses' work stands out for the search for emergency care and operational excellence⁽²⁹⁾. Despite performing multiple tasks in the emergency room, nurses develop cognitive mechanisms to maintain their focus on clinical thinking, which is necessary for patient management and care.

Study limitations

The study was conducted in a single emergency hospital setting and only from the perspective of nurses. Thus, further studies are suggested including emergency services from other locations and inclusion of other health professional categories in order to broaden the compression of the problem in question.

Contributions to nursing, health, or public policies

The research allowed ratifying the importance of nurses' work in the service and systematizing their scope, contributing to increase their professional visibility. The study also contributed to the construction of new knowledge about nurses' professional role by providing subsidies for the improvement of work processes at EHS.

FINAL CONSIDERATIONS

The work process of nurses at EHS is characterized by the emergency setting peculiarities, with centrality in management, assistance and care management. Management is strongly deciphered by the constant need for decision-making for care development. Assistance, in turn, is materialized by the clinical criteria and needs of patients, based on a process of observation and assessment. They determine care actions, allow priorities to be established and work organized, in an intermittent care process between continuous actions and immediate/priority actions, characterizing care management.

The reality inherent in emergency services, where interruptions are common and multiple tasks are performed simultaneously, has been materialized by the expression “put out fire”. Such expression reveals care management in the studied setting. Patient demand and flow are configured as the environmental context of the work being directly related to work process configuration.

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Edited by

EDITOR IN CHIEF: Dulce Aparecida Barbosa

ASSOCIATE EDITOR: Alexandre Balsanelli

Publication Dates

• Publication in this collection
  06 July 2020
• Date of issue
  2020

History

• Received
  19 Apr 2019
• Accepted
  19 Dec 2019