Possibilities and limits of organization of nursing work in the comprehensive care model in a hospital institution

Abstracts

O presente estudo aborda a opinião de trinta trabalhadores de enfermagem que, no processo de pesquisa, introduziram na prática cotidiana aspectos de inovação na organização do trabalho, buscando promover a reflexão e experimentação de práticas alternativas de organização do trabalho que se aproximem do modelo de cuidados integrais em enfermagem. Para tanto, foi desenvolvida uma pesquisa qualitativa convergente-assistencial, em um hospital-escola do sul do Brasil, através de oficinas, articulando momentos de reflexão coletiva, definição, experimentação e avaliação de aspectos de mudança na organização do trabalho. Os resultados apontam quatro categorias: cuidados na insulinoterapia; grau de dependência do sujeito hospitalizado; registro das observações complementares de enfermagem; e cuidados integrais no trabalho noturno. Conclui-se, portanto, que a realização da assistência de enfermagem, pelo modelo de cuidados integrais, implica ações institucionais que passam por condições de trabalho adequadas e pela tomada de decisões dos próprios trabalhadores no cotidiano de trabalho.

Enfermagem; Organização e administração; Cuidados de enfermagem

ORIGINAL ARTICLE

Possibilities and limits of organization of nursing work in the comprehensive care model in a hospital institution¹

Posibilidades y límites de organización del trabajo de enfermería según el modelo de cuidados integrales en el hospital

Julieta Oro^I; Eliane Matos^II

^IM.Sc. in Nursing. Nurse of the Internal Medicine Service I at the UFSC University Hospital. Santa Catarina, Brazil. E-mail: [e-mail]

^IIPh.D. in Nursing. Accredited professor of the UFSC's Professional Master's Program in Management of Nursing Care. Santa Catarina, Brazil. E-mail: [e-mail]

Correspondence

ABSTRACT

The present study relates to the opinions of thirty nurses who introduced aspects of work organization innovation into their routine work practices through the research process. Its objective was to promote reflection on and experimentation with alternative work organization practices which are close to the comprehensive nursing care model. To this end, a qualitative, convergent care study was developed and carried out in a teaching hospital in Southern Brazil, through workshops which articulated collective reflection, definition, experimentation and assessment of aspects of change in organization of the work. The results indicated four categories: insulin therapy care; in-patients' level of dependency; recording additional nursing observations; and comprehensive care during the nightshift. It is therefore concluded that undertaking nursing care using the comprehensive care model entails institutional actions which occur through adequate working conditions and through decision-making by staff themselves in their daily work practices.

Descriptors: Nursing. Organization and administration. Nursing care.

RESUMEN

En el presente estudio se analiza la opinión de treinta trabajadores de enfermería que, en el proceso de investigación, introdujeron en la práctica diaria aspectos innovadores para la organización del trabajo, para promover la reflexión y experimentación de prácticas alternativas de organización del trabajo próximas al modelo de atención integral de enfermería. Se desarrolló una investigación cualitativa, convergente asistencial, en un hospital universitario, a través de talleres en los que se conjugan momentos de reflexión colectiva, definición, análisis y evaluación de los aspectos de cambio en la organización del trabajo. Los resultados señalan cuatro categorías: atención en la terapia de insulina; grado de dependencia del sujeto hospitalizado; registro de las observaciones adicionales de enfermería; y atención integral en el trabajo nocturno. Se concluye que la aplicación de los cuidados de enfermería según un modelo de atención integral implica acciones institucionales que van desde adecuadas condiciones de trabajo y las decisiones de los propios trabajadores en el trabajo diario.

Descriptores: Enfermería. Organización y administración. Cuidados de enfermería.

INTRODUCTION

Since the middle of the twentieth century, discussion has been intensifying on the future of work in society, as well as on the organization of work following the hegemonic Taylor-Ford model, which is widespread both in industry and in the production of services.

The Taylor-Ford model is characterized as a mode of production based in the division of tasks, in the specialization and individualization of the worker, in the imposition of time and movement, in separation of functions of control and execution of work, and in the separation of the functions of conception, decision and coordination of the functions of execution.¹

The health sector has been heavily influenced by this mode of work organization, and over time the work in health has become fragmented, with harmful consequences for both workers and health service users. Such consequences are visible in the organization of nursing work - especially in hospital institutions, where nurses, nurse technicians and auxiliary nurses function.²

The constitution of the nursing team in the Brazilian context, being composed of professionals with different levels of training and with attributions differentiated by the Law of Exercising the Profession, contributes to maximizing the fragmentation of care. The nurse, a university-trained professional, directs the nursing services and undertakes the planning and the assessment of the care, most of which is given by nurse technicians and auxiliary nurses, thus strengthening the fragmentation between manual and intellectual work.^2-3 This way of producing nursing care has been shown to be inadequate for meeting the care subject's multiple needs, and in recent decades indicators and experiments for organizing work with a view to comprehensive care have appeared.^4-5

In the literature, the proposal of organizing work in line with comprehensive care is placed as an alternative to the fragmented model.^2,6-7 In this way of organizing work, the nurse carries out all the care within her professional competence for a patient or group of subjects during her shift. This contrasts the fragmented model, in which a worker provides a set of care actions to all the subjects hospitalized in an inpatient care unit. In both these work organization models the nurse plans and assesses the care, as well as providing the more complex nursing care.^2,6

In a hospital institution where the nursing care on the day shifts is organized according to the comprehensive care model and that of the night shift by the functional care model, it may be seen that fragmentation of care occurs irrespective of the shift or the work organization model adopted. Nursing personnel working night shifts, for various reasons, resist changes in work organization. Heath professionals working the day shift, on the other hand, organize the work in line with the comprehensive care model, although they often promote the division of the care activities.

There is a shortage of studies indicating innovations in the organization of nursing work, with views to constructing practice stimulating the vision of the human being as a whole. Changes can occur through critical, reflexive discussion among the team members of issues which are fundamental to routine activities. How the work is organized can contribute to stimulating the nursing worker's creativity and satisfaction with her work, with positive results for the quality of the care given to the patient.^2,4,6

Overcoming this tendency of fragmentation of the work remains a challenge for nursing, and articulating and integrating different workers' actions can maximize comprehensive care practice. Human beings integrate multiple dimensions: biological, psychological, social and spiritual; and constructing more comprehensive care for the subject depends on being alert to his or her multiple needs, on respect for his or her individuality and uniqueness, and on care organization models which move away from the fragmentation of the care.⁸

The hospitals are an important part of the care network of the Unified Health System (SUS) and within these institutions, a significant proportion of the care for the patient is given by nurses. Therefore, addressing comprehensive care entails rethinking that category's organization of work, seeking work organization models which optimize more comprehensive care.

The present study was developed and carried out with nursing personnel working in an Internal Medicine In-patient Unit in a teaching hospital located in southern Brazil, and sought to identify alternative ways of organizing the nursing work, with potential for supporting comprehensive care for the patient.

METHODOLOGY

Convergent-Assistential Research (CAR) aims to provoke changes in care practice, based on the context experienced by the workers. CAR consists of the intentional articulation of the research with the care practice, in a process in which the care actions are incorporated into the research process and vice-versa.⁹

The research was undertaken in an Internal Medicine In-patient Unit in a teaching hospital in southern Brazil, and thirty nursing personnel participated (seven nurses, 19 nurse technicians and four auxiliary nurses), corresponding to 91% of the unit's permanent staff. Three workers did not participate because they were on holiday or sick leave, and one was the researcher herself. The study's subjects were selected by the following inclusion criteria: to be working in the pre-selected in-patient unit and to show interest in participating in the study.

The investigation was held in workshops, which took place between October 2010 and April 2011. The critical-reflexive process, the trialling of proposals for changes in routines and the collective assessment of the results of the research occurred in these workshops.

The research process included holding 20 workshops: four meetings per work team (morning, afternoon and three teams from the night period) each lasting two hours, thus totalling eight hours of work per team. Four workers missed one of the workshops because of private engagements. The first three workshops with each team took place with approximately one week between them; the fourth workshop took place one month after the third.

Aspects referent to care, nursing care and work organization were discussed in the first two workshops. In the third meeting, the members of the study identified in their routine practice aspects of the organization of work in which they wanted to implement changes so as to bring it closer to the comprehensive care model, and strategies were elaborated for trying out the changes in reality. In the interval between the third and fourth meetings, a period of one month, the members of each work group/shift tried out the innovation which had been proposed. In the last meeting they gave a summary of the experience, pointing out the principal limits and the possibilities for putting the changes into action in the routine work practices.

Data collection took place in the workshops carried out, during the work hours of the participants in the research. While the workshops were being held, the patients were cared for by the workers from the other shifts, thus preserving the quality of the care. The discussions were recorded on a digital voice recorder with the participants' authorization, and were later transcribed by the researcher and presented to the study participants for validation at the next meeting. The information was stored on a computer used exclusively by the researchers and was later to be destroyed.

Data analysis was carried out in accordance with the accounts of those taking part in the research. This process happened through the thorough reading of the accounts obtained in each workshop. The material was grouped by similarity, and analytical categories were constructed based on each group's practical experience, on the results obtained in each experiment, and on the participants' assessment regarding the results. The categories resulting from the study were: comprehensive care for the patient on insulin therapy; reorganization of the allocation of tasks in the comprehensive care model; recording of nursing actions; and the challenge of providing comprehensive care at night.

The study followed the guidelines of Resolution 196/96 of the National Health Council (CNS),¹⁰ and the project was approved by the Federal University of Santa Catarina's Committee for Ethics in Research involving Human Beings (CEP/UFSC), under protocol number 1014/10. So as to preserve anonymity, the study members' statements were identified by the letters "NS" (Nursing Subject), followed by a sequential number.

RETHINKING THE ORGANIZATION OF WORK: RESULTS AND DISCUSSION

The study's development in workshops made it possible for the workers to rethink internally their practices, assessing easy and difficult points for organizing work in the comprehensive care model, as well as formulating proposals to be tried out in reality. The day workers (morning and afternoon), who adopted the comprehensive care model for the organization of work, used the research space to discuss and improve certain aspects of their practices which do not reflect comprehensive care. Among these, 'care for the patient receiving insulin therapy' and 'introducing changes in the preparation of the chart for distribution of activities for care provision' both stand out. Two teams which work at night chose to try to organize work in line with the comprehensive care model. The third team operating at night chose to introduce changes in the organization and form of the records of nursing activities made in the patient's hospital notes.

Comprehensive care for the patient receiving insulin therapy

The care for subjects hospitalized with diabetes includes, as a habitual protocol, the undertaking of the Capillary Blood Glucose Test (CBGT), which is generally undertaken before meals, so as to evaluate the treatment and/or define the dose of insulin to be administered by the nursing workers in following the doctors' instructions. In the unit being studied, even in the morning and afternoon periods, in which the work is organized according to the comprehensive care model, the blood glucose test was carried out in all the patients by only one nursing worker. This way of working does not reflect the logic behind comprehensive care, nevertheless the workers understood that this way of organizing it speeded up the work, as each care unit has only one blood glucose meter, which makes it difficult to organize individualized work.

With the research, in one of the day groups, all the workers started carrying out the tests and the correction of blood sugar levels with insulin therapy on the patients under their care. The reasons why the workers understood this change in their work routines as logical are described below.

As individual care, when a person who isn't caring [for the patient] goes to do the blood sugar test and afterwards another one goes to give the insulin, the patient gets confused, saying that it's already been done - he gets lost. If the same person were to do the blood sugar test and the correction, the patient can't get confused and the care becomes more individualized too (NS-20).

In the assessment of the proposal, the study's members pointed out that the existence of only one blood glucose meter in the unit for carrying out all the blood sugar test controls posed a difficulty for putting the new approach into action. This fact, however, did not stop the change taking place, nor the positive evaluation of its results for care.

It looks like we haven't had much difficulty, despite there being only one [blood sugar] meter. Even like that, we can still get it done. One [worker] takes it first, then another. There haven't been any rows over the meter (NS-21).

One can perceive this group's determination to maximize and valorize the care offered to the patients and their satisfaction in keeping up this action in their daily practice.

They always ask about the result and we tell them there and then whether they'll need insulin or not [...], so he knows the same person will soon come back to do it, and when he doesn't need it it's the same thing, we say it won't be necessary to give the usual insulin this time. I think it's calmer, there isn't that confusion: have they done it yet? (NS-26).

Stimulating creativity and innovation at work, when appropriately done, can allow workers to take pride in their work, with positive results for it and the subject being cared for.¹¹ The innovation proposed for the organizing of work is reflected in the relationship with, and the commitment which the team establishes with, the patient at the time of the care. The motivation which led the workers to promote the change excelled, overcoming even institutional limits such as the insufficiency of materials for individualized care. In the research's results, the participants in the study assessed that the comprehensive care model has potential for offering the patient nursing care which is safer, and that it can also contribute to the satisfaction of the worker and her self-realization with her work.

Reorganization of the allocation of activities in the comprehensive care model

In the unit studied, in the morning and afternoon shifts, one nurse takes responsibility for the care of four or five patients. It falls to the nurse to organize the duties and the decision about which subjects are cared for by each of the nursing staff. In order to define this, and in order to prepare the allocation of duties to staff, the nurses assess each patient's dependency on nursing care, avoiding overburdening any single worker with work. This way of organizing the work is not always considered satisfactory, and - according to the participants in the study - creates bad feeling between the nurse technicians and the auxiliary nurses, and interferes in their relationship with the nurses, and hinders the realization of comprehensive care.

During the investigation, the participants in the study - these being the nurses, nursing technicians and auxiliary nurses - started undertaking a daily review of the distribution of the beds together, seeking a more balanced division of the work. Each patient's care needs and the proximity of the rooms/beds of the subjects being cared for by specific workers were taken into account in this division, reducing the physical strain of moving around the unit's physical space.

Assessing the result of this innovation, the participants in the study highlighted the positive aspects and decided to adopt them routinely in the unit.

When you notice something in the task allocation schedule which didn't work for you, try to warn us before your shift ends [...], before we sit down to start our shift, to give time to change, before our colleagues take over the care (NS-21).

This week I was with different patients all week, both a bed-ridden patient and two independent patients. And hey, it was good! (NS-30).

In the opinion of the participants in the research, the practice showed the potential of the participative experiments in managing care, for the worker's satisfaction and for the result of the work. These findings coincide with findings already described in the literature.^11-12 The fairer distribution of the patients per worker can optimize the organization of the work in the comprehensive care model.

Recording the nursing actions

The nursing records are fundamental for the care, as they make it possible to disseminate information about a patient's situation, and are used by the other shifts and health professionals.

In the institution studied, the nurses use a printed form titled "Nursing Observations" for each patient. In each shift, nurse technicians and auxiliary nurses must note in this document a report of the care and treatment given, progressions in conditions, and other relevant situations.

During the day, which is when the work is organized, each worker records the occurrences referent to the patients under their care, in line with the comprehensive care model. At night, when the activity-oriented approach is adopted, through division of the tasks, one worker records everything that happened with all the patients, even if it was not her who observed or provided the care. This way of working, according to the perception of the group entails situations which may be forgotten, and results in notes which are impoverished due to the excessive amount of information to describe, and overburdens the person responsible for the activity. It should also be emphasized, although this was not the object of discussion by the group, that this practice has ethical implications.

Based on the practice developed in this study, one group of workers started carrying out the activity together (nurse technicians and auxiliary nurses). Putting this proposal into action also led the workers to take responsibility for the commitment to share information with each other so that the records could be made. The result was considered positive by all the members of the group, as it made it possible to get to know better the patients under their responsibility, intensified the relationship among the workers and allowed a more reliable report of the care given and the complications in the patients' conditions. It is stressed that this procedure was incorporated into the dynamic of the group.

For us, it made a great difference [...]. We're going to carry on with it, it's a little thing, which got changed and makes a difference. The division we made [...] helps us to get to know each patient better (NS-15).

The recording of nursing actions and the complications in patients' conditions is one of nursing's commitments, and cannot be disassociated from the assistential care; to a degree it is this that ensures continuity of care, the safety of the patient, and the protection of the worker.

According to the profession's Code of Ethics, all nursing workers are obliged to note down the situations which occurred and the care given, this being indispensable for the continuity of the treatment of the people under their care.³ This condition, however, has not been observed by workers in reality, and influences the comprehensive care and the safety of the patient. This study's results are presented as a first initiative for correcting this distortion in practice, bringing practice closer to the profession's precepts, which are to provide safe care to all those cared for by nurses. In ensuring safer and more reliable notes on the patient's condition and on the care given, the professionals are collaborating in the continuity of the care.¹³

The challenge of providing comprehensive care at night

Among the study's participants, two night shift teams tried organizing the work using the comprehensive care model, during a period of 30 days. According to the participants in the research, the results were considered positive, leading to the discussion of the following aspects of the care; the reviewing of the already 'crystalized' ways of "doing" the work; the perception of the patient in other dimensions apart from only the biological one; the shaping of the link between the worker and the patient; and a more attentive view of these subjects.

I managed to sit with Mr X at his notebook and see his photos, of his family, which is something you don't always have time for [...]. Of course it was much later, after doing everything, but I managed to sit for ten minutes, to converse a little about his problem [...]. We end up not letting ourselves sit with the patient you're caring for and chat, and I thought it was great [...]. When I was caring for Mr Z, I was talking with him and I went to help him get changed, I saw an old dressing from a lumbar puncture, that he hadn't shown anyone. As I had been there talking and I went to help him change his shirt and so on, because of him being independent and not asking for help much, because of being more reserved, that dressing had stayed there, so, in some matters you end up being more dedicated to the patient. We [staff] ended up discussing the things which we've been doing for years together and which we ended up getting used to and because we liked it that way [...]. So, there was more exchanging of information (NS-17).

In contrast, although the teams were interested in making the distribution of activities happen in line with the comprehensive care model and made the effort, the limiting factors for maintaining this way of organizing work during the night shift stood out from the experience.

One first difficulty, raised by the participants in the study, concerns the inexperience and the lack of skill and speed for organizing the work in line with the comprehensive care model.

Even without many seriously-ill patients it was pretty tight, maybe through lack of practice. We didn't have time to eat, the care took until 11 o'clock. [...] It was very rushed. We didn't have the skill to carry out all the care stipulated within the arranged times, often [all], the workers sacrificed their meal break so they could deal with the needs of the job (NS-17).

Every day, towards the end of my shift, I was thinking that we weren't going to manage. It was different from how we were used to doing it. [...] one person dealt with medications and we didn't need to go to the nurses' station to do the medication, we did everything we had to do outside, and it went quicker (NS-19).

Taking into account how short the period was in which the proposal was experienced by the workers, it is understandable that the participants in the research had difficulties in providing individualized care to the patients. The comprehensive care model requires more time for carrying out the work, this being inherent to changing the activity engaged in, in contrast to the division of work separated by task, in which the repetition of tasks with the same worker being kept performing the same activity speeds up the work.¹

The workers did notice, however, the positive aspects of the comprehensive care model and justify the investment in more comprehensive ways of caring. While the activity-oriented organization of the work stimulates a mechanical perspective on the object of the health work and reduces the worker's creativity and involvement, drifting away from the global vision of the subjects to be cared for and their needs, in the comprehensive care model, the focus of the work is on the patient and not only on the tasks to be undertaken, which intensifies the link and the relationship of confidence with the subject, creating more satisfaction and safety for all involved.^2,6

The workers who participated in the study indicated, as obstacles to the provision of comprehensive care, the number of staff on duty during the night and the amount of care necessary, considering in particular the bed-bound patients. Concerning this aspect, they suggested that one way of viabilizing the distribution of activities in line with the comprehensive care model would be the allocation of one more nurse technician on the night shift, as this would permit working in pairs, facilitating the organization of work.

[It would be necessary to] increase by one the number of nurse technicians, so that when it is time to get the patients changed for bed, we can form pairs to speed up the care [...]. Demand was heavy, that's what I felt [...] a great weight, and I left feeling very tired (NS-17).

Associated with the number of staff, there is the concentration of activities in the initial period of the night shift, and this is a limiting factor for organizing the work, both in the functional care model and the comprehensive care model. Most of the direct care for the patient occurs before midnight. After that time, the team concerns itself with permitting the patients to sleep and relax. This condition of night work reduces the time necessary to accomplish all the tasks.

Night time is for sleeping, [...] after midnight they're sleeping and there we are dragging [furniture], turning on the lights and opening the door of the bathroom. It doesn't make sense [...]. At night, how late are we expected to be making noise and dealing with the patients? We try to have everything ready by midnight, but there were so many patients that we weren't managing. [...] and that went dragging on (NS-19).

This aspect of night work has not been sufficiently addressed in the literature when it deals with the organization of the nursing work. In the context studied, not even the managers had discussed this condition. Generally, the approach to the night work considers the amount of work divided into the work period of twelve hours. The issue of the patients' sleep is a real condition, and some studies have highlighted the complaints of patients when the team fails to observe the silence necessary for night-time rest.⁴

Another aspect limiting the organization of the work, in the comprehensive care model, is regarding the work day of twelve hours followed by an interval of sixty hours of rest, as well as the interval for nursing workers to rest during the night shift. In the institution in the study, the nursing workers' work period, on the night shift, was defined based on the understanding of the influence of night work on the worker's physiology. For the participants in the study, the work period also makes it difficult to get to know all the patients, due to the high turnover of hospitalizations. From this perspective, they state that when the work is accomplished using the functional care model, the worker, in her twelve hours of work, can manage to learn a very little about the patients. In the comprehensive care model, she gets to know only a small number of patients during each shift. Bearing in mind the high turnover of hospitalizations, the worker has the feeling of entering an "unknown" environment - a new unit with each shift.

At night, we work one night on and two nights off. I like to go into all the rooms, to say good-night, to chat with everybody a little. When we're working with the functional system, I can manage that [...]. So, what I noticed during these shifts, done that way, is that I didn't get to know all the patients, for example, when I came on the next shift, some people had been discharged and I didn't know (NS-17).

Along with this problem, of the night shift work period, the workers' night-time rest increases the feeling of insecurity in relation to the care which must be given to each patient. Four nursing workers work on the night shift, these being one nurse and three nurse technicians and/or auxiliary nurses. The rest periods are organized after midnight such that two workers relax while the other two are responsible for the care for all the patients. This condition hinders the distribution of the activities in line with the comprehensive care model because at that time the workers are taking responsibility for all the patients, even those whom they do not know. This is considered negative both for the worker and the patient who, from one moment to another, in the early hours, when he is sleepy, sees somebody appear in front of him who he didn't even know was on duty.

In carrying out comprehensive care [...] we lost the notion of the whole and were too slow to get to know all the hospitalized patients [...]. Some patients only had contact with a member of staff in the morning, causing a certain insecurity or anxiety in the patient. In the early morning, patient X, who had antibiotics at two [o'clock] and who already knew me, said this: I didn't even know you were here today, you didn't come here. He made this comment because I hadn't gone into his room yet and it was two a.m [...] he figured something was wrong. Another patient, when I went to do the two o'clock antibiotics, said: 'Where did you come from?' (NS-17).

[On] your way back from your rest break, one person describes the events which occurred to the other, and it is very bad for you to take over an entire unit without having a notion of everything that happened with the patients (NS-2).

The aspects identified by the night staff as limiting the organization of the work, under the comprehensive care model, led the workers to perceive situations which were negative for them, such as the increase in workload and physical and psychological strain involved in effecting this form of care.

It becomes more tiring. How can I put it... it becomes heavier, because things get more piecemeal, it's as if there were more things to do, you really do have to take care of more things. Under the functional care model, on our shift, it's different, because we know that we three help each other, we reached a state of harmony where all three of us could work together very well (NS-3).

Most studies dealing with night work in nursing with an approach based in ergology and worker's health relate its effects to the alteration in sleep habits, and in the implications of this for strain in the worker.^14-15

In the hospital in the study it was possible to perceive a certain belittling of night work, both among the institution's managers and the day staff. Night work is perceived of as lighter, requiring less dedication. This perception of night work is felt by the nursing staff who work at night, and does not contribute to thinking of alternatives for work organization which are more comprehensive. It is understood that, in spite of its particular characteristics, the night work is very similar to that of the day, with the same objectives and commitments: to ensure quality care to the patient. This being the case, promoting changes during night work may be more difficult and slow, and requires the commitment from the institution and workers.

The ergological approach to work brings a significant contribution to understanding the questions raised by the participants in the study. Management of the work cannot be disassociated from the management that each worker applies to herself. In each situation there is the subjects' will, determining the cooperation which they establish among themselves, which can determine the success or failure of a specific experiment.¹⁴ All management presupposes choices, arbitration and hierarchization of acts and objectives, and, therefore, of values in whose name these decisions are developed.¹⁵ In undertaking an activity, there is always variability in the management of the work on the part of the persons who are doing it. The activity is the result of many arrangements: the rhythm of work, the multiple incidents to resolve, the management of obligations resulting from by rules and values. For the author, all work is use of oneself, taking into account use of oneself by others and the use of oneself by oneself.¹⁵ The use of oneself means to say that the work is the locale of a problem, of a tension, a space for possible negotiable situations. A routine task needs resources and skills which are infinitely vaster than those which are explicitly mentioned.^14-15

In these spaces however, the workers, on evaluating the possibilities for change, consider the existing conditions, the limits and potentialities of the change - taking into account that which they are familiar with, their individual and collective experiences, and how much they will have to give of themselves, for the sake of the new possibilities. The choices are made, also, through people taking into account the lower strain on themselves and the group. In this process, the worker takes into account values which she adopts in her practice and in nursing.

The comprehensive vision of the human being is a value of the profession, instilled from the beginning of the training, irrespective of the model of organization of work. This vision, passed on through the professional training, influences the perception which the worker has of her practice. Even understanding the logic of the activity-oriented division of the work, in the collective imagination the vision that "in our work it doesn't happen like that" is defended by the workers and justifies the non-adoption of comprehensive care and the lack of visualization of other proposals for organizing the collective work.

If it is true that the number of workers at night is insufficient, and that the rest of the patients and workers themselves inviabilizes the distribution of the activities in line with the comprehensive care model, would it not be possible to consider establishing two work shifts in this period? Would it not be consistent to organize the workers to attain working conditions which make possible a more comprehensive care for the patient? Many proposals for viabilizing this practice may arise through the actions of the workers themselves, as well as from the institutions'management.

FINAL CONSIDERATIONS

The results evidence possibilities for effecting changes in the context, by building more comprehensive modes of caring in nursing. Despite the limits for developing and carrying out the actions proposed in practice, and despite the difficulties pointed out by participants in the study, it was perceived during the process of the study that these were open to the proposals, and thought up and put into action agreements amongst themselves which made it possible to re-think nursing care and the work itself.

In this perspective, all the work shifts tried out possibilities for organizing the work which were more in line with the comprehensive care model and, at the end of the process, changes were maintained in the daily routine, such as: comprehensive care for the patient on insulin therapy; the organization of the work according to the comprehensive care model, in line with the patient's degree of dependency, and the organizing and recording of nursing activities in the patient's care notes.

Even in the situation of night work, where the limitations were shown to be greater than the workers' capacity to put the changes into action, the process created among them the need to invest in the daily routine, seeking work alternatives which would bring them closer to the patients and their needs. The critical-reflexive process and the trialing of more comprehensive proposals for carrying out their work led them to reconnect with the values of their profession acquired during their training such as, for example, treating the patient as a whole, which itself requires more comprehensive attention.

The difficulties which the participants in the research perceived in adopting the comprehensive care model did not stop them recognizing the potential of this way of organizing work. It follows that realizing these changes in the context can occur through the intensification of the reflexive processes and improvements in the working conditions.

REFERENCES

• 1. Graça L. Novas formas de organização do trabalho. Parte I. 2002. [acesso 2011 Out 15]. Disponível em: http://www.ensp.unl.pt/lgraca/textos164.html
• 2. Pires DEP. Reestruturação produtiva e trabalho em saúde no Brasil. 2Ş ed. São Paulo (SP): Annablume; 2008.
• ³
  Conselho Regional de Enfermagem-SC. Código de Ética dos Profissionais de Enfermagem. Série Cadernos Enfermagem: consolidação da legislação e ética profissional, vol 1, Florianópolis (SC): Conselho Regional de Enfermagem-SC; 2008-1.
• 4. Matos E. Novas formas de organização do trabalho e aplicação na enfermagem: possibilidades e limites [dissertação]. Florianópolis (SC): Universidade Federal de Santa Catarina, Programa de Pós-Graduação em Enfermagem; 2002.
• 5. Matos E, Pires DEP. Práticas de cuidado na perspectiva interdisciplinar: um caminho promissor. Texto Contexto Enferm. 2009 Abr-Jun; 18(2):338-46.
• 6. Costa JS. Métodos de prestação de cuidados [página da internet]. 2004 [acesso 2010 Jul 10]. Disponível em www.ipv.pt/millenium/Millenium30/19.pdf
• 7. Matos E, Pires DEP. Teorias administrativas e organização do trabalho: de Taylor aos dias atuais, influências no setor saúde e na enfermagem. Texto Contexto Enferm. 2006 Jul-Set; 15(3):508-14.
• 8. Morais GSN, Costa SFG, Fontes WD, Carneiro AD. Comunicação como instrumento básico no cuidar humanizado em enfermagem ao paciente hospitalizado. Acta Paul. Enferm. 2009 Mai-Jun; 22(3):323-7.
• 9. Trentini M, Paim L. Pesquisa convergente-assistencial: um desenho que une o fazer e o pensar na prática assistencial em saúde-enfermagem. 2Ş ed. Florianópolis (SC): Insular; 2004.
• 10. Ministério da Saúde (BR). Conselho Nacional de Saúde, Comissão Nacional de Ética em Pesquisa. Resolução 196/96 de 10 de outubro de 1996: diretrizes e normas regulamentadoras de pesquisas envolvendo seres humanos. Brasília (DF): MS; 1996.
• 11. Campos GWS. Subjetividade e administração de pessoal: considerações sobre modos de gerenciar o trabalho em equipes de saúde. In: Mehry EE, Onocko R: organizador. Praxis en salud: um desafio para lo publico. São Paulo (SP): Hucitec; 1997.
• 12. Matos E, Pires DEP, Campos GWS. Relações de trabalho em equipes interdisciplinares: contribuições para novas formas de organização do trabalho em saúde. Rev Bras Enferm. 2009 Nov-Dez; 62(6):863-9.
• 13. Setz VG, D'Innocenzo M. Avaliação da qualidade dos registros de enfermagem no prontuário por meio da auditoria. Acta Paul. Enferm. 2009 Jun; 22(3):313-7.
• 14. Muniz H, Vidal MC, Vieira S. Os ingredientes da competência na gestão da assistência em uma enfermaria hospitalar. In: Figueiredo M, Athayde M, Brito J, Alvarez D, organizadores. Labirintos do trabalho: interrogações e olhares sobre o trabalho vivo. Rio de Janeiro (RJ): P&A; 2004. p. 322-44.
• 15. Schwartz I. Trabalho e gestão: níveis, critérios, instâncias. In: Figueiredo M, Athayde M, Brito J, Alvarez D, organizadores. Labirintos do trabalho: interrogações e olhares sobre o trabalho vivo. Rio de Janeiro (RJ): DP&A; 2004. p.23-34.

1

Recorte da dissertação - O cuidado integral de enfermagem em Unidade de Internação Hospitalar, apresentada ao Programa do Mestrado Profissional Gestão do Cuidado em Enfermagem da Universidade Federal de Santa Catarina (UFSC), em 2011.

Publication Dates

• Publication in this collection
  24 June 2013
• Date of issue
  June 2013

History

• Received
  19 Mar 2012
• Accepted
  18 Sept 2012