Work weaknesses and potentials: perception of mobile emergency service nurses

Rev Bras Enferm. 2020;73(5): e20180926 http://dx.doi.org/10.1590/0034-7167-2018-0926 8 of ABSTRACT Objectives: to know nurses’ perceptions about their work process in a Mobile Emergency Care Service. Methods: qualitative study conducted with 12 nurses whose speeches were submitted to Content Analysis. Results: there are weaknesses related to overload of activities, numerous functions, indirect supervision, risk situations, difficulties in relationship with hospitals, lack of vehicles and professionals, inappropriate places to provide care and lack of knowledge of the population about urgent and emergency care. Potentials were associated with effective interpersonal relationships, continuing training, security when arriving at the place of care, care protocol and taste for what you do. Final Considerations: the identified weaknesses need to be noted by managers and nurses. Thus, they would seek to establish actions to diminish them and maximize potentials, which could improve patient care as well as reduce occupational risks and, in turn, promote workers’ well-being. Descriptors: Emergencies; Ambulances; Emergency Medical Serv ices; Nurses; Occupational Risks.


INTRODUCTION
In Brazil, prehospital care is represented by the Brazilian Mobile Emergency Care Service (SAMU -Serviço de Atendimento Móvel de Urgência). Only in 2012, through Ordinance no. 1.010 of the Ministry of Health, the guidelines for the establishment of SAMU and its Emergency Regulation Center were redefined (1) .
Prehospital care is developed by a multidisciplinary team, which includes nurses and nursing staff (1) . Among the roles of nurses who work at SAMU are management and care, requiring concentration, speed, dexterity, skill, quick decision making, care management, combined with a vast technical-scientific knowledge (2) .
Although this professional needs to add manual and managerial skills, there are nurses who have the facilities to perform good care and have few skills to perform management or vice versa. Thus, it is evident that there may be difficulty in articulating these dimensions in the work process of nurses, which often causes dissatisfaction at work and, in turn, mental and physical problems (3) .
When performing work activities at SAMU, professionals are exposed to occupational hazards, especially environmental hazards, with intense exposure to telephone ringing, horns, noise, light and car streams. Concomitantly, they experience strenuous situations, both physical and psychological due to the profile of patients treated (4)(5) . SAMU activities put workers in complex situations that require agility and quick decisions due to the dynamic and unpredictable nature of service and patient severity. Studies that identify this dynamic are important, showing potentials and weaknesses of the service, as actions can be established to create a safe and healthy work environment for workers. This investigation is justified because it is believed that knowing this reality from the perspective of nurses will contribute to improving the quality of care. In addition, it will enable managers, together with professionals, to plan and establish actions to improve the work environment and optimize patient and worker safety.
In the present study, we adopted the understanding of the work process the activities that the human being intentionally and consciously does. The study aims to produce some product or service that has value to the human being (6) .

OBJECTIVES
To know nurses' perceptions about their work process in a Mobile Emergency Care Service.

Ethical aspects
The study followed the principles of Resolution 466/12 of the Brazilian National Health Board (Conselho Nacional de Saúde), which regulates research involving human beings. It was approved by the Research Ethics Committee, according to Opinion 2,323,274. Participants signed the Informed Consent Form (ICF). Their identities were preserved using an alphanumeric code for their identification: N of nurse, followed by numbering from one to 12.

Theoretical-methodological framework and Type of study
Descriptive study with a qualitative approach, whose data were discussed from the perspective of work psychodynamics. It states that no work is neutral, that is, it is permeated with feelings of pleasure and suffering, which can also be reported for work potentials and weaknesses. Weaknesses lead to suffering and burnout, and the fact of experiencing real life of work must overcome the prescriptions in order to overcome the limits of work organization and deal with unforeseen, that is, with weaknesses (7) .

Study setting
Study conducted with nurses who work in a SAMU based in a city in the state of Paraná. The service provides care in the municipality since September 2003, and acts as a medical regulation service for 21 municipalities of the Regional Health. This service has four Advanced Life Support ambulances (three ground and one rotating wing), five Basic Life Support (BLF) and one Emergency Education Center (NEU -Núcleo de Educação em Urgência). The team consists of 25 nurses, 45 doctors, 60 drivers and 35 nursing technicians.

Data source
For intentionality, nurses from the ground service were invited, who met the following inclusion criteria: being in the active workforce for at least one year. Professionals who were on leave were excluded. To define the number of participants, the precept of data saturation was followed, when by means of speech it was found to be sufficient to configure the study phenomenon, totaling 12 nurses. Theoretical saturation for sample completion is defined as the interruption of the inclusion of new participants in the research, when the previously obtained data are sufficient to configure the study phenomenon. Thus, proceeding with the collection would result in redundancy or repetition of the data (8) .

Data collection and organization
Data were collected from December 2017 to March 2018 by open and individual interviews. It lasted approximately 25 minutes, recorded and conducted by the first author, based on the following guiding question: tell me your perception of your work process at SAMU? In order to ensure privacy and minimum discomfort, interviews were conducted in a private and private place at work, according to participants' availability.

Data analysis
To treat speech, we used the Content Analysis technique proposed by Bardin and followed three steps: 1) pre-analysis; 2) material exploration; 3) treatment, inference and interpretation of results (9) .

RESULTS
Regarding the profile of respondents, it was found that 67% were female, with a mean age of 37.8 years. Regarding time since of Work weaknesses and potentials: perception of mobile emergency service nurses Pereira AB, Martins JT, Ribeiro RP, Galdino MJQ, Carreira L, Karino ME, et al.
graduation and length of service, mean was 13.5 and 4.3 years, respectively. About work shift, 50% worked the day shift. From data interpretation, two categories were obtained presented following.

Weaknesses in the work process of SAMU nurses
Participants verbalized that they experience difficulties in their work process, related to the overload of activities and the numerous functions that nurses need to develop. These aspects are revealed in the following statements: Various responsibilities from the vehicle, check and make up the team of this vehicle, organization of equipment and materials, scale of the team that will act in the following period, from the technical scale, drivers and nurses. We control the oxygen in the yard, the stretchers, the purge, and the space for washing vehicles. If a tire is missing or the oil is missing from the car or a light is burned, we can take it from one car to another. The nurse is the famous handyman. (N1) Activity overload. In case of accidents, it is the nurse who activates the winch, the police and even makes the police report (N4).
Another difficulty revealed by respondents concerns the responsibility of indirect supervision over nursing technicians. This fact is shown in the following statements: The nurse is responsible for the work of nursing technicians even without being present at that time; This leaves a very large gap for the error and you have to answer if anything happens. (N3)

Nurses not following the technician directly is worrying. (N5)
Indirect supervision is a huge difficulty as you are accountable for something you are not directly observing and can evaluate and intervene. (N8) Respondents also indicated that the weaknesses in the work process are experienced by the risk situations to which they are exposed, both when providing care and also where they are waiting for the calls, which was revealed in the statements presented: I have been to the occurrence when I was having a change of fire. We treat patients who have been shot, stabbed, who are marginalized patients, who are linked to crime, drugs, trafficking, and often provide care without the police being present. (N2)

Zero security! Gate that is open 24 hours near drug users and often enter the base. The nursing room has no lock or lock. There is no security and our room is the same, it does not close and it does not lock. (N9)
We go through many risky situations, violent family members, armed psychiatric patients, that in the hospital is not enough, he will arrive contained or sedated. (N10) It also emerged as a factor that hinders the work process of nurses the relationship difficulties with hospital workers. Such experiences were indicated in the following speeches: Respondents experience difficulties in their work process related to inappropriate places where they provide care to patients, leading them to stress. The following lines identify this problem: Extremely tight environment or in the street, or in an environment that is not ours and when we get in the car is tight, with three professionals and the patient, in an emergency situation, where it is necessary to do several procedures quickly and quickly. We live under stress. (N1) We attend inside the patient's house and the family is present and you are there attending, tears streaming, so you think "seal and stop crying! Because it's not appropriate to cry while answering". Public commotion People keep coming at us, touching us, trying to touch the victim and filming. It's a stress. (N12) The lack of knowledge of the population about what are urgent and emergency care needs has a negative impact on the work process of nurses. This is what the following statements show: The population misuses the service, calls to address problems that are not urgent or emergency. Fuel expenditure and employee expenditure. (N9) People ask for ambulance for something they don't need, a sore throat, something they wouldn't need an ambulance. (N12) In addition to being a weakness in the work process of nurses, this situation often causes an overload in the service, also negatively impacting the time of care and patient care that really needs the resource.
of Work weaknesses and potentials: perception of mobile emergency service nurses Pereira AB, Martins JT, Ribeiro RP, Galdino MJQ, Carreira L, Karino ME, et al.

Potentials in the work process of SAMU nurses
Nurses revealed that an effective interpersonal relationship with the team is a factor that facilitates the work process: The performance of work activities by nurses at SAMU is seen as a professional achievement, also arousing feelings of satisfaction.

DISCUSSION
Nurses' work at SAMU is surrounded by the need for skills, aptitudes and requirements. It is also surrounded by the numerous responsibilities and activities to be developed. They are not restricted to direct patient care, but also to managerial functions relating to the organization and control of materials, equipment and the performance of administrative work. These functions, combined with a high concentration requirement and, in a timely manner, associated with care profile and work environment, lead them to work overload. This can lead to occupational stress and impair the performance of your job functions and cause problems in your private life (2) .
In the performance of their work activities, it is essential that nurses consider the ethical precepts, norms and laws governing the profession (10) . As for SAMU, there was a legal deadlock. Nursing Federal Council (COFEN -Conselho Federal de Enfermagem), through Resolution No. 375/2011 and Opinion No. 36/2014, in accordance with the Professional Exercise Law, provides for nurses presence in Pre-Hospital and Inter-Hospital Care, in situations of known or unknown risk. Stresses that all care provided by mobile units should only be performed in the presence and supervision of this professional, including BLF (11)(12) . However, Ordinance 2048/2002 (13) of the Ministry of Health establishes that BLF can be performed without the constant presence of nurses. After the clash, the Brazilian judiciary suspended the COFEN Resolution by injunction and alleges its illegality (14)(15) .
The Ministry of Health did not consider the legislation that regulates the professional practice of nursing when structuring and establishing the necessary composition for patient care by BLF. Furthermore, it left the nursing assistant and technician without direct supervision of nurses, despite its technical responsibility for them. It should also be noted that occurrences attended by the BLF cannot be considered as less complex (16) , since access to SAMU is made by the user and the information is issued via telephone. Nursing assistants and technicians, when displaced to assist patients, go along with the driver only. They may encounter insufficient material or technical-scientific resources to operate in a situation with greater complexity than previously described in the telephone contact (17) .
A study showed that nursing technicians in BLF performed medication administration without direct supervision of nurses after verbal prescription of the distance regulator (16) . However, this practice is the sole responsibility of nurses, as they prepare a report discriminating the urgency in question, the prescribed and executed behaviors, and the patient's subsequent response (18) . Such practice is also advocated at the international level, considering nurses' competence for decision-making, providing greater safety and less risks of care provided (19)(20) .
Regarding safety, it is a fact that the prehospital work environment is seen as peculiar, uncertain and a means of exposure to occupational hazards. The reality of work is not just about care itself through the difficult access to victims, the insecurity in the place of occurrence and the need for assistance inside the vehicle. This reality also refers to the places where assistance should be provided, whether under unfavorable climatic or environmental conditions, public commotion, aggressive people, intense flow of people and vehicles, among other situations (21) .
Investigations have shown that SAMU workers are exposed to numerous adverse conditions. They signal exposure to the hazards of the place of occurrence, such as in the event of an accident, and often encounter the presence of a firearm and other similar objects. Thus, one should not disregard these facts, but take into account all the feelings experienced by professionals in their daily activities, which can emotionally wear them out (22)(23) . The aggressiveness experienced by professionals is due to the profile of the service, in which nurses are directly linked to the population, their weakness, their need to transfer guilt and their emotions (2) .
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Regarding risk situations related to violent family members and psychiatric patients, a study showed that psychiatric emergencies correspond to between 2.4 and 8.9% of the total of care provided (24) . It is a fact that in addition to assisting patients with psychological disorders, they provide care to those who have used licit or illicit drugs, which may be aggressive at the time of care, leading professionals to emotional distress (25) .
In agreement with interviewees' statements, a study showed the existence of problems in the reception of patients taken by the prehospital team in the fixed units (26) . Other research has revealed that, on many occasions, the in-hospital team does not understand SAMU's care profile, objectives, work process and mission. Thus, relational conflicts are established, as well as obstacles to the execution and completion of networking (27) . This situation was also observed with Emergency Care Units (ECU), since prehospital care is seen as responsible for the increase in care demand (28) .
Another issue to be mentioned as a cause of conflict is related to the overload of health services, added to those conducted by prehospital care, since SAMU is supported by Ordinance 2048/2002 (13) . It has the autonomy of the "zero vacancy", in which hospital services cannot refuse patient care. As a result, care must be provided in compliance with the law, regardless of the resource situation of the hospital at that time (29)(30) .
The inadequacy of the prescribed work and the real work are imposed on workers through the unforeseen, evading the prescribed. The activity performed needs to be readjusted in order to approach the required requirements of the task. Thus, conflicts emerge between the worker and what he needs to perform, since, on many occasions, the real diverges from the ideal, causing him to adjust to this reality (7) .
A study conducted in seven Brazilian states belonging to the North, Northeast, Midwest and Southeast regions, corroborates the findings of this research. Participants reported as difficulties the lack of ambulances to develop their activities, either by scrapping or not delivering new vehicles to complete the fleet (31) . In other Brazilian states, studies highlighted as difficulties in the work process: lack of adequate structure (32) , lack of materials, precariousness of the physical space/housing of the team, and lack of human resources (21,(33)(34)(35) ; occupational risk related to traffic accident (34) .
Prehospital service's care profile and its entire work process should be viewed with peculiarities. The setting of action differs from the hospital scope as work activities are carried out on the street, inside the ambulance, at the victim's house, among others. This becomes a challenge for professionals because the work environment is a factor of great negative or positive influence (26) .
Constant exposure generates pressure on nurses during care. Workers often lack protection or safety in space and lack of delimitation, which enables people to observe and even interfere with care (29) . Thus, there is a role reversal, in which the worker assumes the role of subject examined (35) . It is known that acting in certain settings can trigger psychosomatic changes in nurses (2) , and also irritation, waste and frustration (36) .
Stress was also reported by respondents in the present study during care. These results are analogous to research in which professionals identified stress during care as the psychosocial risk to which they were most exposed (34) . High levels of stress are associated with physical and psychological problems, causing workers to look for alternative ways to cope, sometimes taking refuge in drug and alcohol abuse (37) .
Research shows that many service users know little about SAMU's organization, work process and real purpose. This situation causes the service to be erroneously triggered by the population, often to be just a means of transport, providing increased demand and loss of resources made available (26) . This triggers an overload of service and can often harm the individual who really needs care (38) .
For some health professionals working in emergency units, certain complaints made by individuals could be solved at other levels of the network, not being characterized as an urgent or emergency demand. In addition, they consider that this misuse by the population is an important factor for the difficulties in the organization and structuring of the service, as well as influencing the quality of care to be provided (29) .
In this sense, strategies are needed to provide guidance to the population about SAMU in every way, avoiding misuse of this service and, in turn, strengthening care that is needed (39) .
Regarding teamwork, nurses in this study stated that it is a facilitating factor in the work process. Teamwork performed in an integrated manner is a key factor for the good performance during patient care and for it to occur as planned, in addition to contributing positively to resolution of the adversities encountered (2) . In addition, developing their teamwork activities demonstrates mutual trust among professionals, providing not only the exchange of experiences, but also a constant learning, which is of unique importance for the service (40)(41) .
Nurses, through teamwork, develop their leadership role in different services, and state that, when performed well, this role brings quality and effectiveness to the service, which is seen through good results achieved. Concomitantly, interpersonal relationships may be able to provide professional satisfaction (42) .
In interviewees' testimonies, potential emerges in the work process as security when arriving at the place of care and finding other support services and having a protocol of care. A study shows that when performed in an integrated manner between SAMU and other teams, assistance is satisfactory and achieves the expected result (43) . When a friendly and partnership relationship between the services does not happen, it generates loss of resources and difficulties in structuring the network (32) .
Regarding the issue of protocols, they were created with the objective of systematizing care through norms and criteria. For urgent and emergency care, protocols aim to benefit not only patients through assessment and quality of care, but also professionals, by offering protection and safety to workers, as well as minimizing possible health problems and standardization of care (44) .
Protocol is used not only as a tool for the performance of quality daily care through organization and systematization of urgent and emergency prehospital care (45) . It also has the ability to validate professional practice as it establishes its criteria considering evidence, guidelines, and scientific and professional knowledge. Even in the face of unforeseen events, it is essential that emergency services make use of this important tool for quick decision making and other peculiarities (25) .
As established by Ordinance 2048/2002 (13) , for the performance of their work activities at SAMU, professionals must be qualified by NEU (46) . Such continuing education services are important for preserving the 8 of Work weaknesses and potentials: perception of mobile emergency service nurses Pereira AB, Martins JT, Ribeiro RP, Galdino MJQ, Carreira L, Karino ME, et al.
quality of care provided. A quick and effective first approach improves the likelihood of a good patient prognosis and this only occurs if there is continuing education (47)(48) . It also updates the worker about new evidence and established practices and, concomitantly, promotes safety in the performance of their daily activities (42) . In nurses' speeches in this study, professional achievement was highlighted as a factor that potentiates the work. Professional achievement is a protective factor for illness related to nursing work (49) . It goes beyond social recognition by focusing on the ability of workers to feel good and to act safely and quality, even in the face of their own and different adversities (2) .
When there is meaning at work, the process of identifying workers with their work tasks takes place and, in turn, they are proud of what they do. This provides better service to people, as well as positively influences their mental health (50) .

Study limitations
Having been performed with only nurses from a single SAMU, which does not allow generalizations regarding the topic addressed.

Contributions to nursing and health
This study contributes to the knowledge about workers' health as it reveals the perceptions of SAMU nurses about their daily lives. It provides a reflection on the need for strategies for improvement, as well as highlights the potential of the service. They should be explored daily for work process improvement. There may still boost to conduct new research on the topic.

FINAL CONSIDERATIONS
Managers need to have a reflective and critical look at the service structure and the work process of nurses. Weaknesses are pointed to these factors, such as overload for the professional nurse, difficulty of indirect supervision, difficult relationship with hospital professionals, in addition to exposure to risk situations, lack of professional contingent and structure. Thus, managers in conjunction with nurses should plan and establish actions to reduce weaknesses and maximize work potentials pointed out by workers, thus promoting physical, especially mental health.