The meaning of care management attributed by nursing faculty members from the viewpoint of complex thinking

ABSTRACT

Objective

To understand the meaning of care management attributed by faculty members of a nursing course from the viewpoint of complex thinking

Methods

Qualitative and comprehensive research with case studies, and individual interviews with 17 faculty members of a nursing course of a public university in southern Brazil. The data were subjected to comprehensive analysis based on the principle of complex thinking of Edgar Morin.

Results

Two categories emerged: “classical fragmentation versus the contemporary whole” and “teaching care management and the nursing work process”, whereby it was observed that despite the integrating proposal of the curriculum, care management is viewed as fragmented.

Conclusions

Care management must be redefined if it is expected to serve as an aggregator in education. It is necessary to create strategies that enable moments of reflection on the subject, and for education to provoke changes in the work process of nurses.

Practice management; Nursing; Knowledge; Teaching; Education, higher

RESUMO

Objetivo

Compreender o significado da gestão do cuidado para docentes de enfermagem na ótica do pensamento complexo.

Métodos

Pesquisa qualitativa e compreensiva, do tipo estudo de caso, na qual foram realizadas entrevistas individuais com 17 docentes do curso de enfermagem de uma universidade pública no sul do Brasil. Os dados foram submetidos à análise compreensiva à luz do Pensamento Complexo de Edgar Morin.

Resultados

Emergiram duas categorias: “a fragmentação clássica versus o todo contemporâneo” e “o ensino da gestão do cuidado e o processo de trabalho do enfermeiro”, por meio das quais se constatou que, apesar da proposta integralizadora do currículo, a gestão do cuidado ainda é visualizada de maneira fragmentada.

Conclusões

Torna-se necessário ressignificar a gestão do cuidado para que esta tenha um caráteragregador ao longo do ensino. Devem ser criadas estratégias que possibilitem momentos de reflexões sobre a temática, permitindo que o ensino provoque mudanças no processo de trabalho do enfermeiro.

Gerenciamento da prática profissional; Enfermagem; Conhecimento; Ensino; Educação superior

RESUMEN

Objetivo

Comprender el significado de la gestión de la atención para los profesores de enfermería en la luz del pensamiento complejo.

Métodos

Se trata de un estudio cualitativo y global, se llevó a cabo el tipo de estudio de caso, a través de entrevistas individuales con 17 profesores en un curso de enfermería en una universidad pública en el sur de Brasil. Los datos fueron sometidos a análisis exhaustivo a la luz del Pensamiento Complejo de Edgar Morin.

Resultados

Surgieron dos categorías: “la fragmentación clásica versus el todo contemporáneo” y “la enseñanza de la gestión del cuidado y el proceso de trabajo del enfermero,” a través de las cuales se señaló que a pesar del plan de estudios de integralizadora propuesto, la gestión de atención todavía es vista de manera fragmentada.

Conclusiones

Es necesario replantear la gestión de la atención, para que suceda base agregadora de toda la escuela. Para ello, se necesitan estrategias que permiten momentos de reflexiones sobre el tema, lo que permite que la enseñanza provoque cambios en el proceso de trabajo del enfermero.

Gestión de la práctica profesional; Enfermería; Conocimiento; Enseñanza; Educación superior

INTRODUCTION

An organized work process is one of the tools that nurses use to reach their final objective, which is the practice of safe and quality care. These professionals need to incorporate four main dimensions into their daily work routines, namely management, assistance, education and research(¹).

Article 11 of law 7.498/86(²), which regulates the practice of nursing professionals, specifies that the organisation, planning, coordination, implementation, and evaluation of nursing care services are the private responsibilities of nurses. The national nursing curriculum guidelines (“DCN/ENF”)(³) states that higher education institutions (“IES”) are responsible for the education of these professionals, for ensuring that they have the general competencies for healthcare, decision-making, communication, leadership, administration and management, and for providing permanent education(⁴).

Planning, permanent education, supervision, evaluation and the activities cited as being the private responsibility of nurses are instruments that should be used in management. The regulatory law of the professional practice and the DCN/ENF propose that the education of these professionals should promote the development of skills, such as managing the work process(⁵).

However, nurses seem to insist on the paradox of working in a fragmented manner, which suggests a dichotomy between planning and the provision of care. In order to minimise this behaviour, nursing students should have access to curricula and professors that can associate assistance with administrative practices so that these students can incorporate the unified concept of care management(⁶).

It should be noted that the management of care involves a dialogue between the know-how of management and the know-how of care. The coordination of these two dimensions must allow nurses to organise their routine according to the health needs of individuals and, through management actions, improve the provided care(⁷).

With the objective of training competent professionals to work in increasingly complex situations, in 2000, the nursing course of the Universidade Estadual de Londrina (UEL) incorporated the integrated curriculum to rival the traditional teaching model, prioritise an interdisciplinary approach, and pursue foundations from central themes. It adopted theoretical frameworks such as the problem-solving methodology of Paulo Freire and the principle of the spiral curriculum proposed by Dowding, who argued that knowledge should be constructed from the general to specific approaches in increasing levels of complexity and with successive approximations(⁸).

The integrated curriculum is organised through a political pedagogical project to guide teaching actions and ensure that the content is addressed in a comprehensive and interdisciplinary manner throughout the education of students. Thus, the curriculum of the nursing course was divided into 18 modules permeated by cross-cutting topics that cover the four years of graduation. The cross-cutting issues stipulated by national curriculum parameters were called “saps” by the professors of the course, as a reference to the sap of a tree that travels from the roots to the leaves, flowers and fruits(⁸).

The 12 saps that form the curriculum are the social, cultural and historical human being; the social determination of the health-sickness process; the Unified Healthcare System; care management; the care methodology; teaching-service-community integration; health education; communication; scientific research; teamwork; and bioethics and biosafety. These saps are systematically and continuously addressed in the course to ensure the education of qualified, conscious, humane and socially sensible students(⁸).

In this study we decided to emphasize the sap care management, which was initially called nursing management and had a strong conceptual link with the classical theory of administration. Given the conceptual evolution of the course in the pedagogic political project and considering that it should be addressed by professors throughout the modules together with the offered content, we adopted the following research question: what is the meaning of care management attributed by the faculty members of this nursing course?

The aim of this paper was to understand the meaning that the faculty members of the nursing course attribute to care management from the viewpoint of complex thought.

METHODS

This research is based on the dissertation(⁹) entitled “O ensino da gestão do cuidado à luz do pensamento complexo”. This is a qualitative and comprehensive study with case studies conducted at the nursing course of the Universidade Estadual de Londrina by means of semi-structured interviews and audio recordings with 17 faculty members who are in charge of coordinating the 18 interdisciplinary modules that make up the course curriculum. The number of coordinators and modules differs because at the time of the study one member coordinated more than one module.

The case study was selected because the UEL nursing course adopts a non-traditional curriculum with a pedagogical political project that transversally includes the subject of care management in the four years of the course.

The inclusion criteria for selecting the interviewees were faculty members who coordinated the module in 2013, who had worked with the integrated curriculum for at least a year, and who agreed to participate in the research.

Data were collected between March and April 2014 by means of personal interviews with a semi-structured script that contained questions to determine the profile of the coordinators, and the following guiding research question: What is your interpretation of care management?

In order to ensure the anonymity of respondents, they were identified with the letter “D” followed by the number of interview and the course year coordinated by the faculty member. The interviews were comprehensively analysed since a mere understanding of the phenomenon would not be sufficient; the meaning attributed to the phenomenon must also be understood, and that requires putting oneself in the place of another, and understanding the manifestations, opinions, feelings, and beliefs of the interviewee(¹⁰).

The adopted methodological frameworks was content analysis proposed by Bardin(¹¹) in order to understand the content extracted from the interviews and go beyond the meanings detected by simply reading the material. The three stages proposed by the author are: pre-analysis, consisting of skim reading the material; material exploration, which includes the formulation of registry units according to the frequency and intensity with which they appear to form the categories; and, finally, treatment of the results, which involves inference and interpretation of the data, followed by formation of the categories.

The survey results were discussed from the perspective of the theoretical framework of complex thought of Edgar Morin that opposes reductionist fragmentation and therefore denies the simplification and the unicausality of things. This thought seeks to reveal that the knowledge of the parts depends on the knowledge of the whole and vice versa, and, as in the field of education, it is necessary to interrelate the disciplines that are separated by Cartesianism. The three principles that guide complex thinking are: dialogic, recursive and hologrammatic(¹²).

The dialogic principle argues that antagonistic terms, concepts, and notions that provoke the idea of exclusion are actually inseparable, such as order and disorder, real and imaginary, reason and emotion, science and art, and others. Although contrary ideas are articulated, they allow the existence of human beings and promote the evolution of sciences and the universe(¹²).

The principle of recursivity argues that the cause produces the effect and vice versa, that is, society produces the individual through reproducibility in much the same way that the individual produces society through interactions, and building culture and ideas. Consequently, one is connected to the existence of the other(¹²).

Finally, the hologrammatic principle is contrary to fragmentation and Cartesian overspecialization, and is based on the premise of a hologram, in which each part of the record belongs and gives dimension to the whole in which it is inserted. It is therefore understood that the part is in the whole, and the whole is in the part, and that the sum of the parts can be more or less than the whole(¹²).

This study observed the ethical principles of the Brazilian resolution 466/2012(¹³) for research involving human beings, and was initiated only after obtaining the approval of the human research ethics committee of the Universidade Estadual de Londrina, with the certificate of presentation for ethical consideration (CAAE) number 20194013.0.0000.5231, and after the participants sighed the informed consent statement, and anonymity and confidentiality of the data was guaranteed.

RESULTS AND DISCUSSION

In all, 17 interviews were conducted with all the faculty coordinators of the modules, and the results are shown in the form of categories according to the comprehensive approach and the principle of complex thought of Edgar Morin, with special focus on the operating principles of complexity.

Classical fragmentation versus the contemporary whole

Attributing meaning to the term care management produced a strong concept in the statements of the coordinators that was linked to terms such as organization, planning, coordination, administration, as shown below:

Care management happens through tools such as planning, organization, human and material resources, forecast. (D14 – 4^th year)

For care management to happen, nurses need organization and planning instruments, knowledge in human resources, physical resources and materials. (D4 – 3^rd year)

It’s you managing patient care. It’s knowing the steps you have to take to provide the best care. (D16 – 2^nd year)

The results revealed that the terms used by some coordinators to refer to the meanings of care management agree with the classical administration model that has been widely used for decades in health services and is still present in nursing work. Currently, the institutions still show traces of productivity, fragmentation, specialisation and standardisation in the provision of care, which is practiced through control, centralisation, hierarchy and subordination(¹⁴).

This leads to the question of whether the evolution of the sap care management with the implementation of the integrated curriculum was enough to cause changes in the meanings attributed by the faculty members. However, this reflection should also consider whether enough time elapsed for the concepts contained in the institutional documents to be incorporated into the educational practice.

To change this view and the management concept of care, it is necessary to rethink the training of nurses. Educational institutions should seek a management strategy to overcome the inherited model and enable the construction of more qualified professionals by means of integrative attitudes(¹⁴).

The coordinators stated they could not see management disconnected from care, but they did reveal a dichotomy in their statements, which shows they have difficulty reconciling these dimensions in teaching-learning.

Management and care are things that go together. But when we teach the students, we separate them. First you teach them to provide care, and then you say “look, now you have to manage that care”. (D3 – 3^rd year)

We manage care, they are always working together. But in teaching there are moments of fragmentation, where sometimes you manage and other times you provide care. (D1 – 4^th year)

Although the statements revealed some segregation between management and care during practice situations with the students, it is important to remember that these professionals associate the dimensions of care and management in their work process, which allows them to evolve to the concept of care management(⁷). It is therefore necessary to merge the teaching of these two aspects in order to offer students the support they need to provide quality care and to construct a distinctive understanding of this subject(¹⁵).

Moreover, this duality between care and managerial practices reveals that despite the importance of looking at the whole and extending conceptions, there are models that hardly evolved(¹⁶). Therefore, stressing the union of care and managerial dimensions in education can prevent students from forming a traditional and conservative vision of their profession(¹⁷).

It should be noted that the dialogic principle of complex thought is perceived in the work process of the nurses when it comes to the management of care. Recursivity is also linked to the results of this study since it considers the premise that the way teachers teach this sap determines whether the construction of the students’ knowledge will be unified or fragmented, which also reflects on their future professional practice(¹²).

To link the education practices of the educators with the hologrammatic principle of complex thought of Edgar Morin, it is essential to consider care in all its dimensions. The fields of management and care are parts of the whole, and in order to be perceived in this way the student needs to build knowledge in an integrated manner(¹²).

The faculty members must provoke reflection among themselves and among the students, while keeping in mind that knowledge cannot merely consider pathology and biological specificities, but also that human beings are multidimensional, as is the care provided to them. Thus, it is essential to consider the parts as being integrated and perceive the whole through care management, thus eliminating the classic fragmentation between care and management(⁸).

When considering care management as one of the saps of the integrated curriculum it is argued that its operationalisation should be contextualized throughout student education. Therefore, students must incorporate the competency to manage care so that they may create a work process amidst the challenges of healthcare services and understand the needs of the users in their entirety(⁵).

In contrast, some of the statements that suggest a connection with the traditional administrative model consider the meaning of care management in a broader, less rigid manner that is more distant from the classical model of management, as shown in the following lines:

For me to provide care I need to administer care. We’re trying to train professionals who can fully manage, care and management [...] Tend to patient care, for it to happen in the best possible way. (D3 – 3^rd year)

Organise the line of care along which the individual will pass, monitor that individual to receive resolutive, quality and comprehensive care. (D5 – 2^nd year)

Teaching care management and the nursing work process

In the search for the meaning of care management, the statements afforded some insight into the management and care dimensions of the nursing work process. The coordinators mentioned these aspects as being inseparable and stressed the importance of joint organisation to achieve care.

Management and care are complementary. I can provide the best care, but if I don’t plan, don’t assess, the goal cannot be achieved, hence the need for care management. (D5 – 2^nd year)

They are intertwined, I cannot provide care if I don’t manage and I can’t manage, if I don’t know how to provide care. It is highly associated, one cannot survive without the other. (D14 – 4^th year)

Healthcare education should enable the construction of knowledge based on a unified approach to management and care in order to overcome the fragmented and biologicist nature of this education. The professors must encourage students to recognise this form of learning as inseparable, and therefore enable them to continue interconnecting managerial and care activities after they graduate(¹⁸).

By incorporating the essence of care management in their training, students begin to realize that the provision of care directly to patients is also directly related to the management process. Therefore, students will be able to understand that in order to provide care, with all the complexities of human beings, they must reconnect the fragmented knowledge, such as care and management, to attribute a new meaning to learning care management(¹⁵).

According to the coordinators, the nurses are responsible for managing care.

It’s the nurse’s role [...] Management is implicit in all the activities of nurses. (D7 – 1^st year)

It’s nursing, as it were [...] We are care managers. (D15 – 3^rd year)

It should be noted that when the students start their graduate studies, they are unaware of the functions performed by nurses. Inserting them in the fields of practice helps them create ties with health workers and reflect on their duties and responsibilities(¹⁹). Therefore, it is up to the professors to discuss the work process and enable students to understand that their performance will occur within the dimensions of care as well as management, and recognise that these two dimensions are complementary and interdependent(²⁰).

Reflecting on the coordination of management and care can help students overcome the belief that the process of assisting involves more than merely fragmented techniques. It is also necessary to transpose the hegemonic movement in the labour market that still hires care and management nurses, and comprehend that these nurses are the managers of care.

The teaching process is essential for educating professionals that can manage care. The professor is one of the agents of care that can construct complex, contexualised, multidimensional knowledge to counteract the simplification and reductionism that is still present on some education models(⁶).

Complex thought enables the investigation of pluralities and the establishment of relationships between each part of the care management process. Professors need to be aware that, when teaching, this multidimensionality must be approached and explored so students can construct knowledge in a contextualised manner(¹³).

It was noted that although the curriculum proposes the integration of knowledge, the term care management is still viewed in a fragmented manner. For some of the interviewed professors, there is a disassociation between management and care in educational practices.

FINAL CONSIDERATIONS

By analyzing the meanings that course coordinators attribute to the term care management, it was observed that this concept is not fully understood by the respondents since their statements suggest that there is a disarticulation between management and care activities in the nursing practice. The statements also revealed a strong connection with classical administration and the difficulty in articulating care and management dimensions in education. Moreover, few of the respondents had a broad, current and articulated perception of the investigated subject.

Although the interviews were conducted with coordinators of all years, no differences were observed between the conceptual definitions of the coordinators of the initial and final years of the course. This result shows that the coordinators should better familiarise themselves with the concept of this sap so that it may be incorporated and used intentionally, both in theory and practice, throughout the course.

The results also show that the implementation of new curriculum proposals cannot ensure the contextualised and multidimensional education that society needs. The statements revealed that some of the coordinators reproduce traditional educational actions, which is not consistent with the integration proposed by the curriculum.

The dialogic movement defended by Morin indicates that the integrated curriculum created an order that must be followed; however, in educational practices, the meanings attributed to care management have not been unified. To overcome this traditional and fragmented view, the managers of educational institutions should transcend closed concepts and implement strategies that merge these aspects.

The incorporation of these strategies is crucial because change involves breaking away from concepts and paradigms, which can be stressful for those involved. Enabling the presentation of these results to the faculty members of nursing courses in general can encourage reflection on the subject and allow the creation of new meanings that are contrary to reductionist thought.

The faculty of higher education institutions play a fundamental role in the construction of knowledge for nurses in training. Therefore, in addition to technical training, it is important for students to understand the complexity of care and the involved management and assistance that must work together to meet the needs of today’s society.

The main limitation of this study is the inclusion of module coordinators, which limits a full understanding of the phenomenon and prevents the exploration the concepts constructed by the other faculty members of the course. Further studies are required to understand the meanings of care management attributed by undergraduate course students and the extent to which this knowledge was incorporated into the education of future nurses.

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Publication Dates

• Publication in this collection
  2016

History

• Received
  04 Jan 2016
• Accepted
  27 June 2016