Redesigning the nurse admission training process at the Intensive Care Unit

Abstracts

Considerando indispensáveis os processos de desenvolvimento de pessoal nas instituições de saúde e relevando os óbices enfrentados nessa prática, este estudo teve por objetivo reestruturar o processo de treinamento admissional (TA) de enfermeiro na UTI de um hospital privado do município de São Paulo. De abordagem qualitativa, utilizou-se a pesquisa-ação como estratégia metodológica. Para coleta de dados, adotou-se a técnica de grupo focal (11 enfermeiros) e a interlocução com os demais enfermeiros (18) por meio de comunicação eletrônica. Foram realizadas seis reuniões para análise da situação do TA estudado, o que resultou na reelaboração do processo, consistindo em: definição do conceito, objetivos, metas, perfis do enfermeiro da UTI e do enfermeiro-instrutor, conteúdo, instrumento, fluxograma, estratégias, duração e avaliação. O estudo possibilitou, ainda, a discussão dos fatores intervenientes ao TA, como a política de recursos humanos.

Enfermagem; Unidades de Terapia Intensiva; Administração de recursos humanos; Recursos humanos de enfermagem no hospital; Capacitação em serviço

ORIGINAL ARTICLE

Redesigning the nurse admission training process at the intensive care unit^*

Reelaboración del entrenamiento de admisión de enfermeros de unidad de terapia intensiva

Sarah Marília Bucchi^I; Vera Lucia Mira^II

^INurse, Master's Degree in Business Administration in Nursing from the School of Nursing of the University of São Paulo. São Paulo, SP, Brazil. [e-mail]

^IINurse, PhD Professor of the Department of Professional Counseling of the School of Nursing of the University of São Paulo. São Paulo, SP, Brazil. [e-mail]

Correspondence addressed to

ABSTRACT

Considering that personnel professional development processes are indispensable at health institutions and disclosing the obstacles faced in the practice, the objective of this study was to redesign the admissions training (AT) process of ICU nurses from a private practice hospital in the city of São Paulo. Based on a qualitative approach, action research was used as a method strategy. For data collection, the focus group (11 nurses) technique was adopted which favored a dialogue with other nurses (18) via electronic media-based communication. Six meetings were held to analyze the AT status, which permitted to redesign the process and resulted in the definition of the concept, objectives, goals, ICU nurse and educator-nurse profiles, content, instrument, flowchart, strategies, duration and evaluation. Furthermore, the study promoted a discussion on AT intervening factors such as the human resources policy.

Key words: Nursing. Intensive Care Units. Personnel management. Nursing staff, hospital. Inservice training.

RESUMEN

Considerando indispensables los procesos de desarrollo de personal en las instituciones de salud y haciendo un relevamiento de los obstáculos enfrentados en tal práctica, este estudio tuvo por objetivo reestructurar el proceso de entrenamiento de admisión (TA, en portugués) de enfermeros en la UTI de un hospital privado del Municipio de São Paulo, Brasil. De abordaje cualitativo, se utilizó la pesquisa-acción como estrategia metodológica. Para la recolección de datos se adoptó la técnica de grupo focal (11 enfermeros), y se propició la interlocución con los demás enfermeros (18) a través de comunicación electrónica. Fueron realizadas seis reuniones para analizar la situación del TA estudiado, al final de las cuales, resultó la reelaboración del proceso que se constituyó en: definición del concepto, objetivos, metas, perfiles del enfermero de UTI y del enfermero instructor, contenido, instrumento, flujograma, estrategias, duración y evaluación. El estudio posibilitó, incluso, la discusión de los factores intervinientes en el TA, como política de recursos humanos.

Descriptores: Enfermería. Unidades de Terapia Intensiva. Administración de personal. Personal de enfermería en hospital. Capacitación en servicio.

INTRODUCTION

Contemplating assistance and managerial guidelines indispensable to provide healthcare by means of training and development programs targets on promoting personnel's better performance and maintaining organizations' competitiveness and sustainability in the market.

It is unarguable, therefore, the importance of training and developing human resources at healthcare organizations once untrained personnel's performance directly interferes with the outcomes expected from the production. Often enough organizations are economically pressured by the market and have their current social image at risk once they procrastinate training programs, thus jeopardizing their production. Untrained workers produce robotized actions, which compromise the safety of the process and production's outcomes, evidencing the importance of adequate qualification and constant follow-up of workers while they perform their duties^(1-2).

Training is development and both implement rational, qualified and efficacious procedures and they should not be disconnected from a purpose arising from the needs of individual and organizational development representing their actual qualities and transforming individuals in someone who they could actually become^(1-2).

Thus, training and development are a search for increasing theoretical/practical knowledge able to qualify individuals to work efficiently, which corresponds to broadening professional and personal competences standing for tools delivered to individuals to transform the reality. The existence of a human-capital valuation policy able to integrate learning, knowledge and competence supports the training and development programs that stimulate people's self-development⁽³⁾.

Admission training (AT) has been done to prepare professionals of nursing teams to render healthcare based on institutional guidelines and to align them to each institution's mission, vision, values and philosophy.

AT is a systematized process whose objective is to develop skills and competences by means of guided practices including theoretical tutorials and regular evaluation. It can be understood as a resource that promotes the adaptation of new professionals to a certain institution for the purposes of minimizing variations in the care provided, favoring dissemination of norms, routines, procedures and observation of assistance guidelines aiming at, therefore, rendering quality assistance. Nevertheless, and still related to AT, candidates have to deepen their technical-scientific and ethical-political knowledge to provide the care for which they are responsible in the various areas of performance.

The properness of the contents of the nursing teams' initial training process should be the object of analysis and properness to their needs considering the meaning and the objectives of such training program, its duration, teachers and evaluation procedures, among others, so that theory and practice could be effectively integrated⁽⁴⁾.

Nurses' capacity of articulating knowledge and practice in their daily tasks brings them continuous learning resulting from the care provided to patients and the relationship with the multi-professional team, which should be taken into account when an AT is done. The current bibliographical references approaching the AT for nurses in Intensive Care Units (ICU), particularly as to the care provided to adult patients is significant, and most of the studies refer to training ICU's techniques and procedures.

The AT process for ICU nurses, focus of this study, has a dominant role and marks the beginning of the professional education process inside an organization considering that ICU nurses are in charge of providing direct and complex care, of quickly rendering and monitoring information, which determines and changes the therapy proposed for patients, in addition to their being the coordinators of the specialized care provided to patients in serious conditions. Those variables, among others, which interfere with the AT outcomes, should be taken into account when the process is systematized, the consistence with the institution's requirements being observed.

In the ICU of the Hospital where the study was conducted (HCE), the AT for nurses searches for offering subsidies to the nursing care provided to clinical and surgical patients with the objectives of qualifying nurses to interact with a multi-professional team, to correlate signs and symptoms to the healthcare practice and to act proactively to avoid iatrogenic occurrences.

To conduct an AT in the ICU, in 1999 a Script for Nurses' Training in the HCE' ICU was prepared and 36 out of the 39 nurses working in the ICU attended it, out of which 15 had already attended the currently offered AT.

OBJECTIVES

- To analyze the Admission Training process for ICU nurses under the point of view of the ICU nurses in the HFS;

- To restructure the admission training process for ICU nurses under the point of view of the ICU nurses in the HFS.

METHOD

The construction of a qualification process should express the needs of the people who experience it, with their effective participation; thus, for this study with a qualitative approach the strategic methodology chosen was action-research.

This method is developed within a collective structure enabling the participation of the people involved in the problem under investigation, the description and analysis of concrete situations leading to suggestions and interventions oriented towards the problems detected, privileging an empiric approach through a broad and explicit interaction between researchers and the people involved, thus bringing awareness to agents and allowing dynamically studying the problems that lead to decisions and actions towards the process of transforming a situation. Flexible operating phases were set for the researching process⁽⁵⁾. The following phases took place in this study:

Phase 1 - Situational diagnosis

The analysis of the AT scripts conducted in the HFS's ICU from 1996 to 2006, which were used to lever the discussions among the study's subjects, showed aspects mainly related to the contents, strategies and difficulties found in following the nurse instructor. A discussion about diagnosis allowed them to propose the interventions required to restructuring the AT process.

Phase 2 - Selection of subjects

The study was conducted in the ICU of a private institution in the Municipality of São Paulo herein called HFS, which is 110 years old and certified for Excellency by the Brazilian Organization of Hospital Accreditation.

In order to enable the 39 ICU nurses to express themselves and considering the strategy of data collection by means of a focus group, which made unfeasible the participation of all the nurses, the qualitative sampling approach was chosen, which is done by valuating interpretative criteria or argumentatively controlled, thus composing intentional samples.

Thus, the criteria set for inclusion in the focus group were having worked as a nurse in the HFS's ICU for at least three years; being available and interested in analyzing the AT process. 11 (28.2%) out of the 39 nurses who met those criteria were invited to join the focus group.

For the purpose of gathering as many subjects as possible, 28 nurses who failed to meet the criteria were invited to participate in the research by expressing their opinions through electronic messages, as described in the data collection. Out of those 28 nurses, 18 joined in and 10 nurses (25.6%) who were on vacations, on leave or being transferred to another area were excluded, in addition to the researcher.

Phase 3 - Action and data collection for the study

Data were collected by means of the focus group technique which allows, as intended, an approach of qualitative aspects of the reality studied by means of a representation of the collective that experiences the problem⁽⁶⁾.

Concomitantly, there were conversations by electronic means with the remaining nurses, who would receive for analysis the reports of each meeting held. Thus, the ICU nurses subjects of the focus group and the participating nurses could consult spontaneously with each other, thus contributing to deepen the discussion and to do the work that consisted of restructuring the AT process of the HFS' ICU nurses.

According to the schedule proposed by the researcher and approved by the group, six meetings were held from March to May 2008 whose purposes were: 1st meetings: presenting, discussing and approving the schedule for the focus group's activity; 2nd meeting: presenting and discussing the diagnosis of the status of the AT in the ICAU and starting to discuss about the AT process; 3rd meeting: deepening the discussion and defining the concept, objectives and contents of the AT process for the ICU, discussing the profile of HFS' ICU nurses and setting goals of performance for training nurses; 4th meeting: defining how long an AT should last and its teaching strategies; 5th meeting: defining the profiles of HFS' ICU nurses and that of the instructor nurse; and 6th meeting: evaluating the study methodology and the work done.

Phase 4 - Evaluation

The study's methodology and the work done were assessed by means of questionnaires⁽⁷⁾ specially prepared.

Ethical Aspects

The study was approved by the Committee of Ethics in Research of the HFS, protocol 01/08, and ethical and legal dispositions were observed in the study.

RESULTS

In addition to the themes that emerged from the diagnosis of the current status, some factors that intervene in the AT were identified and analyzed, and proposals for interventions to handle them were made.

Holding the meetings and the conversations with the nurses allowed them to express themselves and to build up the tasks in a participative way, which resulted in the Re-elaboration of the AT process for nurses in the HFS' ICU presented next.

The Concept was defined as follows:

Initial process to qualify nurses to provide patients and their families with integrated, individualized and humanized care. It encompasses technical and ethical qualification in a search for developing their autonomy in the work with the multi-professional team.

The Objectives highlighted by the group were: to welcome nurses by integrating them to the team; to qualify nurses to provide care at technical-scientific and relational levels; to direct the care provided according to the care guidelines and nursing philosophy of the Institution; to educate for knowledge exchanges and team's growth; to stimulate development of professional autonomy; to develop a professional stance according to ethical and legal principles, values and norms of the Institution.

As to the Profile of the ICU nurses, the group agreed that this professional is the manager of the care provided to seriously ill patients and for them to perform that role they have to be technically, scientifically and ethically updated, as much as to have commitment and responsibility, in addition to being good communicators, negotiators and leaders.

To accomplish those objectives and start to qualify nurses for the profile intended, some goals were set for the nurses to reach at the end of an AT. The relational, ethical and behavioral goal is to render nursing care based on ethical and legal principles and with autonomy; the technical-scientific goal: to practice essential procedures for ICU patients in the first three months, to practice specialized procedures in the following three months according to the Institution's norms and routines.

Subjects and participants thought that to reach the goals, Duration should be six months, according to the complexity of the activities and the inclusion of nurses' managerial role.

The Strategies and needs they pointed out were: training nurses will be responsible for controlling the instrument; availability of more than one instructor in charge of the training course; qualification of instructors and forming a group of instructors; guidance for highly complex procedures should be provided by specialist nurses; using support materials such as manuals, theoretical texts and texts for reflections; using case studies to develop the ethical dimension.

Based on the complexity of the actions to be implemented in the AT, the nurses also proposed to build up an increasing gradient of complexity in the development of the AT for the ICU nurses, a flowchart being built which was aligned with the need of deepening competences wanted by the group.

In an increasing order of complexity of actions, the Content will be developed as follows: 1. receiving and welcoming new nurses; 2. essential care activities, such as bed bath and hydric control; 3. complex and specialized procedures, such as dyalitic methods with guidance of specialized nurses; and 4. guidance and execution of administrative procedures. Training nurses will be under a constant evaluation process and will progress from one phase to the other when they are capable to meet the requirements.

Attachment 1 shows the AT Instrument illustrating the complexity gradient.

To guide the development of this content and follow training nurses the Profile of nurse instructor was outlined which, in addition to managing the care to be provided, should have updated technical-scientific knowledge, dexterity and skills to provided and be involved with the care. An instructor should be didactic, enjoy teaching, exchange and search knowledge, be ethical and committed. For an instructor to be appointed, he/she should have been working in the HFS's ICU for at least three years; to have his performance assessed and to evidence the requirements described in the profile and to be appointed by the management. It was also set that a group of nurse instructors will be formed to analyze the AT process, and nurse instructors will be qualified by means of educational methodology classes.

The Evaluation of the training nurse will be made directly in the training instrument by the instructor who will carefully assess the performance as to skill (H), theoretical foundation (FT) and relational (R); as to the scores, E = expected, Ab = below expected, Ac = beyond expected; and E equals 70%. The training nurses will have their potential analyzed, their learning rhythm and whether they have reached the goals. Case studies will be adopted as evaluation method. Additionally, evaluation will be done in the first three months to make a decision about hiring the new nurse according to the legal requirements, and training will go on in the subsequent months until the end of the AT.

DISCUSSION

During the analysis of the situational diagnosis, which showed divergences between the proportion of guidance and of execution in the same procedure and between correlated and interdependent procedures, nurses realized that the AT should start by developing essential care to seriously ill patients and then deepened according to the complexity of specific phases of specialized care, and end with a phase of development of leadership in the work team.

Health and education are complex matters because they work with human beings and their relations; therefore, the group's statement about the need of educating carefully is clear, because both are complementary and non dissociable^(8-9).

In the environment studied it was evidenced that there was room for education as a professional and social mediation action, which goes beyond passing technical-scientific knowledge. When they overcome the solely reproductive nature of the AT, those nurses look for promoting the maintenance of their identity as direct nursing providers.

Those nurses' typical actions stand for a search, during the AT, for maintaining the group's identity believing that the education provided during the training course transforms reality, making it an emancipating process.

These are the assumptions that nurses expect from the AT process, instead of a practice implicating in operational repetitions of one or more skills in an standardized and fast way so that they become an efficient and profitable production process which often enough prevents the expression of the humane, the collective and creative freedom of employees, which easily results in a pattern, in production lines, in places where workers can be replaced by machines.

The AT concept defined by the nurses mirrors this idea and shows the complexity involving ICU nurses' performance and also characterizes it as an initial search for their autonomy. Moreover, it searches for developing full individuals so that they can provide full care.

Although the complexity of ICU care and the use of technologies may lead to interventionism and excessively cure-oriented procedures, making it difficult to render whole care ⁽¹⁰⁾.

Training as an educational process extrapolates the development of people; it also encompasses organizational development. In an AT it is important that the nurses working in that area introduce the novel in the team, which should receive and shelter it.

The AT's objectives, as described by the nurses, are consistent with what training nurses expect at the end of an AT process. They seemed aware of the fact that to accomplish that they have to meet what has been set and that the objectives they failed to reach during the AT should be recovered every day by prioritizing opportunities, because they can significantly improve their performance.

In order to restructure the AT nurses followed the logic of elaborating programs based on the identification and analysis of the needs and, thus, defining what will be done and what one should expected from that training. However, it is known that adjustments have still to be made, as much as constant evaluations of the program proposed herein so that needs can be interpreted and met.

Thus, the nurses consistently outlined the goals to be reached at the end of the training program, which correspond to their expectations as to the relational and technical-scientific dimensions. They reflected that goals should not be reached by hindering the relationship among people; what they intend is that an AT is indeed the first step towards education inside the HFS' ICU. They believe in the possibility of starting to develop their scientific-reflective capacity, which does not happen in a short period of time. Additionally, training nurses' motivation and satisfaction are mirrored on the quality of the care provided and interpersonal relationships.

For the nurses of the ICU studied, humanization and respect among professionals are guiding principles of the relationship among them in the work environment, and it can be extended to the nursing care provided to seriously ill patients. Humanity applied to direct care provided to everyone is inserted in ethics, involves conscience and awareness of man as a relational being⁽¹¹⁾.

In this sense, the six-month duration of an AT is justifiable according to the logic of the increasing complexity involving the formation of the profile of ICU nurses defined by the participants because only when nurses reach ethical and technical-scientific qualifications to provide direct care will they be apt to practice leadership in the nursing team.

The strategies presented are consistent with the structure proposed for a new AT and they should contribute to the maintenance of the identity and autonomy of the ICU nurses' group.

The professional's profile is related to frequent traits, posture, awareness of themselves and their way of acting⁽¹²⁾. What the nurses of this ICU expect is an updated, dynamic and ethical professional, able to make a reflexive analysis of the care provided, committed, aware of their responsibilities and limitations, able to make decisions and to take responsibility for them. The nurses showed recognition and pride on being that ICU's nurses, of providing quality nursing care, they know that it is their function and they feel responsible for that.

After all, having initiative and taking responsibilities for problems and events faced in professional situations mean competence and are aspects related to professional ethics in the sense of active freedom and power to act in their field of performance; professional awareness is a practical matter⁽¹³⁾.

Subjects clearly expressed their desire of maintaining the professional respect acquired before the society, acknowledgement of the quality nursing care provided to seriously ill patients, and their autonomy to provide that care together with the multi-professional team.

The diversity of professions and knowledge in a single work environment with a common objective can and should be stimulated by differences, peculiarities and particularities of each profession and of each professional, demanding flexibility and incisiveness, as much as help to complement knowledge.

The relationship among several professionals stimulates in the groups the heterogeneity of talents and, usually, better performance, minimizing the appearance of conflicts of interests and vanities, which promotes the group's recognition⁽¹⁴⁾.

It is also considered a challenge the movement from a group team, which is characterized by asymmetry of the relationships among professions, to an integrative team, which overcomes the position of dispute and moves towards a position of complementation⁽¹⁵⁾.

We are facing the challenge of thinking a new pedagogy - the pedagogy that takes advantage of all others that have ever cared about building self-determined and socially-historically committed individuals. The one able to place at the center of the pedagogical process the ethical-political implication of workers in their daily actions providing healthcare, producing healthcare at individual and collective levels and as a team⁽¹⁶⁾.

The nurse instructor's profile was outlined accordingly to nurses' understanding that sees them as vehicles passing on the group's identity; that is why they should be close to their team and acknowledge its importance and influence in the qualification of new nurses, once a nurse instructor is their mirror. As a starting point to qualify an instructor, a reminder to guide them which, together with the flowchart, define what and how the AT should be done. This flowchart of the complexity eased visualizing and understanding the development of the AT process.

After the importance of welcoming training nurses was broadly discussed, in the new instrument a specific field was included for that purpose and some welcoming words. Welcoming is indispensable to make newcomers more at easy because usually they feel uncomfortable because they do not know the people and the place.

Even if they are experienced professionals, the complexity in the work environment, the need of solving daily situations and the intensity of human relations are never the same, despite being similar inside the same basic situation⁽¹³⁾.

That is why it is important to have welcome messages in order to minimize the discomfort of an insertion in a new work environment.

Evaluation also had its place in the instrument with the objective of assessing and giving immediate feedback right after the activities, systematizing the evaluation by means of concepts in order to mirror the performance evolution during the AT and to guarantee feedback to by showing them and discussing with them their potentialities and deficiencies, which was a constant concern of the group.

This evaluation also improves communication among nurse instructors, making the decision of maintaining or terminating employment agreements at the end of the trial period, a decision to be made by the group, thus decreasing the burden attributed to one single instructor or to the management, which corresponds to the expectations of the nurses who always decide as a group.

Additionally, the performance evaluation allows, among other things, analyzing the methods chosen, identifying needs of training and development, learning objectives and expectations of newly contracted employees and improving individual performance⁽¹⁷⁾.

The first step has been taken to re-elaborate the AT process for the ICU nurses, the nurses absorbed the idea and believe that the evaluation process should be continuous so that it could be improved, but it will never be a finished process; so, they proposed that a training group was created in the ICU which would be annually renewed, with the goal of developing, following up, assessing results and making the applicable adjustments.

In organizations there are contradictions in development policies related to social and corporate reformulations, which may compromise the feasibility of the qualification process for ICU nurses. Organizational support stands for an important factor for the implementation of that process because an education-oriented management process strengthens people's learning, contributes to the development of diversified knowledge oriented towards the organizations' results⁽¹⁸⁾.

Similarly, corporate policies and the AT for ICU nurses should be aligned with the institution and the professionals' needs in the area, where both should understand the needs in the scenario of possible accomplishments inside the reality of the work environment.

FINAL CONSIDERATIONS

Holding six meetings totaling 10 hours and the conversations with the remaining ICU nurses may seem insufficient considering the complexity of the matter and the objective proposed for the research; however, participants were mature and aware of the situation, which allowed carrying out the tasks beyond expectations.

Nurses' increasing participation and expression, consistent with the methodology about several aspects of the TA, intensely contributed with information that exceeded forecasts, and the subsidies necessary to reach the objectives of this study were collected by means of which instruments were prepared, which will serve to systematize the AT process for ICU nurses in the Institution studied, as much as serve as parameters for others.

The research allowed analyzing the complexity inherent to the AT for ICU nurses, showing the way and contributing with proposals of solutions. A great deal was not done and built without, however, exhausting the subject, nor was that ever intended. There is still a lot to be discussed and reviewed because learning is a continuous process and adjustments will be made, as well as going deeper in the matter.

Those nurses' professional autonomy as to providing nursing care to seriously ill patients is the professional ideal of all nurses who work in that ICU, and that said autonomy can be maintained and transmitted, keeping the list of characteristics described composing their professional and human identity, because they feel noble, gratified and accomplished by providing full care to seriously ill patients. That is why they are acknowledged and respected as important professionals inside the multi-professional team.

Nevertheless, corporate support is required to implement the AT process for ICU nurses, the work done here consisting of a concrete instrument for its application and evaluation. ICU nurses are in charge of implementing and evaluating the feasibility among operational, technical and ethical aspects. They also have to find alternatives and complementary paths when the AT process cannot be implemented the way it has been idealized.

The ICU coordinator is in charge of valuing and making this process happen by negotiating with upper hierarchical levels the means to implement it and bearing the market's pressures, which will go on demanding fast and financial responses to a productive healthcare process because a political dimension has a determining influence in the valuation of the Admission Training for ICU nurses.

This study analyzed and recreated the AT process, showing its economic feasibility, which despite seeming expensive at first, the gains achieved are unarguable, the assumptions in its execution being observed.

The desire for the ideal scenario, however, is not easy: the results of this process have to be carefully evaluated. Additionally, one cannot forget the true meaning of the AT process as the initial phase of a qualifying educational process of critical-reflexive, ethical-political professionals, so intensely stated by the nurses that it could not possibly be ignored.

The AT process could be seen as an investment able to improve nurses' qualification, a stimulus to growth and to a healthy competitiveness of knowledge, bringing about the need of developing themselves and standing out to be inserted as healthcare providers for seriously ill patients, as much as their adhesion to the institution and its visibility before the society.

It is necessary to align economic efficiency with educational efficiency in the institution. The paths of adjustments and negotiations for its development should be open because confrontation is not the target, but understanding the importance of both for the survival of the institution in the healthcare market, more and more competitive, is.

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Publication Dates

• Publication in this collection
  15 Dec 2010
• Date of issue
  Dec 2010

History

• Received
  07 May 2009
• Accepted
  08 Mar 2010