versión impresa ISSN 0080-6234
Rev. esc. enferm. USP vol.45 no.4 São Paulo ago. 2011
Nurses' autonomy and vulnerability in the Nursing Assistance Systematization practice*
Autonomía y vulnerabilidad del enfermero en la práctica de la Sistematización de la Atención de Enfermería
Silvia Regina Tamae MenezesI; Margareth Rose PrielII; Luciane Lucio PereiraIII
MA in Administration Sciences and Bioethics, Centro Universitário São
Camilo. Nurse at the Heliópolis Hospital. São Paulo, SP, Brazil.
IIPhysician. PhD in Sciences, Federal University of São Paulo. Professor, Graduate Program in Bioethics, Centro Universitário São Camilo. São Paulo, SP, Brazil. firstname.lastname@example.org
IIIRN. PhD in Nursing, University of São Paulo, School of Nursing. Professor, Graduate Program in Bioethics, Centro Universitário São Camilo. São Paulo, SP, Brazil. email@example.com
The objective of this study was to recognize the autonomy and vulnerability of nurses in the implementation of the Sistema da Assistência de Enfermagem (SAE) Nursing Care System through an integrative literature review, using content analysis. A survey was conducted, and 40 articles published between 1998 and 2008 were selected based on their relevance. Results showed two main categories of meaning: Benefits associated to the SAE practice (to patients, to the profession and to the institution) and Determinants for the Implementation of SAE (nurse's competence, training and education, record-instruments, infrastructure and collective sharing-construction). From the integration of the two categories, the highlights were the autonomy in acting with freedom and responsibility, science-based decision-making, and being valued for their social work, as well as the vulnerability expressed by interpersonal relationships, the wear generated by professional stress and the risk inherent to the service.
Descriptors: Nursing care; Nursing process; Professional autonomy; Bioethics
El estudio objetivó reconocer autonomía y vulnerabilidad del enfermero en el proceso de implantación e implementación de Sistematización de Atención de Enfermería (SAE), mediante revisión bibliográfica integradora, usándose análisis de contenido. Entre los artículos investigados, fechados de 1998 a 2008, se seleccionaron 40 en conformidad con el foco. Los resultados presentan dos categorías principales de significados: Beneficios Asociados a la Práctica del SAE (al paciente, para la profesión y para la institución) y Factores Determinantes para la Implantación/Implementación de SAE (competencia del enfermero, formación y enseñanza, registro-instrumentos, infraestructura y compartido-construcción colectiva). En integración de ambas, se destacó la autonomía en el accionar con libertad y responsabilidad, en la toma de decisiones con base científica y en la conquista del valor de su trabajo social, así como la vulnerabilidad expresada por relaciones interpersonales, en desgaste generado por estrés profesional y en riesgo inherente a la atención.
Descriptores: Atención de enfermería; Procesos de enfermería; Autonomía profesional; Bioética
Given the exponential growth of current knowledge, especially in terms of the technology and interactive innovations that permeate the health field, nursing is faced with the challenge of promoting the development of its staff and providing well-grounded quality care. Nursing is represented by nurses, nursing technicians and auxiliaries who work as a team and have the ethical, legal and technical responsibility to CARE for human beings. The responsibility lies at the primary, secondary and tertiary levels: they provide primary health care, hospital or home care including individuals, families and communities(1).
Nurses' roles are developed beginning in their education, which is based on care actions and knowing, doing and being, carried out by nurses for such care. An important reflection on the nursing field is related to the issue of value. Western society still worships the view of possession and knowledge in a material and individualist dimension compared to being and doing based on basic ethical values and respect for fundamental human rights, a dignified existence and coexistence in both the private and public environments(2).
Therefore, as a profession it embraces care as an instrument for its actions in the representation of a practice deeply committed to the human being. One view that agrees with this idea holds that:
the purpose of caring in nursing is primarily to relieve human suffering, maintaining one's dignity and enabling the management of crises and experiences of living and dying(3).
Nursing employs a work process that systematizes and directs care, ensuring the safety of the users of the health system and its professionals: Nursing Care Systematization (NCS). The NCS represents the nurse's 'toolkit', aiming to identify the needs of patients by presenting a proposal for care and guiding the nursing team through actions that will be implemented. It is a dynamic process and requires practice in technical-scientific knowledge(4).
However, some challenges are part of NCS development in institutions: knowledge, number of nurses in the services, their involvement with the process, acknowledgement on the part of the institution's administration, as well as indicators of care results. At the same time, implementing this process requires from professionals scientific knowledge, skills and attitudes based on ethical commitment, responsibility and the assumption of care provided to others.
Bioethics appears as a new discipline in the field of health, an important guiding axis for its practices, marked by interdisciplinary, globalizing and theoretical themes included in the affirmation and construction of human rights(5-6). In the historical, ethical and legal contexts of the nursing profession, bioethics is part of nurses' education, as well as law related to professional practice and teaching(1).
The principle of autonomy should guide the relationship between health professionals and patients, contributing to a harmonious relationship where each occupies his/her space in an interaction comprising feeling, thinking and acting(7).
The ethical principle of autonomy holds that when an individual is capable of freely and independently thinking, deciding and acting, s/he is entitled to participate in and agree on decisions that concern her/himself(8).
Adopting this proposal in the nursing professionals' practice brings meaning to their way of doing nursing(8).
From this perspective, introducing the vulnerability issue opens up an opportunity to reflect upon its influence on the work of nurses, on the dimension of care, and responsibilities of professionals in implementing the nursing process. Another important assertion is that only those acknowledging themselves as vulnerable are able to care for another(9).
The term vulnerability originates in Latin and vulnus means wound, expressing in general the possibility of someone getting hurt. In consistent terms,
vulnerability may be seen as a persistent human condition (as we are limited and mortal) and as an inevitable situation (in which the limits and wounds are correctly verified)(10).
Based on the discussion of bioethics concerning the principle of autonomy and the concept of vulnerability, the proposed theme opens up an opportunity to analyze the practice of nurses and their social role given the implementation of NCS.
Recognizing the issues related to the autonomy and vulnerability of nurses in the process of establishing and implementing the NCS in scientific publications in the field.
Study's design: This bibliographic, systematic and qualitative study used content analysis to analyze papers in scientific periodicals addressing the establishment/implementation of the nursing process or nursing care systematization. Qualitative research in the Social Sciences works at a level of reality that does not allow one to quantify it, instead working in the universe of meanings, motives, aspirations, beliefs, values and attitudes. These human phenomena integrate
social reality because human beings differ not only because they act but also because they think about what they do and interpret their actions within and based on what they experience and share with their peers(11).
Study's sources: This search was performed in the Virtual Health Library - Nursing (VHL) and Latin American and Caribbean Health Sciences (LILACS) databases and publications in the Scientific Electronic Library Online (SciELO).
Inclusion criteria: Papers published from 1998 to 2008 were selected using the descriptors: Nursing Process; Nursing Care Systematization, Implementation.
A total of 224 papers were found in VHL, 639 in the nursing database and LILACS and 75 papers were found in SciELO. A total of 72 papers were selected through reading the titles and abstracts. Case studies of patients and duplicated studies were excluded, hence 39 papers met the study's criteria. A non-indexed study was added because it was relevant to the theme: a study addressing the systematization of care in State Hospitals in the state of São Paulo, Brazil. Reading conclusions and final considerations grounded the search for meaning units. Summaries were made using key words and important excerpts related to the theme. This enabled the definition of two categories related to the implementation of nursing care systematization or the nursing process.
Content analysis had an exploratory approach and consisted of an open procedure to search categories that were not predetermined, evidencing the proprieties of the papers' contexts, seeking similarities that would allow characterizing what was being presented according to the definition research technique that seeks an objective, systematic and quantitative description of communication content(12).
We classified the similarities among units of meanings that allowed the characterization of issues related to the process of establishing/implementing NCS, from which two main categories emerged: Benefits Associated with NCS Practice and Determinant Factors for the Establishment/Implementation of NCS.
Benefits Associated with NCS Practice
For the patient: the benefit for the patient relies on the quality of care delivered by the nursing team, which has the autonomy to develop it. Individualized care is a privilege of NCS and implies the participation of the patient in the care process. Respect for the patient's individuality is stressed, which enables a favorable relationship among the multiprofessional team, the patient and the family, promoting humanized care. From this perspective, being vulnerable is essential to render another's participation possible, even when maintaining autonomy of care.
Nursing care systematization, as an organizational process, is capable of providing support to the development of interdisciplinary and humanized methods/methodologies(13).
For the profession: the autonomy of nurses with the establishment/implementation of the NCS or Nursing Process was highlighted in some papers. The practice of NCS gives nurses the possibility of applying their knowledge and achieving recognition for the quality of care delivered to patients, both on the part of the institution and the families, reflecting their role in society and professional responsibility.
I've observed that nurses see the nursing care systematization as a way to apply their technical-scientific knowledge, which characterizes their professional practice and guides their professional autonomy(14).
For the institution: working with a scientific methodology not only gives autonomy to the profession but also structures the team's routine, enabling the use of the appropriate tools that facilitate the keeping of records and controls. The process is a strategy to quantify care, control costs and facilitate auditing, in addition to promoting the achievement of quality goals. It also allows implementing actions, evaluating results and changing interventions, which in turn favors the achievement of expected results.
It is believed that this experience was valid not only for the unit, but also for the hospital that needs instruments to facilitate both the recording and recovery of data, quantifying nursing care and costs control and auditing(15).
Determinant Factors for NCS Establishment/Implementation
Nurses' Competence: the breadth of nurses' actions and understanding of responsibilities and duties within the team characterizes competence, which is related to autonomy of leadership and vulnerability of the team dynamic itself, given individual peculiarities. For nurses to implement the process, they need to assume the commitment to apply it in practice and be responsible for implementing its progressive stages, guiding the team, improving and updating knowledge.
More than technical competence, nurses need to be sensitive to grasp emergent needs, the skills to implement and encourage innovating actions, mainly the knowledge and strategic capacity to creatively involve and prompt the remaining health professionals(13).
The Importance of Training and Continuing Education: training and continuing education indicates the importance of theoretical knowledge as a factor that facilitates the establishment and implementation of NCS. The papers emphasize that undergraduate programs should play a role and provide students the knowledge required to put into practice the nursing process, which is not always observed in practice.
Another aspect to be taken into account, though most nurses report having learned and implemented the phases of the process during their undergraduate program, refers to the considerable difficulties identified in practice, which portrays the insufficient theoretical and practical preparedness for implementing nursing care systematization when they leave college(16).
Recording and Use of Instruments: applying the nursing process improves the quality of nursing records favoring the evaluation of care and guiding care actions. Some papers address the development of instruments and their applications as a proposal to allow nurses to modify and structure new models in addition to the need to review standards concerning NCS as part of the process so that results are satisfactory.
The instrument has facilitated the implementation of the nursing process in the hemodyalisis unit despite difficulties faced during its development, which imposed restrictions and required constant changes(15).
Institutional Aspects: commitment from management, leadership, supervision and the institution itself were indicated by many papers as a determining factor in the implementation of NCS, which allows one to analyze the issue of co-responsibility in the process. The contribution of the analyzed papers concerning the discussion of how important the institution is to the NCS process indicates that the organizational structure and culture influences the results of the system's applicability. Therefore, the role of the nursing management is highlighted, whose real interest is to give visibility to the process, establishing organizational structure, mission, philosophy and the service's objectives, exerting leadership and encouraging the implementation of the process. The papers also state that institutions with poor working conditions, those lacking infrastructure, and especially those lacking personnel, hinder or even impede NCS implementation.
The study also shows that the nurses participating in it have knowledge about the process but an analysis of the work context points to hindering factors that impede its use, such as lack of time and the number of inpatients, besides turnover(17).
It is important to acknowledge, however, that nursing management plays an important role in this process of construction and deconstruction of knowledge, especially in relation to NCS implementation. Leading in this case means to provoke internal transformations and uneasiness in order to enable potential cultural and structural changes(18).
Sharing Collective construction: the analyzed papers highlighted strategies to apply the process in the services involving the participation of the team. Scientific meetings, case studies, directed studies and the creation of study groups are considered opportunities to involve the staff.
The participative process adopted in this process shows it requires time and the resolution of all those involved. However, the experience may also enable individual growth, which consequently may result in an effective collective product(19).
Considering that the next stage to be implemented is nursing prescription, the entire team has to be involved so that it is not classified as just another order to be complied with(20).
Considering that in the formal sense of ethics, the autonomy of human subjects is taken as a mandatory requirement for there to be morality, an understanding based on the philosopher Immanuel Kant, for whom autonomy is the ability of humans to impose moral rules upon themselves, we have that for morality to occur, individuals should be free and have responsibility(10).
Incorporating such a concept into nursing actions, we initially have interpersonal and institutional relations that are part of the nurse's work jointly with the team, the multiprofessional team, patient, family, community, management and institution. A study addressing the structure of the social representation of autonomy in the profession showed that nursing co-exists and relates to the health team, client and the institution in its routine, and scientific knowledge as a factor can interfere in the way these relationships are concretized(21).
In turn, vulnerability as an expression of the human condition, the way of being human, of acting with another, points out the concepts of responsibility and solidarity as part of an ethics based on anthropology. It encompasses the view that the way we should act results from the way we are and how we want to be, while our common vulnerability establishes the universal meaning of the sense of duty in human action(22).
The category denominated Benefits associated with the NCS for the professional in relation to autonomy highlights the valorization of the implementation of a care methodology. Autonomy enables nurses to develop their intellectual potential, expressing the moment in which nurses allow themselves to enlarge their practice from a mechanicist point of view and evaluate the patient, make decisions concerning care to be delivered and establish parameters for quality results. At the same time, commitment to humanized care develops, as well as to practice that deals with the population's health issues, inserting the professional in his/her social role. Humanization of care is based on principles and values that guide nursing practice such as compassion, ethics, respect, generosity, commitment and dedication(23).
The social role of nurses is identified in NCS as necessary for a critical evaluation of the appropriateness and relevance of nursing work in relation to meeting health needs(24). The autonomy of nurses, when practicing NCS, is in their social role, the care delivered to patients, in the guidance provided to the nursing team, integral care and the individuality of the human being, and, finally, the results of their work verified by the institution.
The competencies of the nurse in the category Determinant Factors highlight the autonomy to perform tasks with patients, lead the nursing team and manage information, as well as physical, political, financial, material and human resources, in order to provide nursing care(25).
The requirement for nurses to play their role with satisfactory results is having knowledge, skills and attitudes that generate the competence to perform their tasks and at the same time prepare the team for the tasks they have to perform(25). Given the concepts of autonomy and the reflections presented in this study, nurse autonomy in the practice of NCS relies on free acts, on decision-making based on technical and scientific knowledge, professional responsibility, interpersonal and institutional relationships and in achieving acknowledgment from society for their work.
On the other hand, their interrupted work and tasks performed simultaneously wear out the nursing team and pose risks to care delivery, which can lead to inadequate performance, denoting vulnerability expressed especially by the lack of time, the main cause indicated by the team. The team ends the shift with a feeling that they may have failed to accomplish important tasks, which is considered by the nursing professionals to be a stress factor(23).
The use of NCS requires nursing professionals to rediscover their role in relation to patients. The interest in performing actions with ethical, moral and responsible commitment, regardless of the challenges the routine imposes on them, contributes to an autonomous practice. Nurses usually face a practice focused on bureaucracy and mechanically incorporate activities in their routines, losing stimulus and motivation, which makes them vulnerable.
We consider NCS to be a path to autonomy for the profession because it represents a care methodology recognized by nurses that allows them to become closer to patients both at the time NCS is being developed and in care delivery, which is their most relevant competence because it requires scientific knowledge, professional responsibility and commitment to professional practice.
It also represents vulnerability because it is subject to a lack of knowledge associated with non-commitment, non-involvement, a lack of valorization of nursing performance and also a lack of qualification to take part in NCS. Institutional structural difficulties, the absence of stimuli and a lack of support from higher levels are found, as are gaps in the education of formal teaching.
Given this study's results, two countering arguments seem to be established: a nursing practice centered on caring for human beings allied with a scientific methodology within a existential and philosophical view of human beings and, on the other side, a fragmented, reductionist, mechanical and depersonalized practice. Facilitating the establishment/implementation of NCS, in addition to raising awareness within the team and involving nurses, requires one to work with strategies devised through an elaborated planning that facilitates the participation of team, the construction of instruments and the application of stages based on nursing theories. Institutional and management support in the qualification of professionals and the use of computer technology can aid the work of nurses and encourage their adherence to the process.
These issues should be reconsidered and studied in depth since these are important aspects that should be explored in each of the meaning units, to provide elements to the profession that contribute to the continuity of its historical trajectory as a science of caring.
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Received: 18/08/2010 *
Extracted from the thesis "Autonomia e vulnerabilidade do enfermeiro na prática
da Sistematização da Assistência de Enfermagem" Centro Universitário
São Camilo, 2009.
* Extracted from the thesis "Autonomia e vulnerabilidade do enfermeiro na prática da Sistematização da Assistência de Enfermagem" Centro Universitário São Camilo, 2009.