Nurses and the assessment in health system management

Abstracts

Este artigo teve como objetivo refletir criticamente acerca da avaliação, enquanto ferramenta gerencial que favorece a inserção do enfermeiro no processo de gestão de sistemas de saúde. Em decorrência de sua formação, que engloba conhecimentos da área assistencial e gerencial, tendo como centralidade o cuidado, o enfermeiro tem potencial para assumir postura diferenciada na gestão e condições de tomar posições decisórias e de proposição de políticas de saúde. Entretanto, ainda há que se construir e consolidar inserção expressiva em níveis decisórios nos espaços de gestão. A avaliação é um componente da gestão, cujos resultados podem contribuir para tomada de decisão mais objetiva que possibilite a melhoria das intervenções de saúde e a reorganização das práticas de saúde, dentro de um contexto político, econômico, social e profissional; é também uma área de aplicação de conhecimentos que tem potência para mudar o panorama atual da inserção do enfermeiro na gestão.

Avaliação em saúde; Gestão em saúde; Enfermagem

REFLECTION

Nurses and the assessment in health system management

Lucieli Dias Pedreschi Chaves^I; Oswaldo Yoshimi Tanaka^II

^IRegistered Nurse. PhD Professor of the Ribeirão Preto College of Nursing of the University of São Paulo. Ribeirão Preto, SP, Brazil. [e-mail]

^IIPhysician. Full Professor of the School of Public Health of the University of São Paulo. São Paulo, SP, Brazil. [e-mail]

Correspondence

ABSTRACT

The objective of this study was to undertake a critical reflection regarding assessment as a managerial tool that promotes the inclusion of nurses in the health system management process. Nurses, because of their education and training, which encompasses knowledge in both the clinical and managerial fields and is centered on care, have the potential to assume a differentiated attitude in management, making decisions and proposing health policies. Nevertheless, it is necessary to first create and consolidate an expressive inclusion in decisive levels of management. Assessment is a component of management, the results of which may contribute to making decisions that are more objective and allow for improving healthcare interventions and reorganizing health practice within a political, economic, social and professional context; it is also an area for the application of knowledge that has the potential to change the current panorama of including nurses in management.

Descriptors: Health evaluation; Health management; Nursing

RESUMEN

Se objetivó reflexionar críticamente acerca de la evaluación, como herramienta gerencial que facilita la inserción del enfermero en el proceso de gestión de sistemas de salud. Como derivación de su formación, que incluye conocimientos del área asistencial y gerencial, haciendo foco en el cuidado, el enfermero tiene potencial para asumir una postura diferenciada en la gestión, tiene condiciones para asumir posiciones decisorias y de proposición de políticas sanitarias. Mientras tanto, aún debe construirse y consolidarse la inserción expresiva en niveles decisorios en los espacios de gestión. La evaluación es un componente de la gestión, cuyos resultados pueden ayudar en la toma de decisiones más objetivas, facilita la mejora de intervenciones de salud y la reorganización de las prácticas de salud, dentro de un contexto político, económico, social y profesional; se trata de un área de aplicación con potencial para cambiar el panorama actual de inserción del enfermero en la gestión.

Descriptores: Evaluación en salud; Gestión en salud; Enfermería

CONTEXTUALIZATION OF THE THEME

Health is an issue that has been the object of attention and discussion of professionals, communities and governments, both in respect of a condition of life of the people, as well as in relation to a sector of the economy in which goods and services are produced. Hence, each society organizes its healthcare system, according to its own culture, laws, political landscape, and economic status, under the influence of social determinants⁽¹⁾. With regard to the sector of the economy, responsible for the production of services to a given population, it may be said that the discussions are concentrated in two main areas: management and financing. Regarding management, some aspects that are debated are: the care network/coverage; conditions of access; direct provision of healthcare; quality of the care; social participation; human resources; demographic and epidemiological and transport implications for the healthcare system; management instruments such as planning, control, regulation, and evaluation, among others. In relation to financing, the debate is concentrated on the determination of sources and the (in)sufficiency of financial resources; rationalization of expenditures; increasing incorporation of technology; and the participation of the public sector versus the private sector. Basically these are different themes, with a very clear interface and field of tension between the different governmental administrative areas.

The managers of healthcare systems work in two highly intertwined contexts, the political and technical. The political is related to the exercise of management aimed toward the public interest and the solidification of healthcare as a citizenship right. The technical practice is based on policy formulation and action planning; the financing of the system, coordination, regulation, control, the evaluation of services, and the direct provision of healthcare services⁽²⁾. The management of healthcare systems is transversalized by permanent processes of decision making and evaluation. Thus, it is possible to infer that the decision-making processes should be strongly linked to those of planning and evaluation, supported by appropriate information systems⁽²⁾. For example, evaluating mechanisms for linking Primary Healthcare with the other levels of the healthcare system can identify the weaknesses and strengths of the integration strategies adopted, favoring the structuring of innovative mechanisms that contribute to the strengthening of the management of the healthcare system.

It should be noted that, strictly speaking, the terms management and administration are synonymous, both in the vernacular and conceptual aspect, as they refer to the idea of directing and taking decisions⁽³⁾. However, in the healthcare sector in Brazil since the implementation of the Brazilian National Health System (SUS), the term management has been used to refer to the command activities of the macrospheres of action/decision in the municipal, state or national healthcare system context, and the term administration for the internality of the actions in the healthcare units and services. In this article the word management is used as a reference to the area of linkage, interaction, participation and decision making in the municipal and state health secretariats, as well as at the ministerial level of healthcare, that trigger management and care actions in the healthcare units and services. That is, here, the reference is to management in the healthcare system context.

Currently, the multidisciplinary focus of the healthcare area and of the management is gaining support, presupposing a way of organizing the work dynamics and the relationships in collective bases without, however, losing the singularity of the spaces, knowledge and professions. For the professional nurse especially, it is understood that it is a challenge to think beyond the technical, care and management aspects of the professional practice. However, the logic of entry into the organizational structure of the healthcare systems, in the field of management, in a proposal of active and articulated participatory action in the decision-making processes needs to be considered. To work towards integration in the different spaces of management allows nurses to consolidate their practice in the formulation, agreement, monitoring and evaluation of policies concerning the healthcare services and, therefore, the care, in different spheres of the healthcare system. However, today, the role of nurses in decision-making spaces with power to direct and consolidate health policies still seems to be incipient.

The role assigned to the nurse is predominantly focused on care and management technical aspects, reinforcing a supporting action, even though being a professional present and active in the different healthcare services. One possibility to overcome this situation is the investment/development of skills in the management area, from the perspective in which the activities have an articulating and integrative character, being determined by and determining the organization process of services and execution of healthcare policies⁽⁴⁾.

This is not to discuss, question or to place in the background the centrality of the care in the nursing work process, on the contrary, it is political action that is needed to value and prioritize the care, in the sphere of management, in the dimension of the healthcare systems, spanning the various health services in order to promote the best care practices.

The importance of the multidisciplinary practices should also be highlighted without, however, disregarding the identity that characterizes each profession. In this sense, nurses can appropriate management tools in order to equip their participation in the planning and management, i.e. the decision making. This is a wide proposal, however, the aim of this article was to focus on the evaluation, as a field of knowledge application, that provides multiple dimensions of participation. The evaluation is presented as an essential activity in the healthcare policies and programs as it makes changes possible⁽⁵⁾.

Considering the above and the professional experience in the area of evaluation, in the university and in the municipal and state healthcare systems, this article is presented in order to reflect critically on the evaluation as a management tool that facilitates the insertion of nurses into the healthcare systems management process. The article is structured into four parts: contextualization of the theme, the nurse and healthcare management, evaluation in healthcare management and final considerations.

THE NURSE AND HEALTHCARE MANAGEMENT

The socioeconomic, political and cultural context of the contemporary world requires constant reflection regarding the work of the nurses, which is influenced and can influence the scenario that is presented to them. The development of singular work processes with the focus on care and managerial duties characterizes the work of nurses, requiring knowledge and competences that enable them to assume an important role in the healthcare institutions⁽⁶⁾. The nursing work process is organized into sub-processes that can be denominated to care or assist, to administer or manage, to research and to teach, with each having its own objects, methods/instruments and activities, coexisting or not at the same time and in the same institution⁽⁷⁾.

The exercise of the managerial dimension of the work of the nurse varies according to the socioeconomic context of each era, the predominant clinical healthcare model, the health demands of the population, the quantity and qualifications of the nursing human resources available, the healthcare policy, the inclusion of the nurse in the healthcare scenario and the current healthcare system. The nurse is the professional legally responsible for assuming the management activity and for coordinating the nursing team, as well as making the care process viable considering the peculiarities inherent in each healthcare service. In healthcare systems, the management assumes a dynamic, controversial and complex character, which stimulates reflection on the inclusion of nurses in this process⁽⁸⁾. The last 30 years have represented a jump for nursing which has begun to be established as the protagonist, creating political, ethical, technical and human conditions for the development of healthcare, with emphasis on the human care. However, it is understood here that much remains to be done⁽⁹⁾.

Nursing actions must overcome hierarchical positions, the rigidity of organograms and the disputes over disciplinary competence of each professional area, in order to establish the relationship of interaction and construction of technical, clinical, political and relational skills that preserve the professional singularity, but favor the collective practice within the context of the healthcare systems. However, it is not possible to ignore the fact that this management articulated process, the scenario of the political participation of nurses, involves competition and power struggles⁽¹⁰⁾. The limitations of nurses to identify policy aspects in their actions reflect a profession that has historically emphasized the practice of care and management focused on biological and technical knowledge, at the expense of policy aspects⁽¹⁰⁾.

Given the academic background that includes, in addition to technical and scientific knowledge relating to healthcare, knowledge pertaining to the management of services, the Professional nurse has the potential to provide different participation in the healthcare systems. In this sense, the reformulation and implementation of healthcare systems, associated with the rapid and increasingly pronounced incorporation of new technologies, are requiring from nurses a set of political, theoretical, technical and operational knowledge relating to policies of healthcare, law, healthcare economy and management processes themselves, which will allow it to expand and consolidate new areas of activity through critical and competent professional practice. The action of nurses in non-care practices represents a growing challenge to the policies of formation and inclusion into the labor market and issues particularly stand out concerning the management and evaluation of policies that focus on the healthcare system and, therefore, on individual and collective care. Thus, it is understood that it is appropriate to discuss the specificity of the field of healthcare evaluation, from the perspective of the work of the nurse in the context of management.

HEALTHCARE MANAGEMENT EVALUATION

The growing dispute between the demands of the population, the incorporation of new knowledge and techniques, and the need to control public spending, shows the fragility of the healthcare systems and leads to the viability of these systems being questioned. In the face of this global crisis in the healthcare systems, the need for the conception and implementation of a real culture of evaluation seems even more important than it was ten years ago⁽¹¹⁾. Evaluation is not a science or field of science, but rather the field of application of knowledge of various areas, using multiple concepts and methodological approaches that favor a more comprehensive view of the object evaluated⁽¹²⁾. It is a complex task to conceptualize evaluation, a term that can take many meanings and is applicable to different areas of knowledge. The word "evaluate" in its Latin root means to measure, from quantifiable standards and in Greek, its root axiós refers to the production of value judgments, linked to qualitative measurements, etymology which evidences the contribution of various sciences for the field of evaluation⁽¹³⁾. In the normal sense, evaluation is an ancient activity, an essentially human process, which is carried out daily. In a very broad sense, it is to try to judge, to estimate, to measure, to classify, to analyze critically, and finally, to assign value to something or someone^(14-15).

Evaluation is the determination of the value or merit of an object of evaluation or even the

identification, the clarification and the application of defensible criteria to determine the value or merit, quality, usefulness, efficacy or importance of the object evaluated in relation to these criteria⁽¹⁶⁾.

It is a technical-administrative process directed towards decision making, which involves moments to measure, compare and make judgments of value, and means to expose the value assumed from the judgment performed based on previously defined criteria⁽¹²⁾.

To evaluate basically consists of making a judgment of value regarding an intervention or any of its components, in order to assist in decision making⁽¹⁴⁾. This judgment may result from the application of criteria and standards (normative evaluation) or be developed from a scientific procedure (evaluative research).

In this definition, it is clear that evaluation is intended to assist in decision making.

In healthcare management, evaluation becomes essential because it provides a critical look at what is being carried out and compares this to what should be occurring, favoring the search for desirable results. It can take a supportive character for the decision making process in the provision of healthcare services, and can assist in identifying weaknesses in the services installed, measuring the efficiency and effectiveness of care actions and verifying the impact of the healthcare actions on the health condition of the population. In this sense, evaluation may have a prominent role, becoming a tool of great importance in the planning and management process of the healthcare systems and services⁽¹⁷⁾.

It should be noted that, in the context of the SUS, although healthcare evaluation is a prerequisite for the management condition of the local healthcare system, planned since the Basic Operational Standard 93 up to the Health Pact, at the local level, this management tool is not yet used to its full potential, with little incorporation into the quotidian work process. Evaluation has expanded in the late twentieth century, both in scientific production and in its institutionalization. Evaluation may produce information for the improvement of healthcare interventions and also to make judgments regarding the coverage, access, equality, technical quality, effectiveness, efficiency, and the perception of the users of the service. However, both among the managers and among the health professionals there is still an important gap concerning the incorporation of the knowledge produced by the evaluations⁽¹⁸⁾.

Although there are different definitions and assignments for evaluation, it is understood that it must contribute to decision making, having the commitment to improvement the healthcare interventions and, ultimately, the health of the users. From this perspective, promoting the participation of different social actors involved in the evaluation process favors the development of a critical and reflective process regarding the practices developed within the healthcare systems context, in order to make it a continuous and systematic evaluation, mediated by power relationships, constituting an important function of the management. It is believed to be relevant for nurses to invest efforts in this area, since nursing has demonstrated a potential for the deployment, maintenance and development of the health policies that aim to qualify the care. That is, the nurse has assumed the role of executor of healthcare policies, however, it is understood that the professional is able to assume decision making and health policy proposal positions, broadening their participation in the healthcare systems.

FINAL CONSIDERATIONS

Evaluation is a component of management, in which results can contribute to more objective decision making, enabling the improvement of the healthcare interventions and the reorganization of the healthcare practices, within a political, economic, social and professional context. It is challenging to make efforts to institutionalize evaluation as a possibility to encourage the broad and effective participation in the process of decision making. It is an area of application of knowledge that has the potential to change the current landscape of the insertion of the nurse in the area of management of healthcare systems.

In recent years, nurses have contributed to the implementation and maintenance of healthcare policies. As a result of their training, which encompasses knowledge of the care and management area, with the focus on the care, the nurse has the potential to assume a different position in the management of healthcare systems. However, to construct and consolidate a significant inclusion in decision-making levels in areas of management are aspects which are still to be achieved.

It is understood that changes and investments are necessary on several fronts, such as: the process of training future professionals in the development of political, technical and relational skills; the continuous education of nurses already in the labor market from the perspective of an expanded practice and not just in techniques; the participation of professional bodies with the focus on the valorization of the professionals in the healthcare system scenario, as well as on the participation in the decision-making space of the different levels of management; and the construction of partnerships with healthcare professionals, users and institutions for the valorization of health as a citizenship right.

It is emphasized that this work is not easy and free of individual and collective tensions, since it involves aspects of power, conflicting interests, and individual, professional and institutional disputes. However, it is understood that there is a possibility and urgency for nurses to develop and valorize the political skills that promote the care and management practice, with their insertion in the management process. In this sense, it is understood that evaluation can support a different practice in the context of healthcare system management, based on more critical and reflective performance, representing advancement for nurses in the healthcare scenario.

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^*

El enfermero y la evaluación en la gestión de Sistemas de Salud

Publication Dates

• Publication in this collection
  04 Dec 2012
• Date of issue
  Oct 2012

History

• Received
  23 May 2011
• Accepted
  16 Feb 2012