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On-line version ISSN 1982-0194
Acta paul. enferm. vol.22 no.6 São Paulo Nov./Dec. 2009
Politics and technologies in the administration of health care and nursing services
Políticas y tecnologías de administración en servicios de salud y de enfermería
Márcia Maria Bragança LopesI; Jacira Nunes CarvalhoII; Marli Terezinha Stein BackesIII; Alacoque Lorenzini ErdmannIV; Betina Hömer Schlindwein MeirellesV
IAssistant Professor at Faculdade
de Enfermagem da Universidade Federal do Pará UFPA- Belém (PA),
Brazil. Post graduate student (Ph.D.) Nursing Post Graduation Program, mode
DINTER, Universidade Federal de Santa Catarina UFSC Florianópolis (SC),
Brazil. Member of the Nursing and Education Research Group (EDEN)
IIPost Graduation Student (Ph.D.) at the Nursing Post graduation Program, mode DINTER, at UFSC Florianópolis (SC), Brazil. Member from the Study and Research Group in Health and Nursing Management (GEPADES)
IIIPost graduation student (Ph.D.) at the Nursing Post Graduation Program, UFSC Florianópolis (SC), Brazil. Member from GEPADES
IVPh.D. in Nursing Philosophy, Associate Professor at the Nursing Department, UFSC Florianópolis (SC), Brazil. GEPADES Coordinator. PQ 1 A at CNPq. Coordinator at the Nursing Area at CAPES
VPh.D. in Nursing Philosophy, Full Professor at the Nursing Department UFSC Florianópolis (SC), Brazil. Member from GEPADES
OBJECTIVE: To determine if Brazilian nurses
have knowledge of politics and technologies for the administration of health
care and nursing services.
METHOD: A integrative literature review was conducted using the LILACS, MEDLINE, SciELO, BDENF, and PAHO databases. The key words "administration of health care," "health technology," and "health care technology and nursing," limited to publications in Portuguese, Spanish, and English were used to search the databases.
RESULTS: Eleven publications from 2003 to 2007 were retrieved. Nurses could articulate well in the nursing services and had technical competencies for professional nursing practice; however, they were fragile politically; this limited their professional autonomy and made them to be subordinated to other health care professionals.
CONCLUSION: Advancement and continuing changes in health care, particularly in the organizational and technical-scientific levels, require nurses to develop and strengthen their political, management, and leadership skills to participate equally in a interdisciplinary leadership team.
Keywords: Health management; Health technology; Assistance technology.
OBJETIVO: Identificar si los enfermeros
en Brasil tienen conocimiento de las políticas y tecnologías de
administración en los servicios de salud y enfermería.
MÉTODOS: Fue realizada una revisión integradora de la literatura, utilizando las bases de datos: LILACS, MEDLINE, SciELO, BDENF y PAHO y los descriptores: administración en salud, tecnología en salud, tecnología asistencial y enfermería, incluyendo las publicaciones en los idiomas portugués, castellano e inglés.
RESULTADOS: El análisis resultó en 11 referencias completas, en el período de 2003 a 2007. Fue constatado que los enfermeros poseen articulación en los servicios de enfermería y competencia técnica en el ejercicio profesional, sin embargo, se presentan frágiles políticamente, lo que limita su autonomía profesional y los vuelve subordinados de otros profesionales.
CONCLUSIÓN: Delante del avance y constantes cambios en el sector de la salud, particularmente en el nivel organizacional y técnico-científico, es imprescindible que el(la) Enfermero(a) desarrolle sus habilidades políticas, administrativas y de liderazgo con participación responsable y de forma interdisciplinar.
Descriptores: Gestión en salud; Tecnología en salud; Tecnología asistencial.
Management can be defined as a set of processes to plan, build, equip, assess, and keep reliability of spaces and technology. Regarding management of health services, including nursing services, there are a few formal examples of management of spaces and technology in most health units in Brazil. Health services where there is at least one nursing professional aware of this topic and using the methodology which is part of this type of management are also scarce. Management starts procedures and activities to maintain all environment components, infrastructure, and equipment in adequate conditions, making improvements or corrections according to priorities established(1).
The above mentioned reality, associated with developments on the practices of nursing health services lately have led to the development of policies and technologies of management processes that take into account the needs of human beings as dynamic beings that are able to participate actively in the struggle for rights and duties to become autonomous.
In this context, men as social, political, and cultural beings put ideas into actions, especially for solving problems affecting their lives and thus finding new ways. "In this sense, individuals' participation and responsibility in actions for care and health promotion make them responsible for actions, with an active participation, according to their individual, social, economic, and cultural singularities"(2).
As a social being, men interact, share, articulate interests, and get closer to others for fulfillment. Understanding these movements is relevant because it demonstrates the need to conform to practices for health promotion.
Introducing management policies and technologies in health and nursing centers requires the discussion on human diversity; the dialog between partners or social actors; and acknowledging social, political, and cultural similarities and differences of this complex and multiple human being, who is a product and a producer of health practices(2).
To understand men as social, political, and cultural beings in contemporaneity, knowledge is a milestone in the organization of work and in management processes. As knowledge is highly valued by organizations, its management has become more important in organizational practices and in the literature.
The present study is justified because of the great number of Management Nurses in the country. The guiding question is to know how Brazilian nurses master theoretical knowledge of Policies and Technologies for Managing Health and Nursing Services.
The objective of the present study was to identify and assess if Brazilian nurses are aware of the policies and technologies in nursing and health services.
The present study was an integrative review of the literature on management policies and technologies in health and nursing services.
To start the study, the website www.bireme.br was accessed and after searching Health and Science Descriptors, the following descriptors were identified: health management; health technology; care and nursing technology, including the publications in Portuguese, Spanish and English.
Then, on April 28th, 2008, we accessed on the same website data from Latin American and Caribbean Center on Health Sciences Information (LILACS); from the International Literature on Health Sciences (MEDLINE); from Scientific Electronic Library Online (SciELO); from the Nursing Data Base (BDENF); and from the Library from the Pan-American Health Organization (PAHO); using the four above mentioned descriptors.
The following inclusion criteria have been established: full Brazilian texts on management policies and technologies of health and nursing services, written by nurses or with participation of nurses, published from 2003 to 2007.
At LILACS, 4,986 references have been found, 12 were full texts. Among full articles, we have excluded two references, thus resulting in 10 texts.
At MEDLINE, 20,402 references have been found, two were full articles and one article was included.
At BDENF, 282 references have been found, all of them were abstracts; at SciELO no references have been found on the issue; at PAHO, 1,089 references have been found, six were full articles, all of them have been excluded from the study because they did not match the inclusion criteria.
The 11 complete references freely available obtained from LILACS and MEDLINE that formed this sample were first organized and then assessed according to: type of publication; journal in which it was published; year of publication; political, technological and management idea; type of service, and perceived professional domain. All 11 articles have been described in the reference and have been mention on the article, and also on Table 1 from the present article.
The main difficulty was the limited number of full text regarding the references found. Data were treated through analysis of simple absolute frequency.
As for journals assessed in the present study, we show where the 11 articles have been published and how many articles have been published by each journal. Thus, the journal Texto & Contexto Enfermagem had three publications. The journal Arquivos Catarinenses de Medicina had two publications and the journals Revistas Latino-Americana de Enfermagem, Ciência & Saúde Coletiva, Cadernos de Saúde Pública, Revista da Escola de Enfermagem da USP, Revista Brasileira de Enfermagem, and Revista Baiana de Saúde Pública had one publication each respectivelly.
Making a correlation between the journal, the year of publication, and the type of text published, we have observed that the journal Cadernos de Saúde Pública published one original article in 2004; Revista-Latino Americana de Enfermagem published one original article on the theme in 2005; Arquivos Catarinenses de Medicina published two original articles in 2005; Revista da Escola de Enfermagem da USP and Revista Brasileira de Enfermagem published one reflection article; Revista Baiana de Saúde Pública published in 2007, an experience report; Revista Ciência & Saúde Coletiva published a reflection article in 2007, and Revista Texto & Contexto Enfermagem publised three original articles in 2007. This last journal published more articles on the issue in 2007 because it is a theme journal.
Despite diversification on production, the context of the political approach focused by authors refers to the following five central themes: SUS construction and its different social actors; Policy of Elderly Care; political disqualification of Nursing; creation of Continuous Education Programs and Improvement in Work Relations at the Brazilian Unified Health System.
The context of the technological approach had four central themes that are: achieving management and leadership knowledge and skills; access to different levels of technologies; the different ideas on technology, and the assessment instrument.
The context of the management focused by the authors is based on the following ten central themes: the role of nurses as articulators in the process of elderly health care; instrumentation for management; technologies to enhance care provided to elderly in Intensive Care Unit (ICU); nursing political disqualification; new management models; integral care as a guiding axis for health practices; problems and potential in ICU work organization; social control; technological domain of nurses regarding management issue; nurse behavior regarding care management; and human resource management.
The analysis of the political idea presented in eight of the 11 texts highlights the Brazilian National Health Policy, making references especially to the introduction and effectiveness of SUS which was introduced two decades ago and is still being built. It claims for the participation of some of the following different social actors: public management from the different sectors of the government, private health sector providers, health workers, and the organized civil society, it points out to the principles of SUS especially those of integrality of actions and decentralization of services.
Authors also make reference to innovations and achievements of health policies and the challenges that have to be faced. Among the innovations and achievements mentioned is the process of SUS implementation in the history of public health in Brazil, both in the field of health policies and in the macropolitics of the country's reform, and the creation of continuous education programs for nursing workers inside and outside hospitals, as an important political achievement for nursing.
Regarding the challenges to be faced, authors mention the need to invest in human resources policies, making work relations at SUS more democratic, in the way people are introduced in the service, respecting workers' rights, granting social protection, improving professional education/qualification(3) and, thus, improving health care, and making services more humanized(4).
As for nurses specifically, authors refer that nurses present a "political fragility" which reflects on the "political vacuum" of their speeches, in the small participation in public spaces, and in their difficulty to be leaders, especially in interdisciplinary health work(5-6).
This political fragility is clear in the participation of Nursing disconnected from the construction of health policies which has "legitimized health policies that may or may not favor the consolidation of SUS"(5). Furthermore, these professionals are frequently in intermediate levels of the management hierarchy, their management hierarchy is limited and confusing, distant from interdisciplinary practices, jeopardizing quality of care provided(7).
A study carried out on the influence of nursing work in public institutions providing health services in Latin America shows that the biomedical model which is impregnated in the institutions these nurses work lead to work overload and loss of professional autonomy(8).
Finally, and even worse, is the fact that these nurses accredit the achievement of their space in the local management at SUS only or mainly due to their technical power. Thus, nurses' potentiality is only on the technical ability, with greater emphasis in control, and a political power exercised in an alienated fashion which makes these professionals subordinated to superior hierarchical levels or even to other professionals at the same level(6).
Nursing technical capacity is directly connected with the biomedical model of health, guided by fragmented care and the Technology Policy developed in Brazil from the 70's to the 90's, with important developments in the health area, especially the industrialization of heavy technology for hospitals which led to the need for technical qualification of workers to handle sophisticated equipment correctly(9).
In the analysis on the idea of technology demonstrated by 8 of the 11 articles selected for review, we see that it is seen as an essential element to organize health services. To that end, nursing professionals should have knowledge and master the several tools used, to provide a more efficient and high-quality care.
For authors, technology is a set of knowledge and actions related to products and materials that define therapies; work processes are instruments or extensions of our physical and mental abilities to perform actions which occur in a cultural, social, and professional relation in health promotion(10).
Mastering these new care practices should be accompanied by techniques of interpersonal relations sustained by a different and innovative use of the several types of technologies. Health technologies are classified into three types: hard, soft-hard and soft technologies. Hard technology is formed by machines, instruments, rules, routines, and organizational structures. Soft-hard technologies are structured knowledge such as Phisiology, Anatomy, Psychology, Clinic, and other types of knowledge which are part of the health work process. Soft technologies are related with the knowledge on the relations between individuals. Thus, technology has several meanings according to the different forms and context of its application. For some people, it is just technique, for other, it is machines and equipment. Some people consider it as a tool, an instrument. However, a broader view technology sees it as a process, as a reflective activity implying scientific knowledge, instrumental relations, structured knowledge and a product(9).
So that nursing can foster, in all levels of care, an action planned by scientific knowledge, it should acquire knowledge, technical, management, and leadership abilities as primary needs to develop their labor activities. Thus, continuous education has an imperative role to reach the goals of any nursing action for successful care(5).
Using the expressions from authors, we also agree that technology should serve human beings, especially in hospitals where professionals must master it to guarantee a safe and efficient use with no stress to those using or operating it. We have to remember that that technology should and must be employed in the routine of our interpersonal relations in any context or reality of our practice(10).
The analysis of the idea of management approached in the 11 texts assessed demonstrates that the main focus of this approach is almost exclusively in Technical Management of Care in detriment of the Management of the System and Health Policies.
This corroborates the political fragility demonstrated by nurses in their work context. Because these professionals focus care and techniques, their action field is limited to the context of the health system and their participation in the public spaces, this fact is strongly reflected in the difficulty they have to be leaders in interdisciplinary health work(10).
This study shows that the work of nurses presents limitations and contradictions, their main role seems to be the technical domain, especially the control, both of personal and materials to organize the care environment, performed not only by nursing, but also by the other health professionals, which makes clear that nurses do a lot more for others, in detriment of their own work which should be performed with competence in its different dimensions.
Thus, professional work of nurses is basically based on their technical domain, as a moral and ethical support is very small and limited. And therefore we ask: aren't these limits too small for a profession which is growing and becoming increasingly important, a profession that is considered the career of the future and that presents a great potential to articulate health services? Nurses "have power" in their work, or at least they should have. Why don't nurses use this power, why do they feel so helpless and have so little authority in their work? Power is not bad or good in itself, it depends on the use made by individuals. Power can be positive and depending on what nurses do or do not do with it, it can hinder the work of the nursing team and the care provided to patients.
When we concluded the present study of integrative review of the literature to identify and assess if Brazilian nurses know the management policies and technologies in health and nursing services we saw that they present a great potential to articulate health services, especially nursing services, they present great technical competence however, they are still politically fragile, which restricts their professional autonomy and makes them subordinated to other professionals.
In the analysis of their conception of technology, we have seen that it is perceived as an essential tool to organized health services. Nurses point out that they chose to take up management functions because of their involvement, availability, responsibility, and resoluteness regarding their technical work.
However, because of the developments and constant changes in the health sectors especially in the organizational and technical and scientific level, nurses must develop their political, management and leadership skills with a responsible and interdisciplinary participation. To that end, nurses must be prepared to carry out their functions properly.
This preparation should start in professional education making nurses ready to perform their functions of management and leadership, that is, their political functions and their work at SUS, thorough their education period in a cross-sectional and in-depth fashion since this system is still being built.
To ensure Nursing Foster actions based on scientific knowledge in all levels of work, it should acquire knowledge, technical, management and leadership skills as a primary need for developing their labor activities. Thus, continuous education also plays an important role in achieving the goals of any nursing action for a successful care.
References to public health policies are present in all texts and SUS was treated as central in all contexts discussed with emphasis to the principle of integral health care to the population, taking into account the differences expressed in health demands and decentralization of services. This is the great challenge to nurses, since integral care and decentralized services require that nurses are involved, instrumented, prepared and committed so that they can develop their different technical, political, technological, and management skills, abilities and competences.
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Corresponding author: Article received on 12/23/2008 and approved
Márcia Maria Braganças Lopes
Rua Generalíssimo Deodoro, 1 - Umarizal
Belém (PA), Brazil
Article received on 12/23/2008 and approved on 03/23/2009