Nurse instructor in the process of admission training of nurses in the intensive care unit

Abstracts

OBJETIVO: Definir e analisar o perfil do enfermeiro-instrutor do treinamento admissional de enfermeiro de Unidade de Terapia Intensiva. MÉTODOS: O estudo desenvolveu-se na perspectiva da pesquisa-ação, adotando-se a técnica de grupo focal e a interlocução por via eletrônica, para coleta de dados. Assim, contou-se com a participação de 29 enfermeiros, sendo 11 nas sessões de grupo focal e 18 na interlocução eletrônica. RESULTADOS: Dentre as competências do instrutor, definidas pelo grupo, destacaram-se o conhecimento técnico-científico atualizado, postura ética e habilidade para ensinar e ao instrutor foi atribuído papel fundamental no processo de treinamento admissional. CONCLUSÕES: A pesquisa promoveu reflexão no grupo e nas pesquisadoras sobre os aspectos intervenientes no processo educativo e a respeito da identidade do grupo caracterizada pelo papel assistencial e pela autonomia de ação, sendo papel do instrutor transmitir esses valores aos ingressantes.

Capacitação em serviço; Unidade de Terapia Intensiva; Administração de recursos humanos

ORIGINAL ARTICLE

Nurse instructor in the process of admission training of nurses in the intensive care unit^*

Enfermero instructor en el proceso de entrenamiento de admisión del enfermero en una unidad de Cuidados Intensivos

Sarah Marília Bucchi^I; Vera Lúcia Mira^II; Eloá Otrenti^III; Maria Helena Trench Ciampone^IV

^IPostgraduate Student (Doctor) of the Postgraduate Program in Nursing Management of the "Escola de Enfermagem, Universidade de São Paulo" - USP. São Paulo (SP), Brazil

^IIPh.D in Nursing from the "Escola de Enfermagem da Universidade de São Paulo". Professor of the Department of Professional Counseling of the "Escola de Enfermagem, Universidade de São Paulo" - USP. São Paulo (SP), Brazil

^IIIPostgraduate Student (Master) of the Postgraduate Program in Nursing Management of the "Escola de Enfermagem, Universidade de São Paulo" - USP. São Paulo (SP), Brazil

^IVProfessor of the Department of Professional Counseling of the "Escola de Enfermagem, Universidade de São Paulo" - USP. São Paulo (SP), Brazil

Correspoding Author

ABSTRACT

OBJECTIVE: To define and analyze the profile of the nurse-instructor training for nurses on admission to the ICU.

METHODS: The study was developed from the perspective of action research, adopting the technique of focus group dialogue and the use of electronic data collection. The sample included 29 nurses: 11 in the focus group sessions and 18 in the electronic interchange.

RESULTS: Among the responsibilities of the instructor, defined by the group, the updated scientific and technical knowledge were highlighted, along with ethics and the ability to teach; the instructor was identified as having a key role in the process of admission training.

CONCLUSIONS: The research has promoted reflection by the group and the researchers on the issues involved in education and about the identity of the group characterized by the charitable role and autonomy of action, and the role of the instructor to transmit these values to new nurses.

Keywords: Inservice training; Intensive Care Units; Personnel management

RESUMEN

OBJETIVO: Definir y analizar el perfil del enfermero-instructor del entrenamiento de admisión del enfermero a la Unidad de Cuidados Intensivos.

MÉTODOS: El estudio se desarrolló en la perspectiva de la investigación-acción, adoptándose la técnica del grupo focal y la interlocución por vía electrónica, para la recolección de los datos. Así, se contó con la participación de 29 enfermeros, siendo 11 en las sesiones de grupo focal y 18 en la interlocución electrónica.

RESULTADOS: Entre las competencias del instructor, definidas por el grupo, se destacaron el conocimiento técnico-científico actualizado, postura ética y habilidad para enseñar, atribuyéndosele el papel fundamental en el proceso de entrenamiento de admisión.

CONCLUSIONES: La investigación promovió la reflexión en el grupo y en las investigadoras sobre los aspectos intervinientes en el proceso educativo y respecto a la identidad del grupo caracterizada por el papel asistencial y la autonomía de acción, siendo el papel del instructor transmitir esos valores a los ingresantes.

Descriptores: Capacitacion em servicio; Unidades de Terapia Intensiva; Personal de enfermería em hospital

INTRODUCTION

Training and development programs have been conducted in organizations in an intensive way, aiming to promote better functional performance and to maintain both the competitiveness and sustainability of such organizations in the market. With the globalization, Brazilian companies understood the meaning of the word "competition", enabling them to observe that individuals are the ones who make a difference⁽¹⁾. The performance of workers without training directly interferes with the expected result of production, which can be measured using organization productivity and quality indicators^(1-3).

Organizations are often economically forced by the market and they risk their social image by postponing training due to the urgency of production, disregarding the policy of development of their human resources and promotion of organizational culture.

In nursing, new employee training (NET) has been developed with the purpose of preparing team professionals to provide health care based on institutional directives and to follow the mission, vision, values and philosophy of each institution. As a result, this is a structured process, where individuals develop abilities and achieve a certain level of competence through guided practical experience and regular feedback⁽⁴⁾.

Consequently, institutional NET can be understood as a resource that promotes the adaptation of new professionals to the institution, aiming to minimize variability in the way that health care is provided, promoting the dissemination of norms, routines and procedures and the following of health care directives to provide quality care. For this reason, such training must be structured and systematized, otherwise it will cause newly hired nurses to face difficulties and to feel anxious.

NET is considered as the initial process of integration and qualification of nurses, part of the continuing education process, whose actions have effects on quality of nursing care, thus turning it into an instrument for the nursing team and nurses to act and think. In addition, this instrument stimulates professional autonomy and enables nurses to express themselves and have a critical and reflective approach in a proactive and argumentative way, as members of a multi-professional team⁽⁵⁾.

The present study focused on the analysis of the NET of Intensive Care Unit (ICU) nurses in the Hospital Field of Study (HFS).

The needs of specialized nursing care provided to ICU patients are implemented using nursing care systematization, which seeks to promote individualized comprehensive care to patients, aiming to contribute to improve their health as much as possible.

The complexity of nursing care provided in the ICU, the dynamism and monitoring of information, which determine and change the therapy recommended to patients, require adequate and constant preparation of nurses. Thus, it is essential to seek to maintain and promote team qualification, showing that specialized and qualified professionals produce better results.

In this sense, the objective of the NET in the ICU is to prepare nurses, from the moment they are hired by this unit on⁽⁵⁾, raising the level of complexity from the simplest to the most specialized procedure in heath care provided to patients in a critical state, aiming to guarantee the safety of these patients, their family and professionals. As this is a continuous process of development of knowledge, abilities and attitudes and of acquisition of autonomy in the performance of health care to patients in a critical state, NET should be considered as the beginning of the professional education process in organizations, emphasizing the fact that the time required for the ICU nurse to be "ready" to perform is not defined.

The progress of processes associated with health care and administrative models forces NET programs to be constantly updated, establishing goals that correspond to modern requirements. Current literature on the NET of ICU nurses, especially in health care for adult patients, is not extensive, and the majority of studies were found to refer to the teaching of techniques and procedures performed in the ICU.

A strategy used to optimize training courses is the designation of professionals to perform as tutors or instructors of a group; the criteria of selection of instructors and group are defined by the institution, according to the need.

A Nursing Training Guide was designed in the ICU of the HFS to perform the NET in this location

At that moment, the formal criteria to select the instructor-nurse from the ICU nurses had not been established. The recommendation was made spontaneously by group consensus, considering the technical-scientific knowledge, abilities and attitudes towards routine situations and problem-situations. Although being a subjective choice, this one had an empirical basis, because nurses' knowledge requires a rationality that enables them to decide their action⁽⁷⁾.

This professional knowledge, reflected in health care, is the product of integration of a set of aspects involved in the health care practice of nurses. Thus, it is the instructor-nurse's responsibility to identify the pace of learning of the new nurses and to conduct the NET in the ICU, respecting their needs and abilities, so that the learning and teaching process is promoted.

The NET process must be viewed as an investment that will improve the qualification of nurses and the safety of patients and the institution. Thus, conditions must be sought to enable this process to occur and professionals included to be able to fully perform it. As a result, a stimulus to growth and healthy competitiveness of knowledge flourish. Professionals have the need to develop themselves and to stand out to feel included as professionals who provide health care to critical patients, in addition to their aiming to participate in the multi-professional team. When they are thus encouraged, they adhere to the institution and promote its visibility in society.

Concern about the health care qualification of professionals is always debated; however, it is essential that this concern should also be extended to the qualification of those responsible for qualifying such professionals. The American Society for Training and Development develops training and refresher programs and promotes international conferences, research projects and the analysis of world trends of this issue⁽⁸⁾. Thus, the continuing process of learning and qualification of nurses has to be reflected on and promoted, because it is understood that they should learn continually in their qualification and practice, being responsible for and committed to their education, in addition to the future generations of professionals⁽⁹⁾.

In an ICU, the NET must be held in a space which has been guaranteed for this purpose, promoting a coherent, humanized and qualified performance to provide health care, mainly through the instructor, maintaining updated and shared technical-scientific knowledge, a key characteristic of this NET, due to the way it is conducted.

Thus, the present study aimed to analyze the profile of the instructor-nurse of New Employee Training for nurses of Intensive Care Units, revealing the importance of such training in the ICU, with the purpose of recommending interventions appropriate for the improvement of this process.

METHODS

The present study was conducted in the Intensive Care Unit of a tertiary care hospital of the private health network of the city of São Paulo. The research project was approved by the Research Ethics Committee of this hospital, which requested that its name was not identified, thus being defined as Hospital Field of Study - HFS (research protocol 01/08). Participants signed an Informed Consent Form and the requirements of Resolution 196/96 were met.

Based on the belief that the construction of a qualification process must meet the organizational objectives and express the needs of the individuals who experience it, thus requiring their effective participation, this qualitative study followed the action research methodology, which is developed in a collective structure that enables the participation of individuals involved in the problem investigated, through the description and analysis of concrete situations that lead to suggestions and interventions directed towards the problems detected⁽¹⁰⁾.

To achieve this and with the objective of obtaining reports from as many individuals as possible, 29 nurses out of a total of 39 participated in this study; thus, 11 participated in focus group sessions in person⁽¹¹⁾ and 18 participated via the internet through email. A sample with qualitative representativeness was selected to choose focus group participants, according to the following inclusion criteria: to have worked in the ICU of the HFS for at least three years and to be available and interested in analyzing the NET process. A total of six meetings were held to achieve the focus group task, between March and May 2008, all booked according to the researcher's suggestions and group approval. Focus group nurses were responsible for the analysis of the profile and role of the instructor-nurse while conducting the NET, based on the situational diagnosis of the NET process which is now developed and considering the changes according to current needs.

Nurses who participated via the internet gave their opinion about what was discussed in the focus group, thus guaranteeing an opportunity for all ICU nurses to express themselves. Focus group participants and nurses participating in the group were encouraged to consult each other spontaneously to contribute to a more in-depth discussion. In this way, the results achieved reflect what was reported by focus group nurses and those who participated via the internet.

RESULTS

As part of the discussion to construct the instructor's profile, it was necessary to define the profile of the ICU nurse of the HFS a priori, which was thus established: the ICU nurses manage the care provided to the critical patient; they need to be qualified and constantly updated on the technical-scientific and ethical-political dimensions to perform their function; they must be good leaders with communication and negotiation skills; and they have to be committed to the team, health care and organization, constantly performing responsible work.

Based on such aspects and including more in-depth group discussions and suggestions on what is required of an instructor, made via the internet by the remaining nurses, the instructor's profile was thus defined.

This profile is described as follows: "In addition to managing care, the instructor-nurse must have updated technical-scientific knowledge, dexterity and ability to provide and be involved in health care. They also need to have teaching skills; enjoy passing on, exchanging and seeking knowledge; and be ethical and committed". The criteria of selection of the instructor-nurse were thus defined, and nurses could only become an instructor from their third year of work at the ICU on, according to their performance assessment and recommendation from management.

In addition to the profile, nurses working at the ICU of the HFS considered it essential to provide qualification to instructor-nurses and suggested a group of instructors should be formed to schedule the educational activities necessary to prepare and improve actions of instruction, follow-up and assessment of the entire NET process.

Nurses were aware of the problems involved in the NET follow-up conducted by only one instructor, reporting operational difficulties such as: the overlapping of health care and teaching functions and the interruption of follow-up when the instructor-nurse is absent. As a result, they suggested that there should be more than one instructor responsible for the new nurse and that, given the importance of this activity, the nurses designated as instructors should perform this function exclusively.

Apart from designing an instructor and aiming to achieve a uniformity of abilities and conduct, nurses specialized in ICU were recommended as those responsible for more specific training. In general, they added that specialists must be instructors, including nurses with a longer time of experience in the ICU.

Finally, they concluded that the nurse recommended as instructor will have the right of refusing such task.

During the discussion about profiles, nurses stated that humanization and respect among professionals are principles that guide work environment relationships, including the trainee-instructor relationship, which extends to the nursing care provided to critical patients. They considered the NET process as a moment that enables an exchange of knowledge between the new nurse and the group, representing an innovative process in the qualification of true teams. In addition, they clearly expressed the desire of maintaining the professional respect acquired in society, through its recognition of the quality of nursing care provided to critical patients and through their autonomy to develop such care with the multi-professional team. They believed that this recognition and group characteristics are solidified and maintained according to the way the NET process is conducted and to the closeness between nurse and instructor-nurse in this process.

DISCUSSION

The way ICU nurses expressed themselves about several aspects of the NET and instructor-nurse's profile occurred in an increasing manner and in accordance with the methodology proposed, providing great help with information that surpassed the purpose of constructing a profile, where aspects included in the work and essential to the purpose proposed to them were obtained and understood.

This shows that the group self-analysis process is not achieved from top to bottom, nor from outside to inside, but rather in the heterogeneous core of the interested group⁽¹²⁾. Participants also showed their concern about humanized and ethical care, which includes man's conscience and increasing awareness as a relational being⁽¹³⁾.

In the environment studied, it was shown that there was space for education, such as social and professional mediation actions that go beyond the transmission of technical-scientific knowledge. Health and education are complex questions, because they work with man and their relationships⁽¹⁴⁾; thus, the group's statement about the need to educate oneself about health continually and permanently^(5,7-8) becomes clear, because both are complementary and inseparable.

As a result, by going beyond the NET's exclusive reproductive character, nurses promote the maintenance of their identity of direct nursing care providers. This shows the characteristic of the group of professionals according to the way they act and care, seeking to preserve the group identity in the process of training and in the definition of the profile of the instructor-nurse and nurse who works and will work in the ICU, because they believe that education, the exchange of knowledge and their socialization, which occur during training, are capable of transforming reality, turning it into an emancipating process.

The focus of care as a professional characteristic is also revealed in the nurses' concern about welcoming new nurses, which is expressed in the consideration and awareness of the value of the newly hired professional's previous knowledge⁽⁶⁾. This, in its turn, evidences that the newcomer's individual potential should be added to the collective potential, promoting the emergence of the individual's and their group's potential of coming to be.

To accept the function of being a NET instructor means to be willing to teach and learn, accepting the teachings that the new nurse brings, which will certainly be a part of the learning and teaching process.

Thus, adherence to the group is promoted, which considers and takes advantage of the actual possibility of using individual abilities originated from previous knowledge.

Valuing, transmitting and sharing knowledge sustain the maintenance of the idea of team autonomy, when a higher number of individuals acquire the same abilities and values⁽¹³⁾. The purpose of this group is not to enable mechanized care and education, nor to transform these into an assembly line.

Continuing and permanent education of health professionals cannot leave out technologies or ethical principles, which guide a health care model that, in order to be viable, requires action from well-prepared and capable professionals, who are willing to intervene in the social reality, as they have the ability of passing on their knowledge, enabling them to contribute and to be used on behalf of man and humanity in a liberating and ethical-educational dimension⁽¹⁵⁾.

The group aims at a critical and reflective educational process, which has the main purpose of qualifying a professional who seeks to reflect on actions, problematizing them and not being alienated. Thus, this group cannot be regulated by the logic of classification, measurement and discipline⁽¹⁵⁾, which refers to the ethical-political dimension of professional education.

Otherwise, dependent individuals would be qualified, and they would be more easily ruled, non-critical, conformed to the information received, without creativity and the ability to reflect on the reality in which they live or where they will perform. Nurses believe that understanding goes beyond the transmission of technical-scientific knowledge, which is essential, but cannot occur to the detriment of the relational space.

The practice performed as the mere application of knowledge is empty of meaning and it establishes a linear and simplistic relationship between knowing and doing, denying the understanding that individuals' routine work experience and the actual situations experienced by them represent permanent learning⁽¹⁶⁾.

In this relational space, the interaction and transmission of knowledge occur, using the memory, the search in the live memory, and the act of doing, based on the technical-scientific knowledge of competent communication, which arouses the learner's interest, in addition to passing on what more experienced individuals know^(17-18).

These nurses believe that the NET system proposed should contribute to the maintenance of the identity and autonomy of the group of ICU nurses, apart from maintaining homogeneous language and action. That which is desired by the nurse is represented in the profile designed by the group. The professional's profile is associated with frequent characteristics, posture, self-perception and their way of acting⁽¹⁹⁾. Moreover, an up-to-date, dynamic, ethical and committed professional is expected, with the ability to make a reflective analysis of the health care provided, who knows their responsibilities and limits and who is capable of making decisions and being responsible for them. Professional awareness⁽²⁰⁾ is a practical issue.

The diversity of professions and knowledge in the same work environment, whose objective is the same, can and must be encouraging due to the differences, peculiarities and particularities of each profession and professional, requiring flexibility and resolvability. In addition, it helps different types of knowledge to complement each other, which promote heterogeneity of talents and a frequent improvement in the performance of groups, minimizing the appearance of conflicts of interest and envy, and thus encouraging group recognition⁽¹³⁾.

The profile of the instructor-nurse was designed in accordance with the nurses' understanding, who consider this instructor-nurse to be the vehicle that transmits the group identity. For this reason, they must be close to their team and recognize their importance and influence on the qualification of the newly hired nurses, once these look up to the instructor.

In this way, nurses who have just arrived at the ICU can become instructors in the future. The criteria established to select the instructor-nurse combine with the profile designed. When nurses complete three years of work in this ICU, they will have spent the time necessary to experience innumerable situations requiring an attitude and posture from them, thus helping these nurses to become instructors, capable of passing on their technical-scientific and ethical knowledge to new professionals, and developing them towards the desired profile.

Certain studies^(20-21) emphasize the fact that the partner nurse's and tutor-nurse's performance in the qualification of nurses and in training programs enables both professionals and the unit where these programs were developed to achieve gains.

However, it is essential that health care nurses be prepared, so that they can perform satisfactorily as educators and multipliers in the ICU⁽²²⁾, once they participate in the training process, which is not an isolated activity in the work plan.

The instructor-nurse's need for specific preparation, understanding that educating new nurses goes beyond the reproduction of technical abilities, includes the idea of being side by side with an individual in the formation and emergence of their professional identity.

In this sense and despite the varied words used to designate the role of the instructor-nurse, such as tutor, teacher or partner, it is their responsibility to be present, to teach much more than theory, techniques or practice, to enable education to occur, and to teach how to know, do and act. Thus, the instructor's activity is included in the education process, which reflects the way of being and the uniqueness of each individual⁽¹⁴⁾.

This is not a simple action, as one must still undergo an "educational acculturation"⁽²³⁾. In view of such complexity, preparing the instructor requires more than classes on educational strategies, it involves the need to develop a qualification program that includes the cognitive and affective dimensions to act on the educational process. This is because the challenge of thinking about a new type of education has to be faced now - the education of implication, which makes use of all those that have been concerned about the construction of individuals who are socially and historically committed and aware of their duties^(15,18).

This will make the difference in maintaining the nurses' desire to guarantee the maintenance of autonomy, placing the ethical-political implication of the worker in their routine practice of health services at the center of the educational process and providing care on the individual and collective levels. An instructor needs to have knowledge to understand the newly hired nurses in their different developmental stages and readiness to learn, in addition to the educational assumptions used to assess their suitability to the function. Apart from this, it is essential that they know the reality of the group, work and environment, where the newcomer will be trained, acting as one that problematizes the teaching process and facilitates their interaction with the new nurse and that between the new nurse and the team.

As it can observed, the role of instructors is not exclusively educational, also including political and ideological dimensions, because they are expected to pass on ethical-professional values, in addition to the institutional culture and group autonomy and identity. All this is achieved through humanized actions.

FINAL CONSIDERATION

The professional autonomy revealed by the group of nurses is the ideal expected by every ICU nurse. The researchers of this study agree with the nurses' expectations, in the sense that the characteristics described which comprise their professional and human identity should be maintained and passed on, because they find ennoblement, gratitude and fulfillment when fully caring for critical patients.

The present study contributed to the view of nurses and managers, with regard to the importance of preparing instructor-nurses, in addition to emphasizing their need to be free to perform this function exclusively, thus benefiting the NET process of ICU nurses.

The political dimension will have a deciding influence on the valuing of the New Employee Training for ICU nurses and on the reach of goals, objectives and the professional's expected profile, thus reflecting the quality of nursing care.

The ideal is what is expected, although it is not easy. However, the true meaning attributed to the NET process must not be disregarded, as this is the initial part of the educational process that forms a critical-reflective and ethical-political professional. Nurses state this very strongly, giving support and space to the performance of the instructor-nurse, because this is an educational process that must not be replaced.

It is necessary to align the economic efficiency with the educational efficiency of the institution. The paths to adjustment and negotiation of its development must be open, because a confrontation is not what is expected, but rather the understanding of the importance of both for the survival of the institution in the health market, which is ever more competitive.

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^**

, in 1996, aiming to prepare new nurses to provide health care for critical patients

^***

⁽⁶⁾ and integrate them to the team. This guide was identified by the names of the new employee and instructor-nurse and it also included assessment instruments. In addition, bibliographical references were recommended for consultation and the ICU material was made available for reading.

Publication Dates

• Publication in this collection
  01 Aug 2011
• Date of issue
  2011

History

• Accepted
  01 Feb 2011
• Received
  26 Aug 2010