Work organization in hospital nursing: literature review approach

Organización del trabajo en enfermería hospitalaria: abordajes en la literatura

Abstracts

The objective of this study was to analyze aspects of work organization in hospital nursing and its articulations with care, by means of an integrative review. A total of 25 studies were identified, from the period between 2000 and 2009. Based on the understanding of the work organization and its application in nursing, the following analytical categories were structured: conceptual and theoretical aspects, personnel management, care management, technologies, hospital accreditation, planning and material resources management. The literature evidenced the complexity of this work organization theme and the importance of studies on its application in nursing. The analysis of the publications points to the need to rethink work organization in such a way as to build less wearing and quality work alternatives, assuring the safety of both the user and the worker.

Nursing; Administration; Health management

En el presente estudio se realiza una revisión integradora con el objetivo de analizar aspectos de la organización del trabajo de enfermería y sus relaciones con la atención. Se identificaron 25 estudios, de 2000 a 2009. A partir de la comprensión de la organización del trabajo y su aplicación en la enfermería, se estructuraron las siguientes categorías de análisis: aspectos teóricos y conceptuales, gestión de personas, gestión de la atención, tecnología, acreditación de hospitales, planificación y gestión de materiales. La literatura muestra la complejidad de este tema de la organización del trabajo y la importancia de los estudios sobre su aplicación en la enfermería. El análisis de las publicaciones muestra la necesidad de repensar la organización del trabajo a fin de construir alternativas para un trabajo menos estresante y de calidad, lo que garantiza la seguridad del usuario y el trabajador.

Enfermería; Administración; Gestión en salud

Este estudo, por meio de uma revisão integrativa, teve como objetivo analisar aspectos da organização do trabalho hospitalar da enfermagem e suas articulações com a assistência. Foram identificados 25 estudos, no período de 2000 a 2009. A partir da compreensão de organização do trabalho e sua aplicação na enfermagem foram estruturadas as seguintes categorias analíticas: aspectos teóricos e conceituais, gestão de pessoas, gestão da assistência, tecnologias, acreditação hospitalar, planejamento e gestão de materiais. A literatura evidenciou a complexidade desta temática de organização do trabalho e a importância de estudos sobre a sua aplicação na enfermagem. A análise das publicações aponta para a necessidade de se repensar a organização do trabalho, de modo a construir alternativas de trabalho menos desgastantes e de qualidade, garantindo a segurança do usuário e do trabalhador.

Enfermagem; Administração; Gestão em saúde

INTRODUCTION

Management activities are constitutive of nursing practice, especially for nurses, as of the institutionalization of the profession in the mid-nineteenth century. During these more than 150 years, the organization of the therapeutic environment has been an important part of the nursing work, being grounded on the technical and social division of the work since its conception.¹ More recently, there has been a consolidation of the understanding that the professional role of the nurse is identified by the dimensions of the service in health care, education, research and management, and that these articulated dimensions directly influence the quality of care.

Several analyses and diagnoses made in Brazil point to relevant weaknesses in the management process of the health sector in the country. The advancement and consolidation of the Brazilian Unified Health System (SUS, as per its acronym in Portuguese) require confronting the management aspect as one of the highest priorities concomitant to the funding of needs.

In the context of the SUS, performance of nurses in leadership positions at various levels of health institutions stand out, from the direction of basic health units, functions at the central level of municipal, state and federal spheres, as well as the direction of nursing organs in hospitals and the coordination of care units at this level of care. The responsibility of nurses for delivering nursing care to users in all areas of health care requires the application of typical management skills.

Organization is one of the basic functions of management/administration in all institutions, companies or organizations in society, along with planning, coordination, leadership and evaluation. The assignment of organizing is a complex activity of formatting the organizational structure, involving the definition of people, technologies, materials and other resources needed to achieve the objectives of a particular institution, company or organization. It involves the division of labor, responsibilities, levels of authority and the type of management to be adopted. The formatting of organizational structures has its graphical representation in organizational charts.²

The management of nursing care applies these elements of the organization process for the accomplishment of its mission to ensure safe and quality care in situations of health and illness. Within its scope of action, nursing adopts choices of managerial design, personnel scaling, the use of materials and technologies, the kind of labor division, hierarchical structure and relationships of power.² In this sense, the management dimension in nursing encompasses the organization and management of health care and administrative processes that constitute the nurses´core work.³

Considering the relevance of the activity of work organization to manage the care of nursing and administrative processes, the aim of this integrative review of studies from 2000 to 2009 was to identify and characterize aspects of the organization of nursing work in hospital care.

METHODOLOGY

An integrative review was conducted, using a qualitative approach, and with the aim to identify and characterize the aspects addressed in studies related to the organization of nursing work in hospitals.

To guide this study of integrative literature review, a formal and rigid work structure was included, based on a previously developed and validated research protocol.⁴ The following steps were used in its development: identification of the topic and definition of the research question; establishment of inclusion and exclusion criteria of articles for sample selection; approximation of the material in accordance with common characteristics; analysis and discussion of results, identification of differences and conflicts, and presentation of results.

After the definition of the subject, i.e., the organization of nursing work in the hospital setting, the literature review was carried out to answer the following research question: what aspects are addressed in studies on the organization of nursing work in hospitals?

The Virtual Health Library (VHL) database was used to compose the study, which contains publications from General Health Sciences sources, such as: Latin American Literature in Health Sciences (LILACS), International Literature on Health Sciences (MEDLINE) and Scientific Electronic Library Online (SCIELO), and also specialist areas such as the Bibliographic Database of the Nursing Area in Brazil.

The search period occurred during June and July 2010, using the combination of the words "Labor" and "Nursing", and it resulted in a total of 181 articles, of which 31 were initially selected for the study. The inclusion criteria were: complete papers; published in Portuguese, with results available within the selected database, in the period established between 2000-2009, involving the hospital context. Considering the established period, duplicate studies were excluded, those which had no relation to the scope of this research, as well as those that were not complete, thus totaling 25 articles.

The aspects identified in the publications dealing with the organization of nursing work in hospitals were organized into the following categories: a) theoretical and conceptual aspects of work organization; b) work organization and personnel management; c) work organization and care management; d) work organization and technology; e) work organization and hospital accreditation; f) work organization and planning; and g) work organization and material resources management.

RESULTS AND DISCUSSION

The organization of work, in general, in health care and nursing, involves multiple and complex dimensions and determinations.

The aim of this study is not to present and reflect on this broad theoretical field. Nevertheless, it is necessary to note that aspects of work organization express internal choices and external constraints of economic, political, socio-cultural and technological order, among others. These choices and constraints contain an underlying view of the world, and social objectives, within a particular historical moment.

The initial characterization of the 25 selected studies indicates that, chronologically, there was greater interest in the subject from the year 2004 on, as it may be seen in figure 1, which presents the annual distribution of production.

Figure 1
Selected studies by year of publication, 2000-2009

Aiming to facilitate understanding and analysis, and based on the approaches found in the selected publications, the articles were systematized into categories according to the following table.

Table 1
Studies by category of analysis

Analytical categories	n. of publications
Theoretical and conceptual aspects of work organization	07
Work organization and personnel management	08
Work organization and care management	03
Work organization and technology	03
Work organization and hospital accreditation	02
Work organization and planning	01
Work organization and material resources management	01
Total	25

Theoretical and conceptual aspects of work organization

To analyze the specificities of work organization, in its institutional focus, it is necessary to understand, initially, how this organization occurs in its general aspects.^{5 - 7} In this sense, one must consider that the institutionalization of nursing as a profession, promoted by Florence Nightingale in the second half of the nineteenth century, incorporated its own knowledge and practices of administration since the beginning, configured in the organization of the therapeutic environment in hospitals. It established the division between intellectual work for the nurse and manual labor for other nursing staff members and the hierarchy, where the nurse plays the role of a centralizing knowledge manager who dominates the conception of the work process and delegates partial activities to the other practitioners.⁶

The concepts of work management and organization, termed as scientific, classical and bureaucratic, and currently considered as traditional, formulated by Taylor, Fayol and Weber, respectively, were dominant in the production process of goods and services in society for many decades. From the 1950s, these concepts started to suffer criticism and the search for alternatives to meet the new demands of productivity and constant changes in the working world were intensified. This process has been accelerating since the 1980s, with a view to overcome this conception, and replace it with management visions and practices, called innovative and participatory.

The authors call attention to the fact that the healthcare sector and nursing in this context are still strongly attached to the traditional concept of management, despite the existence of initiatives and participatory experiences, however, insufficient to point out significant changes in nursing services.^{5 - 7}

Management stands out as the possibility of gaining a new professional role for the nurse and the challenge is to become a de facto leader in the health system.⁵ A strong identity of the authors is perceived, with the need for urgent and substantial changes in the management and organization of nursing work, especially toward the organization of work by the 'comprehensive care' model, participatory management with involvement of the nursing staff and the assisted individuals in care management, education at work and the welfare of the care-giving subjects.⁹ Furthermore, overcoming poor management practice, linked to the momentary and urgent aspect that masks the existing disorganization and compromises the quality of the result of the nursing work.⁶ These aspects are advancing in different areas of nursing action.

Regarding general aspects, the organizational structure and culture guide the organization of work that involves all the activities undertaken by workers, hierarchical relationships and labor relationships present in an institution/organization. Current macro policies in society influence and affect the organization of work.¹

Hospitals and health institutions in general can be considered as "professional bureaucracy" type organizations, according to Mintzberg's Organizational Theory.⁸ In these organizations, the "operating core" consists of well-educated and trained professionals who hold considerable control over their work and enjoy relative autonomy due to their specialized knowledge and the complexity of the work. There is, in these institutions, a dual system of authority, on the one hand, the administration, involving the hospital staff, with a rigid, authoritarian and centralized hierarchical scheme and, on the other, the knowledge-power of physicians who may confront the administration and are the only professionals with effective autonomy.⁹

The centrality of the medical work, prevailing in this reality, reflected in the care process, and in power relationships. The interdisciplinarity which could play a key role in bringing about change, is far from being a concrete practice. Although centered in the medical work, in organization and the management of work and care practice, each professional category holds a certain autonomy in assessment and decision making.¹

In nursing, in general, the organizational principles based on Taylorism and Fordism prevail, such as a rigid hierarchy, division of work tasks, doing to the detriment of thinking, a strong concern with manual procedures, routines, standards and task distribution scales, providing, among other things, the fragmentation of care to users.¹ Nursing is strongly influenced by the management sector and by physicians, and the nurses work is still primarily administrative. Thus, the nursing work in the hospital is performed both in the "operational core" and in the ​​"advisory support" areas.⁹ This management model hinders the manifestation of subjectivity and the creativity of workers, a reality that can be modified with the adoption of new forms of organization of the nursing work, with participatory processes, where mid-level workers and users are included as subjects.¹

The nursing service in hospitals is focused on three areas: nursing care to users, the organization of the therapeutic environment and the management of the nursing staff. The Systematization of Nursing Care (SNC) and the management of inpatient units concentrate the working process of nurses.¹⁰

An experience report shows the difficulties of changing the management model in hospitals, from the traditional (biomedical, hierarchical and authoritarian) to an epidemiological model, oriented to comprehensive and decentralized care, based on democratic, interdisciplinary participation and co-responsibility. It demonstrates the resistance of nursing and that health professionals are not prepared for a reorganization and/or restructuring process.¹¹

Work organization and personnel management

Considering personnel management, studies in the literature regarding the sizing of personnel identify workload, quality indicators, subjectivity and ergonomic aspects. It should be stressed that personnel management is one of the most important dimensions in institutional organization.

In this regard, Brazilian nursing has been devoted in recent years to study and provide input in the area of ​​personnel sizing, also driven by legal support from the resolution 293/2004 of the Federal Nursing Council.¹² It is understood that safe and quality nursing care for users requires the anticipation and provision of an adequate nursing staff, and the profession has developed instruments to determine the quantity and quality of nursing staff needed to provide nursing care to a group of users according to the philosophy and uniqueness of each service.¹³ This sizing requires the establishment of different variables, which appear in the studies identified, such as the average daily workload of nursing, a measure that involves the use of Patient Classification Systems (PCSs), technical safety index and effective working time.^{14 - 16}

Among the studies, it is worth noting one that addresses the time distribution of nurses in an inpatient medical surgical unit, showing that 50% of their time was spent in indirect care, 22% in direct care, 18% in personal time and 10% in associated activities. Thus, there was an evident need to review work processes, from the perspective of providing more time for the performance of specific professional activities.¹⁴

Another aspect addressed in the studies concerns PCSs, which constitute a way to determine the degree of patient dependency in relation to nursing, allowing to establish the time spent in direct and indirect care. Patient Classification Systems provide more objective subsidies for the definition of the nursing workload needed and, therefore, assist in negotiating with and hiring nursing staff, and in quantity and empowerment, influencing the organization of work.¹⁵ Regarding this aspect, a system for patient classification, proposed for the Brazilian reality¹⁵, and the Nursing Activities Score (NAS) system are addressed.¹⁶

Indicators as care markers for specific issues with results can be structured in the following categories in personnel management: continuing education, work organization, participation in decision making, proper staff sizing, absenteeism, turnover, titration, scientific production, accidents at work, occupational diseases, time off, and work satisfaction and dissatisfaction.¹⁷

Focusing on work organization and personnel management, approaches that refer to the subjectivity of nursing also appeared, as well as indications of the importance of this relationship.^{18 - 19} One study examined identity aspects of nurse managers in a hospital context of strong transformations oriented toward participatory management practices with decentralization, reduction of hierarchical levels, more flexible communication and the pursuit of professional responsibility as for results.¹⁸ Nurses have had increasingly strong participation in management positions in hospitals with an emphasis on people management and financial, material and technological resources.¹⁸ The carrying out of management and care activities often presents situations of conflict and a blurring of roles that interferes with the nurses' identity.¹⁸ In this case, nurse managers have a professional identity characterized by preservation and the strengthening of the social identity of nurses, "nurse's soul" with a trajectory of evolution in healthcare practice management with an appreciation for the experience and activities of direct care. In terms of organizational identity, a strong ideological and emotional attachment to the institution appears, a sense of belonging and a driven attitude from the healthcare team to achieve the organizational objectives.¹⁸

Another study presented a very negative reality of the organization of nursing work in an obstetric center, and the corresponding consequences for workers. The traditional organization of nursing work, which is fragmented, hierarchical, authoritarian and lack teamwork, brings the presence of strong dissatisfaction, suffering and an undervalued self-image.¹⁹

In one case study, in clinical units of a hospital, the authors analyzed the relationship between occupational accidents and ergonomic risks in the organization of nursing work. In this situation, occupational accidents were considered high, 35% of workers participating in the study had suffered some kind of accident. Of these accidents, 84% occurred in the process of carrying out procedures and 65% affected their hands.²⁰ The risk factors identified were unsatisfactory division of labor, concentration of activities at rush hours (e.g., 10:00 a.m.), concomitant accumulation of tasks and total occupation of workload during the shift.²⁰ Protective factors were: taking regular breaks during work, availability of Personal Protective Equipment (PPE), use of PPE, compatibility between the position and the highest level of training, feedback from leaders as regards the performance carried out and professional accomplishment.²⁰

It is important to highlight the importance of the sufficiency of human resources and professional satisfaction for the care of appropriate ergonomic bases in the organization of nursing work.²⁰

Work organization and care management

Regarding the management of care, the SNC stands out, which constitutes an important tool in the practice of nursing care, since it provides a process of care with planning, implementation and evaluation, indispensable as a basis for safe and quality care. The SNC and its institutionalization in appropriate records are a substantive component in attitude and practice that values ​​the profession, however, it still does not receive due credit from nurses who often act only as facilitators of the work of other healthcare professionals and prioritize administrative and bureaucratic activities.²¹

The shift change is a significant care management tool, organized and developed by the nursing staff. It is an important activity to ensure the adequate continuity of care, 24 hours a day, as well as team integration; besides being a rich space for communication and collective learning.²²

Nurses play multiple roles in hospital administration. In a general supervisory function during night shifts and weekends, they assume the representation of management throughout the organization, facing and routing the various problems and issues, such as staff shortages, bed occupancy, conflicts, lack of materials and others.²³

Work organization and technology

Another aspect identified in studies refers to computerization and the use of other technologies that interfere with the organization of work in hospitals, with three articles that show specific situations regarding the introduction of new technologies, which interfere in the organization of work.^{24 - 26}

The first study, upon analyzing the process of computerization in surgical hospital units, with the introduction of electronic health records, describes it as significantly interfering with the work of nurses. There was, in this case, resistance from the professionals, who demonstrated disinterest in this practice and a preference for the old handwritten form. The process of computerization has caused isolation, stress and withdrawal from direct care, despite being seen by sectors of the institution and the administration as positive.²⁴

The second study analyzes the use of material technologies in the ICU, such as monitors, mechanical ventilators, infusion pumps, defibrillators, pacemakers, computers and others, called by the authors as hard technologies; part of the idea that there is a strong relationship between the organization of nursing work in ICU and the use of technologies.²¹ They concluded that the presence of obsolete materials, shortages and insufficient continuous training harm nursing work and cause suffering, dissatisfaction and an intensification in the work, among other consequences, with the use of technology not replacing the necessary personal interaction between caregivers and assisted subjects.²⁵

The third study describes the construction and implementation of a computerized nursing prescription in the ICU, in which the initiative and the process were considered positive and included the broad participation and compliance of the entire nursing staff.²⁶

Work organization and hospital accreditation

As regards the organization of work in nursing and hospital accreditation, it is important to consider that the evaluation of the work results in an institution is an indispensable and permanent need, along with planning, structure and organizational practices. In the analysis of the weaknesses of health management in Brazil, there is a strong absence or fledgling culture of evaluation of results of health services. The most widely used instrument is auditing, usually limited to costs and financial aspects.

In the last decade, this situation has begun to change and part of it is the creation of the Brazilian National Accreditation Organization (ONA, as per its acronym in Portuguese), focusing on the hospital. Hospital accreditation is a certification process that confirms that a hospital organization has implemented and maintains certain standards of quality in the results of their work.

In both studies identified, the elements involved in the hospital accreditation process are addressed,^{27 - 28} with the ONA methodology being suggested as reference for nursing actions in an Emergency unit.²⁷ In another study, on the analysis of institutions already certified by the ONA, the indicators/criteria applied to the performance of nursing services are identified. Of the 24 criteria/indicators identified, 13 are classified as administrative, six as related to care and five as regarding teaching and research.²⁸

Work organization and planning

The study on work organization and planning describes the experience of applying the methodology of Situational Strategic Planning (SSP), formulated by Carlos Matus, with the nursing staff of a medical surgical unit and emergency department of a hospital. The SSP was considered an appropriate instrument and shown to enable the practical concept of participatory management in nursing and it positively modified the process of nursing work with effective reflections in improving the working environment and providing more humanized and comprehensive care.²⁹

The application of the participatory planning tool in diverse instances, services and care units, under the coordination of nursing, is a priority and an important initiative for the proper operation and greater visibility and recognition of the profession.

Work organization and material resources management

As regards the management of material resources, this is an important area for the organizational dimension of an institution. Moreover, the adequate management of material resources directly influences the performance of the organization in general and, in particular, in the health services that deal with promotion, protection and the recovery of people's health.³⁰

The World Health Organization believes that the hospital, as an entity for the management of acute and critical events, must make exclusive use of therapeutic possibilities and the technological density compatible with its complexity. ³¹

Nurses use a variety of tools and materials in performing their work, especially in hospitals, hence the need for a prominent role in the management of material resources. In this perspective, one study describes an initiative considered as innovative in nursing, at a university hospital. The performance of nursing in this area is now recognized and institutionalized through the establishment of a Standing Committee on Care Resources. This committee manages about 400 types of materials, involving specification, standardization, acquisition and quantitative and qualitative control. The results of this experiment have affected the organization of work in the profession.³⁰

FINAL CONSIDERATIONS

The categories drawn from the studies identified in this integrative review indicate the various dimensions of work organization, from its conception to its influence in ergonomics, consolidating what many authors have asserted, i.e., that work organization is still guided mainly by the traditional Taylorism and Fordism, and that hospitals remain as medical institutions where the biomedical model is practiced. New care practices and redefining the mission of health institutions, especially hospitals, from the perspective of an integrated health facility to the service network, are still the objective to be achieved, as well as new forms of work organization, enabling the participation of workers effectively in the management of the institutions and the working process.

These general aspects of work organization are reflected in the work of nursing, where there is little space for new forms of organization, as if the current, fragmented and partial model was crystallized in the profession. There are advances, such as the implementation of the care system, computerization, the application of innovative instruments of people management in nursing, comprehensive care and even strategic planning, but these do not significantly alter the relationships between the professional categories. It is necessary to think of ways of organizing the work, so that sharing is a transitive verb, in which the capitalist division of labor, still very strong in the profession, is replaced with an organizational model that coordinates nursing professionals, valuing their knowledge and practice. The concrete practice of management principles adopted by the SUS is needed, such as democratic management, user participation and workforce valuation.

The nursing staff is made of nurses who play a fundamental role in the management of work, especially as it relates to aspects of the management of people, materials and care. Therefore, it is up to these professionals to encourage team reflection on nursing work, because we believe that new forms of work organization will only be possible if nursing workers become actors in the process, from systematic reflections on work organization and current implications of how nursing work has been occurring over the years; corroborating what studies show, that the organization and management of work has also interfered in the wear and tear processes of the workers and in their work satisfaction.

It is possible to state that models of participatory organization and the distribution of activities by the comprehensive care model can facilitate the accomplishment of the worker in the work process, as well as meeting the real needs of users. There is, therefore, a need to build on the basis of the information already available new forms of work organization that ensure this practice is carried out safely, with quality, pleasure and satisfaction, considering the actors involved in the process - users and workers.

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Publication Dates

• Publication in this collection
  Dec 2014

History

• Received
  29 May 2013
• Accepted
  28 Sept 2013