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Escola Anna Nery

versão impressa ISSN 1414-8145versão On-line ISSN 2177-9465

Esc. Anna Nery vol.24 no.4 Rio de Janeiro  2020  Epub 29-Jun-2020

https://doi.org/10.1590/2177-9465-ean-2020-0005 

Research

Nursing care systematization: the nursing practice of small-sized hospital

Mayckel da Silva Barreto1 
http://orcid.org/0000-0003-2290-8418

Eleandro do Prado2 
http://orcid.org/0000-0003-2403-5462

Ane Caroline Rodrigues Miranda Lucena3 
http://orcid.org/0000-0002-2390-1894

Leydiani Karina Rissardo4 
http://orcid.org/0000-0001-9498-0959

Mara Cristina Ribeiro Furlan5 
http://orcid.org/0000-0003-3227-7074

Sonia Silva Marcon6 
http://orcid.org/0000-0002-6607-362X

1Faculdade de Filosofia, Ciências e Letras de Mandaguari, Departamento de Enfermagem. Maringá, PR, Brasil.

2Faculdade Guairacá, Departamento de Enfermagem. Guarapuava, PR, Brasil.

3Universidade Estadual de Maringá. Maringá, PR, Brasil.

4Centro Superior de Ensino de Maringá, Departamento de Medicina. Maringá, PR, Brasil.

5Universidade Federal do Mato Grosso do Sul, Departamento de Enfermagem. Três Lagoas, MS, Brasil.

6Universidade Estadual de Maringá, Departamento de Enfermagem. Maringá, PR, Brasil.


ABSTRACT

Objective

to describe the experience of nurses working in a hospital unit in relation to Nursing Care Systematization (SAE).

Method

a descriptive study with a qualitative approach, conducted in two small hospitals in a municipality in the extreme northwest of Paraná. Data collection took place between May and June 2018, through open and audio recorded interviews with 14 nurses. After transcription in full, interviews were subjected to Content Analysis, thematic modality.

Results

Two thematic categories were elaborated: “Difficulties faced by nurses for the application of SAE” and “Strategies employed to facilitate the application of NCS in daily nursing”.

Conclusion and implications for practice

Aspects related to leadership, hierarchy, work process and sensitization of nurses about SAE made its application difficult. In contrast, nurses pointed out that the use of standardized tools, the training of the nursing team and the support of hospital managers is essential for the application of SAE. These findings show that it is still necessary to promote, in education and service, actions / strategies that allow nurses to empower yourself and apply the SAE in the hospital context.

Keywords:  Nursing Process; Nursing; Nursing Care; Hospitals

RESUMO

Objetivo

descrever a vivência dos enfermeiros atuantes em unidade hospitalar em relação à Sistematização da Assistência de Enfermagem (SAE).

Método

estudo descritivo, de abordagem qualitativa, realizado em dois hospitais de pequeno porte de um município do extremo noroeste do Paraná. A coleta de dados ocorreu entre maio e junho de 2018, por meio de entrevistas abertas e audiogravadas, com 14 enfermeiros. Após transcrição na íntegra as entrevistas foram submetidas à Análise de Conteúdo, modalidade temática.

Resultados

Foram elaboradas duas categorias temáticas: “Dificuldades enfrentadas pelos enfermeiros para a aplicação da SAE” e “Estratégias empregadas para facilitar a aplicação da SAE no cotidiano da enfermagem”.

Conclusão e implicações para a prática

Aspectos relacionados à liderança, hierarquia, processo de trabalho e sensibilização dos enfermeiros acerca da SAE dificultaram sua aplicação. Em contrapartida, os enfermeiros apontaram que a utilização de instrumentos padronizados, o treinamento da equipe de enfermagem e o apoio dos gestores hospitalares são imprescindíveis para a aplicação da SAE. Esses achados mostram que ainda é preciso promover, na formação e no serviço, ações/estratégias que permitam aos enfermeiros se apoderarem e aplicarem a SAE no contexto hospitalar.

Palavras-chaves:  Processo de Enfermagem; Cuidados de Enfermagem; Hospitais

RESUMEN

Objetivo

describir la vivencia de los enfermeros actuantes de la unidad hospitalaria en relación a la Sistematización de la Asistencia de Enfermería (SAE).

Método

estudio descriptivo con aproximación cualitativa, realizado en dos hospitales pequeños de un municipio en el extremo noroeste de Paraná. La recopilación de datos tuvo lugar entre mayo y junio de 2018, a través de entrevistas abiertas y grabadas en audio con 14 enfermeras. Después de la transcripción completa, las entrevistas fueron sometidas al Análisis de Contenido, modalidad temática.

Resultados

se elaboraron dos categorías temáticas: “Dificultades que enfrentan las enfermeras para aplicar la SAE” y “Estrategias empleadas para facilitar la aplicación de la SAE en el cotidiano de la enfermería”.

Conclusiones e implicaciones para la práctica

Los aspectos relacionados con el liderazgo, la jerarquía, el proceso de trabajo y la sensibilización de las enfermeras acerca de la SAE dificultaron su aplicación. En contraste, las enfermeras señalaron que el uso de instrumentos estandarizados, el entrenamiento del equipo de enfermería y el apoyo de los gerentes hospitalarios son esenciales para la aplicación de la SAE. Estos hallazgos muestran que aún es necesario promover, en la formación y en el servicio, acciones / estrategias que permita a las enfermeras hacerse y aplicar el SAE en el contexto hospitalario.

Palabras clave:  Proceso de Enfermería; Enfermería; Atención de Enfermería; Hospitales

INTRODUCTION

Nursing care systematization (SAE) has become the basis of contemporary practice in the provision of nursing care in various parts of the world and a central component of nursing education.1,2 It is, internationally recognized as a method that organizes and directs professional work, with the main objective of systematizing and qualifying care for the patient, family and community. Through the SAE, the nurse applies his technical and scientific knowledge to organize, plan, execute actions and instrumentalize the team responsible for nursing care.3,4

SAE is regulated in Brazil by Resolution No.358/2009 of the Federal Council of Nursing (COFEN), proposing that it should be implemented in all health care units that offer nursing care. This systematic tool that guides and manages nursing care is composed of five non-linear sequential stages: nursing history or data collection; nursing diagnosis; nursing planning; nursing care implementation and; nursing evaluation.5,6 The use of this tool guarantees that the nurse identifies the needs of each patient/group, directing care from established priorities, which favors implementation of holistic, integral and personalized care.7

However, although the SAE operationalization is mandatory in the Brazilian institutions that house nursing services, its application is often not undertaken in a correct or complete manner. Other contexts show similarities and differences. Spain, for example, compared to the United States and Canada, presents, as well as Brazil, weaknesses in the SAE implementation. This may be due to the fact that, in North-American countries, the teaching and application of SAE in the hospital environment began almost three decades earlier.2

For several countries such as Brazil,8,9 Ethiopia,1 Italy10 and Spain,2 the difficulties in implementing the SAE refer to: fragility in the understanding of many nurses who claim little knowledge and/or lack of training and preparation on methodology and theoretical models; perception of work overload, with excessive bureaucratic and administrative activities and; lack of human resources for its application.1,2,8-10 It is believed that all these aspects added together lead to the gaps between theory and practice with regard to the application of the SAE by nurses in the hospital service, especially smaller units.

On the other hand, in general, the lack of involvement of the technical team in the conception of the care plan, the lack of communication among nursing professionals, which makes it difficult to understand the prescriptions prepared by the nurse, as well as the lack of support and interest of hospital institutions and their managers in the viability and applicability of the SAE can also be considered as obstacles to the implementation of the SAE in the hospital environment.5 Therefore, understanding how nurses experience the application or not of the SAE in their care practice can help to explore and understand the reasons that hinder or facilitate the process of using the method for the professional´s decision making in their daily work.

Thus, in view of the numerous challenges that nurses, especially those in small-sized hospital units, face in their daily work to implement the SAE, allied to the absence of studies that point out the facilitating strategies implemented by them to achieve, at least in part, develop it, this study is justified, whose objective was to describe the experience of nurses working in hospital units in relation to the nursing care systematization.

METHOD

A descriptive study, with qualitative approach, carried out in two hospitals, both of small-sized, in a municipality in the extreme northwest of the state of Paraná, Brazil. Institution “A”, which is public, is composed of 31 beds divided into Adult (PA) and infant emergency care and clinical and surgical hospitalization of adults. Institution “B”, which is public-private, has 44 beds, 30 of which are for the Unified Health System (SUS). It is divided into obstetrics, outpatient, clinical, surgical and pediatric hospitalization and constitutes as a reference for the region´s municipalities. It is noteworthy that these are the only hospital institutions in the municipality where the study was carried out.

The potential participants of the research where the 18 assistant nurses working in these units (10 belonging to unit A and eight to unit B). The following inclusion criteria were applied: to be an assistant nurse and to work in one of the services for at least six months. In turn, three professionals who were away at the time of data collection were excluded (one on maternity leave, one on sick leave, and one on vacation). It should be stressed that one nurse refused to participate in the study, so 14 professionals were interviewed.

Data collection was carried out between the months of May and June by two interviewers who were nursing interns in the units and, therefore, knew the routines. It should be noted that the two interviewers participated in all interviews together and during the interviews a semi-structured questionnaire was used, consisting of two parts, the first with socio-demographic questions, and the second, elaborated based on the objective proposed in the investigation, composed of the support questions and the following question: What difficulties and /or facilities do you face in your daily life to apply SAE? The interviews, which last an average of 35 minutes, were conducted at times previously established by the nurses according to their availability, and took place in the own hospital. The audios were recorded and subsequently transcribed in full.

The data were submitted to Content Analysis, a thematic modality proposed by Bardin,11 through the stages of pre-analysis, exploration of the material and treatment of the results obtained. In the pre-analysis, interviews were organized and then floating readings were made, observing the relationship between the content and the proposed objectives. In the second stage, the exploration of the material, there was fragmentation of the speech, and later these fragments were grouped, by semantic similarity, into more comprehensive categories that consisted in the classification of the elements according to their similarities and differences, with subsequent regrouping, according to common characteristics.11

In the last stage, after saturation of the preliminary categories, identified through the acquisition of sufficiently dense categories, whose later analyses noted the absence of new information, the results were treated and, based on their presentation in tables, inference and interpretation were performed, from which inferences were made about the content according to the specific literature on the subject.11 This exhaustive analytical process led to the identification of two thematic categories, namely: “Difficulties faced by nurses in applying the SAE” and “Strategies employed to facilitate the application of the SAE in the daily activities of the nursing”.

The research project was analyzed and approved by the Permanent Committee of Ethics in Research Involving Human Beings of the State University of Maringá (COPEP), under the number CAAE 88904018.1.0000.0104, receiving the opinion No. 2.759.729. The participants were clarified as to the objective of the study and their rights, according to Resolution No.466/12 of the National Health Council and its complements, and signed the Informed Consent Term (TCLE) in two copies of equal content. For the identification of the statements, codenames constituted by the letter “E” of Nurse and an Arabic number referring to the order of carrying out the interviews.

RESULTS

Characterization of the Participants

Of the 14 nurses participating in the study, eight belonged to unit “A” and six belonged to unit “B”. Their age varied between 25 and 40 years, and 11 were female. The time for the academic training varied between three and thirteen years, and nine nurses were specialized in the area. All had been working for more than a year in the current health service, of which five had more than one employment relationship.

Difficulties faced by nurses in implementing the SAE

The testimonies made it possible to identify the existence of different factors that interfere with the application of the SAE in the hospital institutions researched. Demotivation with colleagues and the workplace were perceived as determining factors for not performing the SAE.

At first, I did, but then I saw that there was no time left and it makes no difference, because nobody else does, nobody gives continuity, and then you end up discouraged (E03).

We don´t have much motivation due to the technicians in nursing, there is a lack of greater integration between the technicians and us nurses [...] (E02).

[...] I think that here because it´s [a small hospital] I don´t see so much need, but in large institutions that I´ve seen, I´ve even done shifts, there is has to work, but here it´s not necessary [...] (E04).

For other nurses, the lack of teamwork and disrespect for hierarchy, which still persists in the nursing team, emerged as the main difficulties for the implementation of the SAE.

[...] I even have difficulty charging them [nursing technicians] to check their medication [...] I you guide them to something they will not accept [...](E13).

The biggest difficulty we have in implementing this systematization is that you arrive in one place and have an employee who has been there for 30 years, he won´t accept to do it the way you want to do it and there´s no point in hitting him head-on [...] (E06).

It´s very complicated for you to change, they won´t accept it. I already have trouble asking, “Hey, don´t leave the material like this, when you´re done save it”, now imagine changing everything, a different routine, the employee himself will find it bad (E10).

The study participants also pointed out that the lack of time of nurses, mainly attributed to work overload and the reduced number of professionals in the hospital unit, interferes with the applicability of the SAE.

There are days when we don´t even have time to spend in the rooms visiting [...] The team is already out of step and P.A. [Ready Care] lives crowded (E12).

Nursing is always overloaded, so I think this is the difficulty we have to use the SAE in our daily life [...] Besides doing your job as a nurse, you also have to help your technician to do his activities [...] (E07).

[...] the nurse is full of things to do he is a lot of paper and part bureaucratic (E09).

It was also observed that some nurses assume that the fact that doctors prescribe basic care planning would be enough for patient care, exempting the nurse from the obligation to perform the SAE.

[...] the patient is hospitalized there, we will treat only his disease, he has already come with the doctor´s prescription, so what we will do is medicate [...] (E10).

When there´s a change of decubitus or something like that, they [the doctors] already prescribe, so we put the schedules. When there´s a lot of need, for example, when there are many bedsores, the doctors prescribe a change of decubitus, the use of ointments, the change of the dressing, so we just put the schedules. So, it is a stage that would be ours, a care of ours, but they prescribe from there we execute and guide the family too (E03).

Nurses also reported that they sometimes perform the SAE, but find it difficult to record the planning and care provided to the patient. This occurs mainly because of the lack of space in the medical records.

There is no place for us to put all the stages of the nursing process, for example, a nursing process can be elaborated through the SAE, but there is no form that we can do this control [...] (E08).

We don´t have a separate sheet to make the SAE [...] no one ever makes the SAE, they only make that very basic report, they only write that they were admitted for clinical treatment, they don´t write the why, what they have or anything, so the error begins there, they have to have a slightly better report [...] (E03).

In summary, it was possible to identify that the discouragement of nurses due to difficulty in leading teamwork, resistance in adhering to the care plan by nursing technicians, lack of time due to work overload and reduced team added to the fact that some doctors prescribe care and the absence of space for registration, which are factors that hinder and succumb the application of the SAE.

Strategies employed to facilitate the application of the SAE in the daily of the nursing

According to the reports, some participants in the study recognized the benefits generated from the application of the SAE, understood as a tool that allows organizing, planning and standardizing professional care and practice:

[...] the standardization of care makes it much easier and you have the control to know what the staff is doing without you being around (E06).

[...] helps to organize our work as a nurse. We can put the nursing processes into practice [...] (E08).

[...] is a working tool of the nurse. We manage to organize the planning of patient care [...] (E07).

In addition to the organization of the service, many nurses attribute to the SAE the role of trainer of direct patient care, reporting that the application of this tool can favor their recovery.

[...] is a set of actions of the nurse that will be directed to the recovery of the patient, so, in fact through the SAE is that the nurse puts into practice all the actions that fall to him [...] (E09).

[...] The SAE is a way of delimiting a line of work with the team, because sometimes the technicians do not have that view of the need that the patient has [...] implementing SAE gives a differential in care, because otherwise you are just doing the medication or giving the bath, when you start working with the SAE you see that it gives a different result in improving the patient [...] (E05).

Some nurses, on recognizing the relevance of implementing the SAE, reported that in the face of numerous difficulties, to make it effective in daily work, it would be necessary to employ different strategies. For example, there were cases in which nurses were able to perform the SAE only for the most severe patients:

[...] it has to go to the most critical patient, the one who needs it most, [...] as it usually happens of not giving time, so it goes mainly to the most critical [...] (E11).

Another strategy applied to achieve nursing planning was mentioned by the nurses of institution “B”. They developed a checklist document, on our own initiative, in which there are some pre-established care plans to be selected when necessary, and there is also a space for records and checking of care performed by the team. This tool helps nursing professionals to prioritize their actions and develop broader and more comprehensive care.

We have prepared a pre-prescription on the nursing evolution side to facilitate our work (E05).

Here in the institution you have the nursing prescription that we prescribe: the type of bath, the type of dressing, the material you will use in the dressing [...] You prescribe in the nursing prescription and the staff has to check (E06).

Here in the chart we also have the nursing prescription directed to care, we go there and look at the patient, see what nursing care is needed and put it in the medical records. This is the nursing prescription we make [...] (E07).

Another strategy employed by nurses is to summarize, in a chart, some special care for patients, according to their clinical condition and risks. The printed chart is fixed on the patient´s bed, which makes it easier for the nursing team to see it.

Here at the hospital we have a board for each bed with the patient´s name on it. Below, there are the risk that we usually point out: [...] risk of thrombosis, post-surgical patient, so we point out [...] this makes it much easier for us [...] (E01).

[...] I do that risk classification of the patient also to call more attention [...] has at the bedside the identification of the patient, so we can put some care and if it has risk, then the team can see [...] (E07).

In addition to these strategies already implemented to facilitate the use of the SAE, the nurses suggested that there should be training of the nursing team to ensure adherence, especially, by technical professionals, and good results with the practice. There was also a need to computerize records, to contribute to the standardization and production of data on patients.

[...] It would have to take the staff and do a training, a recycling [...] (E02).

[...] if you had a computerized system, I think it would be much easier [...] because you could prescribe care, collect data from previous hospitalizations [...] (E03).

Finally, some participants were also concerned about the need for greater commitment on the part of hospital managers, so that the application of the SAE would be more demanded of hierarchical superiors in the institutions. This, according to them, would enhance recognition of the need and relevance of the SAE.

[...] you have to follow the management´s orders, if they say that the SAE will work then it will work! I don´t know if it would be the way it has to work, but it would already help (E04).

[...] it´s not something that the upper management charges, even though they know that every institution has to have. So, if they (managers) were more aware of the relevance of the SAE and demanded of nurses and technicians it is quite likely that their use would increase [...] (E03).

In summary, according to the nurses, the implementation of the SAE organizes, directs and standardizes the work of nursing. For its effectiveness in daily life, it is necessary to use strategies such as prioritization of the most seriously ill patients, use of a checklist type of care plan and better training of the nursing team, in addition to computerization of records and commitment by hospital managers.

DISCUSSION

From the results obtained, it can be identified that the nurses experienced different challenges in their daily work, which made it difficult to implement the SAE. The reality presented in this study, to a certain extent, can also be experienced by other nurses assigned to small hospitals in the interior of Brazil. Therefore, the findings herein may be useful to think and rethink the professional practice of the nurse and to guide the development of strategies for interventions that can help to reduce weaknesses and strengthen the potentials, in order to increase the use of the SAE in the field of work of the nurse.

The participants in this study showed discouragement for the employment of the SAE, mainly, due to the lack of appreciation and recognition of such actions by other team members. It was possible to notice some difficulty in establishing an efficient communication process and a satisfactory professional relationship between the leading nurse and the nursing team. In this sense, a study carried out by means of an integrative review of the literature on the participation of the nursing technician in the SAE, showed that the lack of communication and integration between the team and the failures in the nursing prescription, failing to elaborate integral and specific care for each patient, made the technicians question the validity of the SAE and its applicability in the work process.12

In turn, a study conducted with 13 nurses from a public maternity ward in northeastern Brazil showed that demotivation to apply the SAE in practice also occurred.13 However, in this scenario it was related to the fact that the nurses themselves could not associate what is learned in the theoretical field and its applicability in the practical field. Thus, regardless of the reason that led to demotivation of nurses, the discredit regarding the use, as a trainer tool of the care and promoter of professional autonomy, leads to non-adherence to its applicability.14

Faced with these differences, it is necessary for the nursing team to understand that efficient and quality care for patients involves the personal interest of each member of the team and, at the same time, working together. Therefore, it is essential that, as a leader, the nurse develops skills such as communication and good interpersonal relationships to outline the care and help his team to execute this planning, thus achieving the expected results and improving the quality of care for the patient and his family.12

It was also possible to identify from nurses' reports that the lack of application of the SAE occurs due to the accumulation of functions, especially bureaucratic, inherent to them, as well as the reduced staff and work overload. Different research conducted with nurses in northern3 and southern Brazil4 and in Ethiopia1 pointed out that among the various challenges for proper implementation of the SAE was the work overload of the nurse, caused by insufficient labor in the nursing team and the high number of patients to be assisted.

In this way, the overload that affects nurses, especially those inserted in small-sized hospitals and who end up also performing other activities/functions, not included in the list of their areas of operation, has represented an obstacle to the qualification of nursing care through the use of the SAE.8 Therefore, the nurse does not have time to apply all the steps involving the SAE in a continuous, systematic and appropriate manner. However, lack of time is not seen as a solid reason to prevent implementation of the SAE when it is prioritised.15,16

Prescription of nursing care is a foundation for the actions of the nursing team, understood as a moment in which a set of measures is planned in order to direct care to the patient.17 However, some participants in this study mentioned that the fact that doctors also deliberate on nursing care for patients, meant that nurses did not recognize the need to apply the SAE. However, it is necessary that nurses realize that the SAE provides autonomy, value and visibility to their professional work.18

Finally, the absence and necessity of own forms or larger spaces in the patient's medical records for the adequate recording of the application of the SAE was highlighted. Therefore, this is also a difficulty to be overcome, as it impairs the continuity of care and compromises the safety of the patient, since much of the information relating to his clinical condition is centralized in nursing, as it is the closest team that remains with the patient for the longest time.19

In this sense, a study conducted with 32 nurses in three hospitals located in southeastern Brazil showed that there was an important deficiency in nursing records related to the SAE,9 which was also observed in a study conducted in Italy.10 Another research conducted with 56 Portuguese nurses revealed that there was a perception that filling out the SAE in the medical records took up too much time of the professional.19 These aspects need to be worked on and rethought, because the absence of records and the lack of understanding about their relevance make it difficult to evaluate professional practice and result in little visibility and recognition for the nurse.6

Even in the face of all the challenges mentioned by the participants of this study, for the application of the SAE in daily life, some professionals used different useful and practical strategies to put this work methodology into action. For these participants, the SAE was perceived as an indispensable tool for the qualification of care and, therefore, it was implemented, although in a fragmented manner. In this sense, a survey conducted with eight nurses from a pediatric hospital located in northeastern Brazil showed that the application of the SAE led to improvements in the organization of the service and in the care offered to the patient, enabling extended assessment of care needs, which encouraged nurses to apply the steps of the SAE.20

One of the strategies engendered by the participants of the aforementioned study to promote/stimulate the application of the SAE was the prioritization of patients, i.e., those most seriously ill were most commonly given nursing care based on the SAE. A study with five nurses in the medical clinic sector of a public hospital in the northeast of Brazil identified that, in view of the difficulties in implementing the SAE for all patients under follow-up, its occurrence was limited to those more serious.3

On the other hand, a study developed with 10 nurses working in the adult intensive care sector, in a large-sized private hospital, located in southeastern Brazil, revealed that the complexity of patients in this sector generated barriers in the application of the SAE, related to the high demand for invasive procedures.21 Therefore, not only the severity of the patient's clinical condition should guide the implementation of the SAE, as well as the fact that the number of nurses is sufficient to prepare the SAE and perform the most complex technical and scientific care.

Nurses participating in this study also mentioned the use of a pre-established care plan such as a checklist as a strategy for implementing the SAE. In this model there were a series of risks whose patients are exposed and right below the main nursing care applicable to each situation. This contributed to a faster diagnosis of the patient's general condition and to the identification of the most appropriate care for the case. In addition, this checklist cooperated in the dissemination of information on the patient's clinical condition, since it remained in a place of easy and quick visualization by all members of the health care team.

In this sense, a study conducted with 13 nurses working in a hospital in southern Brazil, which offers medium and high complexity care, showed that the application of the SAE subsidizes, improves communication and management of nursing care, contributes to assertiveness in the decision making of the nurse and facilitates the implementation of the service.22 Therefore, patients and nursing professionals are benefited with greater safety from the implementation of the SAE in different health services.

It is important to remember that, according to what was identified in this study, in order to be effective in the application of the SAE, training of nursing team members in health services is necessary. This had already been highlighted in a previous investigation with eight nurses in a hospital service, located in a northeastern state, who pointed out that continuing and permanent approaches are indispensable to overcome the difficulties concerning the practical application of the SAE.23

The recognition of the need for training for the team was also mentioned in another study, developed with 56 nurses from 19 hospital centers in Portugal, allowing the identification that the effective implementation of the SAE only occurs when the entire nursing team is properly prepared and engaged.19

Another important aspect mentioned by the interviewees was related to the absence of support, encouragement and political will of hospital institutions administrators for realization of the SAE. Therefore, the nurses believed that if there was a greater demand from hospital managers about the applicability of the SAE, it would be possible to stimulate and postulate its use in a systematic and continuous way. In this sense, a bibliographic study showed that the implementation of the SAE is unknown to most hospital managers, since it is often understood as a specific and exclusive knowledge of the nurse.15

It was verified in a study with 30 nurses from a University Hospital located in the Southeast region that for the effective application of the SAE, planning is necessary, as well as considering the reality of the institution, political structure, management and institutional interest in the proposal and its practical feasibility, the number of professionals of the nursing team and the training of professionals involved.24 However, it is necessary that the nurse, on a daily basis, direct his professional practice in order to highlight to the management of the hospital institution and make it aware of the benefits arising from the application of this tool in their daily work, although structurally and politically their institution is not prepared.

In light of this, the recognition of the SAE by health professionals will only be possible after the results of its use have been disclosed to the nurse and his team, as well as to patients, relatives and managers. For its effectiveness in the daily work, the participants of the study state that it is necessary to start its implementation, even with small actions and/or in an isolated manner, since they will represent an important step for the qualification of the care and disclosure of the SAE. This, in turn, may raise awareness among professionals and managers about the need for subsidies and structure for the adequate applicability of the SAEs in all health care institutions, including small-sized hospitals.

FINAL CONSIDERATIONS

It was possible to identify that different factors hampered the implementation of the SAE in small-sized hospital units, scenarios of this study, such as overload of work of the nurse, lack of adequate documents to carry out the records, disinterest of the team for implementation and lack of support from the hospital institution and its managers. This caused the operationalization of the SAE to occur in a fragmented and partial way, especially by those nurses who recognized the relevance of this work methodology. Therefore, they sought different strategies to face the difficulties, such as prioritization of the most severe patients, use of standardized tools, training of nursing staff and support from hospital managers.

Possible limitations of the study refer to the fact that the interviews were conducted in the hospital unit and during the work day of the nurses, since sometimes during the interview, the nurses showed concern about returning to work activities, in addition, they might be afraid to reveal aspects related to the units as challenging for the implementation of the SAE. However, it should be noted that the choice to conduct the interviews in the health units themselves resulted from the fact that access to participants was facilitated and, therefore, the number of participants in the study was increased. Finally, it is highlighted that triangulation in data collection was not used, which could have contributed to potentialize the findings.

When identifying the challenges faced by nurses in small-sized hospitals in implementing the SAE in their work routine and pointing out how they have managed, at least in part, to operationalize the SAE, it is believed that the results can be useful in facilitating discussion of the theme and in highlighting the relevance of applying the SAE, including in small-sized hospital services, and in enabling feasible measures by which the challenges can be creatively overcome. It is believed that more studies on the subject are pertinent to expand knowledge in the area. Investigations that identify, as an example, the perception of the mid-level nursing team seem to be important to think about strategies that stimulate these professionals to understand the practical relevance of the SAE in the care.

REFERÊNCIAS

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Received: January 14, 2020; Accepted: April 08, 2020

Corresponding author: Mayckel da Silva Barreto. E-mail: mayckelbar@gmail.com

AUTHOR'S CONTRIBUTIONS:

Review study design. Acquisition, data analysis and interpretation of results. Writing and critical review of the manuscript. Approval of the final version of the article. Responsibility for all aspects of the content and integrity of the published article. Mayckel da Silva Barreto. Eleandro do Prado. Review study design. data analysis and interpretation of results. Writing and critical review of the manuscript. Approval of the final version of the article. Responsibility for all aspects of the content and integrity of the published article. Sonia Silva Marcon. Interpretation of results. Writing and critical review of the manuscript. Approval of the final version of the article. Responsibility for all aspects of the content and integrity of the published article. Ane Caroline Rodrigues Miranda Lucena. Leydiani Karina Rissardo. Mara Cristina Ribeiro Furlan

ASSOCIATE EDITOR:

Ivone Evangelista Cabral

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