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Organizational context and care management by nurses at emergency care units

Contexto organizacional y gerencia del cuidado por enfermeros en unidades de urgencias

Abstracts

The purpose of this study was to understand the meanings attributed to the organizational context and the role of nurses in care management at emergency care units. This study was based on qualitative research and the Grounded Theory methodological framework. Data were collected from September 2011 to June 2012 by means of semi-structured interviews with 20 participants from two emergency care units (UPA) in southern Brazil, divided into three sample groups. The context is marked by constraints that hinder communication and interaction between professionals and the search of assistance by patients with demands that are not resolved at other levels of care. This scenario highlights the performance of nurses in the managerial dimension of their work, who assume the responsibility for managing care and coordinating professional actions in favour of improved care practices.

Nursing care; Management; Emergency nursing; Emergency medical services


Este estudio tuvo como objetivo comprender los significados atribuidos a la configuración del contexto organizacional y el papel de los enfermeros en la gerencia del cuidado en unidades de urgencias. Se realizo una investigación cualitativa con el marco metodológico de la Teoría Fundamentada. La recolección de datos se llevó a cabo a partir de septiembre de 2011 a junio de 2012, a través de entrevistas semiestructuradas con 20 participantes, en dos unidades de urgencias del Sur de Brasil, distribuidos en tres grupos de muestreo. El contexto está marcado por la presencia de obstáculos que dificultan la comunicación e interacción entre los profesionales y la búsqueda de atención por pacientes con demandas no resueltos en otros niveles de atención. Los enfermeros sobresalen por el desempeño de la dimensión gerencial de su trabajo, asumiendo la responsabilidad de la gerencia del cuidado y coordinación de las acciones profesionales con vistas a mejores prácticas de cuidado.

Atención de enfermería; Gerencia; Enfermería de urgencia; Servicios médicos de urgencia


Este estudo teve por objetivo compreender os significados atribuídos às configurações do contexto organizacional e à atuação dos enfermeiros na gerência do cuidado em uma Unidade de Pronto-Atendimento. Realizou-se uma pesquisa qualitativa que utilizou como referencial metodológico a Teoria Fundamentada nos Dados. A coleta de dados ocorreu de setembro de 2011 a junho de 2012, por meio de entrevistas semiestruturadas com 20 participantes, de duas Unidades de Pronto-Atendimento do sul do Brasil, distribuídos em três grupos amostrais. O contexto da UPA é marcado pela presença de limitações que dificultam a comunicação e a interação entre os profissionais e a busca por atendimento de pacientes com demandas não resolvidas em outros níveis de atenção. Nesse cenário, os enfermeiros destacam-se pelo desempenho da dimensão gerencial do seu trabalho, assumindo a responsabilidade pela gerência do cuidado e pela articulação das ações profissionais em prol de melhores práticas assistenciais.

Cuidados de enfermagem; Gerência; Enfermagem em emergência; Serviços médicos de emergência


INTRODUCTION

The organization of care provided for patients at emergency services is an emerging discussion in several countries due to the epidemiological and socio-demographic shift of the global population. As a result of a greater life expectancy and higher morbi-mortality rates of cerebrovascular and coronary diseases, the search for emergency services has progressively increased ( 11. Knapman M, Bonner A. Overcrowding in medium-volume emergency departments: effects of aged patients in emergency departments on wait times for non-emergent triage-level patients. Int J Nurs Pract. 2010;16(3):310-7. - 22. Nugus P, Forero R. Understanding interdepartmental and organizational work in the emergency department: an ethnographic approach. Int Emerg Nurs. 2011;19(2):69-74. ).

In light of this scenario, one of the strategies of the Brazilian Ministry of Health is the implementation of emergency care units, or UPAs, that integrate the fixed pre-hospital component of the care system to emergencies proposed by the Política Nacional de Atenção às Urgências (National Emergency Care Policy (PNAU) to provide care in emergency situations of any nature and at different levels of seriousness. The PNAU was established in 2006 and updated in 2011 and is based on the premises of humanization, organization of care networks, medical regionalization of emergencies, and permanent training and education, in accordance with the precepts of the Unified Health System (SUS).

The PNAU states that the population suffering from acute conditions should be accepted at any level of the healthcare system, from primary care units to hospital and specialized medical services ( 33. Ministério da Saúde (BR). Resolução MS/ANVISA nº. 443, de 9 de junho de 2011. Aprova a conformação da Rede de Urgência e Emergência (RUE) e a criação da Força Nacional de Saúde do Sistema Único de Saúde (FN-SUS). Diário Oficial da União [da] República Federativa do Brasil. 2011 jul 18;148(136 Seção 1):61. ). This strategy seeks to correct the existing distortion in the flow of primary healthcare service users, considering that difficulties in accessing these services forces them to resort to emergency services at hospitals or emergency units to find care ( 33. Ministério da Saúde (BR). Resolução MS/ANVISA nº. 443, de 9 de junho de 2011. Aprova a conformação da Rede de Urgência e Emergência (RUE) e a criação da Força Nacional de Saúde do Sistema Único de Saúde (FN-SUS). Diário Oficial da União [da] República Federativa do Brasil. 2011 jul 18;148(136 Seção 1):61. - 44. Andreuccetti G, Carvalho HB, Korcha R, Ye Y, Bond J, Cherpitel CJ. A review of emergency room studies on alcohol and injuries conducted in Latin America and the Caribbean region. Drug Alcohol Rev. 2012 Sep;31(6):737-46. ).

Within this context, nursing practices and knowledge are important to provide effective and resolutive emergency care. It is the task of nurses, as those responsible for coordinating the nursing team and for care management, to find ways to guarantee availability and quality of material resources and infrastructure that will allow the team to provide emergency care, based on patient needs, and to conciliate organizational objectives with the objectives of the nursing team ( 55. Santos JLG, Garlet ER, Lima MADS. Revisão sistemática sobre a dimensão gerencial no trabalho do enfermeiro no âmbito hospitalar. Rev Gaúcha Enferm. 2009;30(3):525-32. ).

Care management is the combination of managerial and care dimensions of the nurses work in a way that management becomes the means to an end, which is care ( 66. Hausmann M, Peduzzi M. Articulação entre as dimensões gerencial e assistencial do processo de trabalho do enfermeiro. Texto & Contexto Enferm. 2009;18(2):258-65. ). With care management, the nurse promotes professionals relations, interaction and associations and develops multiple care actions by assisting and educating, building knowledge and combining the different hospital and out-of-hospital services to improve the quality of care as a civil right( 77. Erdmann AL, Backes DS, Minuzzi H. Care management in nursing under the complexity view. Online Braz J. Nurs [Internet]. 2008 [cited 2013 nov 14];7(1):[cerca de 10 p]. Available in: http://www.uff.br/objnursing/index.php/nursing/article/view/1033
http://www.uff.br/objnursing/index.php/n...
).

Key care management actions carried out by nurses during their professional practice in healthcare services are: dimensioning of the nurse team; leadership in the work environment; planning of nursing care; training of nursing team; management of material resources; coordination of the care provision process; realization of care and/or more complex procedures and assessment of nursing practice results (8). However, according to characteristics of the organizational context of nursing practices, care management can assume specific characteristics.

This panorama, considering that the UPAs are a relatively recent professional practice field for nurses, and the importance of care management, led to an interest in conducting this study based on the following research question: What are the meanings attributed to the organization context and care management performed by nurses in an emergency care unit (UPA)?

To answer this question, the study aims to understand meanings attributed to the organizational context and the role of nurses in care management at an emergency care unit.

METHOD

This study is based on qualitative research and the Grounded Theory (GT) methodological framework( 99. Strauss A, Corbin J. Pesquisa qualitativa: técnicas e procedimentos para o desenvolvimento de teoria fundamentada. Porto Alegre: Artmed; 2008. ).

The investigated scenarios were two UPAs in Florianópolis, SC, Brazil. These emergency care units are located in the southern and northern regions of the municipality to facilitate user access to 24-hour emergency services, according to the principles of the PNAU. The UPA Sul was inaugurated in September 2008; and the UPA Norte, in February 2009.

As established in the GT method, participants were listed from the creation of three samples groups that constituted the theoretical sample of this study. The first sample group (E1-E8) comprised eight nurses that practiced in the UPAs. Subsequently, considering the statements of nurses on the importance of team work for care management, the second sample group was created (E9-E14) with six participants: three physicians, two nursing technicians and a social worker. Finally, a third sample group (E15-E20) was created comprising six patients of the UPAs, to explore how they perceive the practice of nurses and the organization of services for the received care.

Size of the theoretical sample was determined by theoretical data saturation, which was reached with 20 participants. In the GT, saturation is reached when there are no new important data in relation to a given category; when this category is well developed in terms of properties and dimensions; and, when relationships between categories are well established and validated ( 99. Strauss A, Corbin J. Pesquisa qualitativa: técnicas e procedimentos para o desenvolvimento de teoria fundamentada. Porto Alegre: Artmed; 2008. ).

Data were obtained by means of semi-structured interviews conducted from September 2011 to June 2012, which were recorded and transcribed. Interviews with the first sample group were based on the following question: What is the meaning of nursing care management in the organization context of the UPA? With the second sample group, the initial question was: How do you perceive the practice of nurses when managing care at the UPA? All the interviews were conducted in the participant's work place, that is, in one of the two UPAs, on a previously scheduled time and date. Patients were also interviewed at the UPAs, after receiving care. Data were collected by a researcher and a scholarship student of scientific initiation, both authors of this paper.

Data were analysed using the constant comparative method, by means of open, axial and selective coding. This type of analysis determines that data be treated concomitantly by comparing indicators and identifying similarities, differences and levels of consistency between data ( 99. Strauss A, Corbin J. Pesquisa qualitativa: técnicas e procedimentos para o desenvolvimento de teoria fundamentada. Porto Alegre: Artmed; 2008. ). In open coding, each incident was coded into sub-categories to comprehend its significance based on the experience of research participants. After this stage, in axial coding, codes were grouped according to similarities and conceptual differences to form categories that were provisionally given names that were more abstract than the codes. In selective coding, the last stage of the analytic process, categories were refined and integrated to compose a central explanatory concept or phenomenon ( 99. Strauss A, Corbin J. Pesquisa qualitativa: técnicas e procedimentos para o desenvolvimento de teoria fundamentada. Porto Alegre: Artmed; 2008. ).

The category and sub-category agglomeration process, from the data analysis paradigm( 99. Strauss A, Corbin J. Pesquisa qualitativa: técnicas e procedimentos para o desenvolvimento de teoria fundamentada. Porto Alegre: Artmed; 2008. ), resulted in the phenomenon "Managing care in emergency units for specialized and differentiated healthcare and nursing care", which is supported by five categories: "Organization and structuring of the UPAs for the provision of emergency care" (context); "The nurse self-perceived and considered by the health team as being responsible for care management" (causal condition); "Revealing obstacles for care management" (intervening conditions); "(Re)organizing the flow and process of care" (strategies); and, "Providing differentiated care" (consequence). In this study, categories related to the context and causal condition are presented.

The project was approved by the Research Ethics Committee (Decision n° 1991/2011). Study objectives and the adopted methodology were explained to research participants, after which they signed an informed consent statement. Interview statements were coded with the letter "E", corresponding to the interview, followed by the number of the order in which interviews were conducted.

RESULTS

Organization and structuring of the UPAs for the provision of emergency care (context)

The sub-categories "presenting the physical structure of the UPAs", "characterizing the performance of nurses" and "listing the main care procedures conducted at the UPAs" represent the context of the phenomenon.

Describing the physical structure of the UPAs

The UPAs are divided into two floors, according to the type of care that is provided. The ground floor is for initial care, in which patient risk is classified. On the first floor, patients are medicated, held under observation and/or wait for tests, transfer or release. This organization was sometimes considered inappropriate because it hinders communication and the exchanging of information between the nurses that are on different floors.

The UPA is divided into two floors: the ground floor is the emergency unit, the resuscitation room and screening. Screening is where all patients are attended by the medical clinician. The first floor is for observation, where eventually patient wait for tests or transfers, which is a little more serious (E2).

The actual ground plan of the UPA is inappropriate because we have two floors. When you're on the first floor, you don't know what's going on on the ground floor, which is quite a nuisance (E6).

Listing the main care procedures conducted at the UPAs

In relation to care provided at the UPAs, the healthcare professionals emphasized a distortion of the main care objective of the UPA, which has been mainly visited by people with issues that could be dealt with at regular healthcare units. Among these main care demands, the participants highlighted situations of social vulnerability with psychosocial alterations.

We´ve noticed that the UPAs are turning into or have already turned into massive out-patient units where demands, instead of being dealt with at our primary healthcare reference units, are all concentrated in these UPAs. We've noticed this huge distortion in relation to the objective of providing emergency care at the UPA (E3).

We are providing out-patient care, but as the focus is emergency care, when it appears, we leave primary care for a wound, for example, that the patient could have treated at the medical unit (E8).

Lots of demands are: situations of social vulnerability, mental health, substance abuse, suicide attempts, depression, psychological behavioural disorders, which are usually based on some family issue, some social and economical problem, some conflict, for example, going through some rule adaptation process (E12).

Interviews with patients revealed the subjectivity that permeates the conception of emergency and the motives that lead them to seek assistance at the UPAs. The main reasons for seeking assistance mentioned by patients were chronic incommunicable diseases, discomfort, pain in the articulations and indisposition or feeling unwell.

I came here because I wasn't feeling well [...]. My pressure was high and I wasn't feeling well and I had to be interned in the Hospital de Caridade (E15).

I have a back problem and a problem in both knees. When I get really strong crises, I have to come and I have to take some heavy medication (E16).

I have high blood pressure, and I've come lots of times because of my pressure. The other time I came because I felt chest pain, I've come lots of times [...] (E18).

I came to the UPA because of renal colic, I was already pregnant [...] (E20).

Characterizing the performance of nurses

During professional practice in the UPAs, the main activities of nurses are related to screening with risk classification, care for intercurrent illnesses, support in medicine administration, test collection and procedures that are part of the nursing profession, according to the Brazilian Professional Nurse Practice Act.

Half the shift is for screening and taking care of resuscitation inter-events (E3).

We go to the ground floor to help with the medication, collect tests and assist patients that are interned there (E4).

Most work is basically centred around organizing the Nursing team, some pre-established routine work exclusively performed by nurses, bladder probing, collection for gasometry, just about everything that's in the COREN, in our ethics code (E5).

The nurse self-perceived and considered by the health team as being responsible for care management (causal condition)

In this context, nurses see themselves and are considered by the team as being responsible for care management. In this sense, managing care becomes an activity that is naturally performed by nurses based on actions such as organization and coordination of unit operations, both in relation to staff structure and the prevision and provision of material and equipment needed for patient care.

We coordinate and administer the shift itself, and we work with the team, that is fixed, during the twelve hours we're in here (E7).

I check the psychotropic medication, because we're the ones who have to control that, although there's me and another colleague of pharmacy, but it's nursing that controls that. After that, I go to check the emergency equipment, especially the resuscitation trolley. I consider that a priority because if anything happens at the start of the shift, the minimum has to be there. We also organize the parallel service charts, monthly schedules, who's going where (E8).

In addition to the performance of nurses in care management, statements of the healthcare team professionals and patients showed their participation in organizing care activities. The nurses are responsible for solving problems that arise during the daily care routine and request the presence and/or help of other healthcare professionals to ensure that care is provided in the best possible way.

The nurse is essential, excellent, has a coordination that works, administers well that issue of referrals, coordinates the team and the technical staff that accompanies it, the doctor during removal, the transportation of a patient from one place to another (E9).

The nurses are always with the nursing technicians, [...] they coordinate the teams, they try to solve the problems that appear during the shift [...] I see they are very participative and active, they are always with the doctors, too, when there are cases they have to solve and have to discuss it together with the doctor. They demand quite a lot from social services, too (E14).

The most important professional for my care at that moment was the nurse [...], because of her care, her attention and because she realized that it was a delicate matter, her technical capacity. Then she called the doctor (E16).

The categories and subcategories and their relationship with the phenomenon are shown in Figure 1.

Figure 1.
Graphic representation of the context and causal condition of the detected phenomenon. Florianópolis, SC, 2013.

DISCUSSION

Research allowed a better understanding of care management as an important professional attribution of nurses in Brazilian healthcare services, especially in emergency medical services. Furthermore, results contribute to existing literature on this increasingly popular topic by focusing on a practice scenario that is currently being organized and expanded in Brazil, as is the case of the UPAs.

The organization and structuring of the UPAs present limitations for emergency care. One of these limitations is the existence of two floors that hinders the accompaniment of patient care and the relationship between nurses and the healthcare team. A similar situation was found in a study conducted at an UPA in Mossoró, Rio Grande do Norte, where the structural organization of the unit did not favour the provision of care ( 1010. Oliveira KKD, Amorim KKPS, Fernandes APNL; Monteiro AI. Impacto da implementação do acolhimento com classificação de risco para o trabalho dos profissionais de uma unidade de pronto atendimento. REME: Rev Min Enferm. 2013;17(1):148-56. ).

Another relevant aspect in relation to the work context was the profile of care provided at the UPAs, considering that patient complaints could have been remedied at the primary health service units. This finding supports the results of a study conducted at an emergency unit in Ribeirão Preto, state of São Paulo, in which the motives for seeking assistance were: cough, cold or flu, sore throat, diarrhoea, epigastralgia, sprains, headache, and lower back pain. These symptoms represent acute cases of sickness and do not pose an immediate risk to patients ( 1111. Gomide MFS, Pinto IC, Gomide DMP, Zacharias FCM. Perfil de usuários em um serviço de pronto atendimento. Medicina (Ribeirão Preto). 2012;45(1):31-8. ).

Results of this study show that the UPAs are becoming an alternative for emergency hospital services. Before the establishment of the UPAs, most of the population did not have regular access to a healthcare service and hospital services were the main alternative for health problems that were unresolved and undiagnosed at other care levels, especially in primary care. Common sense dictates that hospitals have a collection of resources that make them more resolutive, whether for consultations, medication, nursing procedures, laboratory tests or hospitalization ( 1212. Santos JLG, Lima MADS, Pestana AL, Garlet ER, Erdmann AL. Challenges for the management of emergency care from the perspective of nurses. Acta Paul Enferm. 2013;26(2):136-43. - 1313. Coelho MF, Chaves LDP, Anselmi ML, Hayashida M, Santos CB. Analysis of the organizational aspects of a clinical emergency department: a study in a general hospital in Ribeirao Preto, SP, Brazil. Rev Lat-Am Enfermagem. 2010;18(4):770-7. ). Consequently, chaotic use, over burdening of services and a shortage of hospital beds create difficulties both for patients seeking care and the healthcare teams that provides it ( 22. Nugus P, Forero R. Understanding interdepartmental and organizational work in the emergency department: an ethnographic approach. Int Emerg Nurs. 2011;19(2):69-74. , 1212. Santos JLG, Lima MADS, Pestana AL, Garlet ER, Erdmann AL. Challenges for the management of emergency care from the perspective of nurses. Acta Paul Enferm. 2013;26(2):136-43. ).

It should be noted that, in Brazil, the PNAU establishes that care for individuals with acute health conditions must be provided in all the entrance points of healthcare units of the Unified Health Service to allow integral resolution of demands or responsible transfers to a service of greater complexity, within a hierarchized and regulated system organized in regional emergency care networks, as the links that connect a life maintenance system in growing levels of complexity and responsibility ( 33. Ministério da Saúde (BR). Resolução MS/ANVISA nº. 443, de 9 de junho de 2011. Aprova a conformação da Rede de Urgência e Emergência (RUE) e a criação da Força Nacional de Saúde do Sistema Único de Saúde (FN-SUS). Diário Oficial da União [da] República Federativa do Brasil. 2011 jul 18;148(136 Seção 1):61. ).

In this context, the UPAs should be linked to the primary care units, the emergency ambulance service, or SAMU, the hospital network, the diagnosis and therapeutic support network and any other healthcare network. If necessary, the UPA should refer users to reference services, according to the complexity, with the help of the emergency regulation central (3), as revealed in this study. The main purpose of the UPAs is immediate access to healthcare services in case of emergency, contributing to the organization of comprehensive emergency care networks in Brazil, and assist users with acute or chronic pathological conditions, with or without life threat risks ( 1414. Gehlen GC, Lima MADS. Nursing work in care practice at emergency care units in Porto Alegre/RS. Invest Educ Enferm. 2013;31(1):26-35. ).

Based on this line of thought, there is a need to discuss the problem-solving capacity, organization and structure of primary healthcare services to provide emergency care, considering they do not always have readily available professionals qualified for emergencies or adequate material resources for this purpose. Another equally important issue is that the population is still not sufficiently aware of the network organization of emergency care and the choice to resort to a UPA or primary care unit is based on subjective aspects or prior experiences in relation to use of these services.

In relation to the performance of nurses in care management at the emergency services, the need to constantly develop the best strategies that help to overcome the challenges of a work environment marked by the constant search for care should be especially observed.

Similarly to findings of this study, previous studies identified that management is an essential and predominant activity of nurses in emergency services( 1313. Coelho MF, Chaves LDP, Anselmi ML, Hayashida M, Santos CB. Analysis of the organizational aspects of a clinical emergency department: a study in a general hospital in Ribeirao Preto, SP, Brazil. Rev Lat-Am Enfermagem. 2010;18(4):770-7.

14. Gehlen GC, Lima MADS. Nursing work in care practice at emergency care units in Porto Alegre/RS. Invest Educ Enferm. 2013;31(1):26-35.
- 1515. Montezelli JH, Peres AM, Bernardino E. Demandas institucionais e demandas do cuidado no gerenciamento de enfermeiros em um pronto socorro. Rev Bras Enferm. 2011;64(2):348-54. ). Moreover, informally, daily negotiations of internal and external problem-solving in the emergency unit are usually carried out by nurses, which enhances service provision ( 22. Nugus P, Forero R. Understanding interdepartmental and organizational work in the emergency department: an ethnographic approach. Int Emerg Nurs. 2011;19(2):69-74. ). To reach these objectives, nurses must combine time control, theoretical substantiation, discernment, initiative, emotional stability and leadership capacity, which requires the development of skills such as communication, interpersonal relationships and decision-making ( 1515. Montezelli JH, Peres AM, Bernardino E. Demandas institucionais e demandas do cuidado no gerenciamento de enfermeiros em um pronto socorro. Rev Bras Enferm. 2011;64(2):348-54. ).

Results also revealed the important role of nurses in the reception/screening of patients at the UPAs, because it is their responsibility to establish the order of priority of assistance and refer patients, when necessary, according to the identified risk level. For reception, checking the risk level and establishing the time patients can wait to be attended, nurses emphasized the importance of clinical knowledge on the symptomatology of diseases.

Clinical knowledge is very important when providing emergency care because it allows identification of signs and symptoms of pathologies that demand quicker assistance and/or intervention. However, the performance of nurses in these contexts must also include the appreciation of subjectivity and the multiplicity of human beings, considering that care is the interaction/integration/relationship link between professionals and patients (16).

As a care management strategy, nurses should try to explain how reception works and the flow of assistance provided at the UPAs. This conduct is important because the reception and risk classification process should observe actions that tranquilize patients and family members, such as providing clear information on the time, areas and flow of assistance, that prioritizes patients with more serious conditions than those with less serious conditions. These guidelines are important for patients to trust the classification system and not consider it yet another obstacle for assistance. Furthermore, they contribute to the provision of differentiated and specialized nursing care and healthcare and favour a welcoming and humanized environment (17).

In the context of the nurses work, a welcome reception is therefore an important strategy for care management, based on activities that involve user evaluation, decision-making, classification and the prioritization of assistance at the emergency unit according to seriousness, as mentioned in previous studies ( 1818. Acosta AM, Duro CLM, Lima MADS. Activities of the nurse involved in triage/risk classification assessment in emergency services: an integrative review. Rev Gaúcha Enferm. 2012;33(4):181-90. - 1919. Randow RMV, Brito MJM, Silva KL, Andrade AM, Caçador BS, Siman AG. Articulação com atenção primária à saúde na perspectiva de gerentes de unidade de pronto-atendimento. Rev Rene. 2011;12(5):904-12. ). Consequently, nurses must focus on the continuous development of managerial competencies and skills and communication to improve awareness on the specificities and peculiarities of the work environment at the UPAs.

FINAL CONSIDERATIONS

This study allowed an understanding of the meanings attributed to the organizational context in which nurses manage care at the UPAs.

Results showed that the UPAs are undergoing an organization and structuring process for their full operation in the scenario in which this research was conducted. The physical structure is divided into two floors, which hinders communication between professionals at the unit and even transportation in case of emergency situations. The context is marked by the search for assistance of patients with non-urgent demands from the biomedical standpoint, showing that the UPAs are becoming care alternatives for people with demands that were unidentified and/or unresolved at other care levels, as in the case of primary care. Nurses inserted in these care environments perform the managerial dimension of their work, assume the responsibility for care management and the organization of professional actions to improve care practices.

For the education and assistance of nursing, these results can provide support for students, nurses, healthcare professionals and managers of the UPAs and of emergency services to reflect on their practices and invest in the development/improvement of strategies that strengthen organization and structure to provide an increasingly qualified service that complies with the intended care purposes.

Although this study sought to obtain a deeper understanding of the investigated context, the fact that the UPAs are still being implemented when data were collected may represent a bias in relation to the presented findings. Therefore, implications for the scope of research are the need for other studies to be conducted in other scenarios to obtain a broader understanding of the studied topic, thus contributing to the effective implementation of an emergency care network.

REFERENCES

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    Knapman M, Bonner A. Overcrowding in medium-volume emergency departments: effects of aged patients in emergency departments on wait times for non-emergent triage-level patients. Int J Nurs Pract. 2010;16(3):310-7.
  • 2
    Nugus P, Forero R. Understanding interdepartmental and organizational work in the emergency department: an ethnographic approach. Int Emerg Nurs. 2011;19(2):69-74.
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    Ministério da Saúde (BR). Resolução MS/ANVISA nº. 443, de 9 de junho de 2011. Aprova a conformação da Rede de Urgência e Emergência (RUE) e a criação da Força Nacional de Saúde do Sistema Único de Saúde (FN-SUS). Diário Oficial da União [da] República Federativa do Brasil. 2011 jul 18;148(136 Seção 1):61.
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    Santos JLG, Garlet ER, Lima MADS. Revisão sistemática sobre a dimensão gerencial no trabalho do enfermeiro no âmbito hospitalar. Rev Gaúcha Enferm. 2009;30(3):525-32.
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Publication Dates

  • Publication in this collection
    Dec 2014

History

  • Received
    24 Feb 2014
  • Accepted
    28 July 2014
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