Nurses in the Kanban: are there news meanings of professional practice in innovative tools for hospital care management?

Cecílio, Luiz Carlos de Oliveira; Reis, Ademar Arthur Chioro dos; Andreazza, Rosemarie; Spedo, Sandra Maria; Cruz, Nelma Lourenço de Matos; Barros, Luciana Soares de; Carapinheiro, Graça; Correia, Tiago; Schveitzer, Mariana Cabral

doi:10.1590/1413-81232020251.28362019

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ARTICLE • Ciênc. saúde coletiva 25 (1) • Jan 2020 • https://doi.org/10.1590/1413-81232020251.28362019 copy

Nurses in the Kanban: are there news meanings of professional practice in innovative tools for hospital care management?

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Kanban is a care management tool that values multi-professional work and intensive use of data and has been growingly used in Brazil to address overcrowding in hospital emergency services (HES). The researchers monitored the Kanban for ten months in multiple wards of a municipal HES, and their observations were recorded in field diaries and discussed in biweekly research team meetings. The empirical material was organized from two questions: Are there changes in “traditional attributions” of Kanban-operating nursing? Are Medicine-Nursing interprofessional relationships transformed? A strong nurse adherence to this tool was observed, coupled with greater specialization and fragmentation of their work: nurses working as diarists assume more traditional administrative functions, while those on-call develop more direct assistance to patients. Nurses consider that clinical decisions are still in the doctors' hands, although Kanban provides them with a stronger influence on such decisions. Nurses' role in the management of significant mass of clinical and operational data, central to Kanban's operationalization, strengthens their professional authority.

Key words
Nursing; Emergency medical services; Patient-centered care; Kanban; Medicine-Nursing relationships

Name	Site	Description	Periodicity	Professionals
Pediatrics Kanban	Pediatric Room	Professionals sit freely around the room on chairs and tables. The nurse stays at the computer updating the spreadsheet and conducts the meeting, informing the patient's situation. Doctors get into some clinical aspect, and the other professionals, into some specific demand.	Daily 11h	Social Worker NIR Nurse Horizontal Nurse On-call Nurse Speech and Language Therapist NIR Doctors and Pediatricians
Pediatric ICU Kanban or Round	Small room in the ICU	Professionals standing or sitting discuss cases. Everyone has a voice. The nurse is the driver, informs the patient's situation regarding the procedures performed or not, medication and needs. Doctors talk about the case and exchange information between them. Other professionals act when there is demand.	Daily 11h30	Social Worker NIR Nurse Horizontal Nurse On-call Nurse Physical Therapist Speech and Language Therapist Nutritionist Psychologist NIR Doctors and Pediatricians
Pediatric Multi-professional Kanban	Playroom	All pediatric professionals, including ICU and semi-intensive care. The nurse leads from the census worksheet. The atmosphere among professionals is very quiet, with moments of relaxation.	Weekly 11h	Social Worker NIR Nurse Horizontal Nurse On-call Nurse Physical Therapist Speech and Language Therapist NIR Doctors and Pediatricians Nutritionist Psychologist
Green Axis Kanban	No fixed place	Nurses, doctors, and social workers are always present. Nursing conducts with the census, informing the patient's situation. The social worker explains the social situation, in particular, concerning discharge.	3 times a day	Social Worker NIR Nurse Horizontal Nurse On-call Nurse NIR Doctor Doctors Psychologist
Hospitalization Unit Kanban	Study room	Nursing conducts, informing the patient's situation concerning procedures implemented or not, medication and needs.	Daily	Social Worker NIR Nurse Horizontal Nurse On-call Nurse Physical Therapist Speech and Language Therapist NIR Doctor and Doctors Nutritionist Psychologist
Yellow and Red rooms Kanban	In the entrance corridor	The diarist nursing staff conducts and informs the patient's entry status, procedures performed, medication, and needs. Doctors talk about the case, exchange information between themselves, and indicate the possibility of referral.	Daily 11h 22h	Social Worker NIR Nurse Horizontal Nurse On-call Nurse Physical Therapist NIR Doctor Doctors Psychologist
Yellow Room Round	In the yellow room	The diarist nursing staff conducts, along with the diarist doctor who is on the computer and writes down goals and conducts. Both inform the patient's entry status, procedures implemented or not, medication, and other needs.	5 times a week	Horizontal Nurse On-call Nurse Pharmacist Physical Therapist Speech and Language Therapist Preceptor Doctor - diarist Resident Doctor Nutritionist Psychologist
Adult ICU Fast Hug - Kanban		A wheel where not everyone looks at each other and the climate is cold. The diarist nurse conducts and informs the patient's general status, tests, and changes. It is a discussion centered on the clinical case, with much medical leadership and rare participation of other professionals.	5 times a week	Horizontal Nurse On-call Nurse Pharmacist Physical Therapist Speech and Language Therapist Doctor - diarister and on-call Nutritionist Psychologist

Technique used	Stakeholders and location	Objective
Participant observation	Teams involved in the operationalization of Kanban	Characterize the functioning of Kanban observing the relationships of teams, professionals and users and places
Seminários compartilhados	- Research Coordinators - Field Researchers - Hospital Managers and Coordination of the axes: green, critical, hospitalization, and adult and child ICU. - Internal Regulation Center - Professional Supervisions	Discuss with the institutional stakeholders the first analysis of the findings obtained from the participant observations.
Seminars shared with Nurses	Researchers and nurses: managers, clinic coordinators, diarists, on-call staff	Discuss with nurses the issues set in the seminars

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[1] Collaborations

LCO Cecílio: conception, design, analysis, and interpretation of data, drafting of the paper and its critical review, and approved the version to be published. AA Chioro dos Reis and T Correia: contributed to the conception, design, analysis, and interpretation of data; drafting of the paper and its critical review; read and approved the final version of the manuscript. R Andreazza: performed the empirical research; contributed to the design, analysis, and interpretation of data; drafting of the paper and its critical review. SM Spedo: contributed to the conception, design, analysis, and interpretation of data; drafting of the paper and its critical review. NLM Cruz and LS Barros: performed the empirical research; critical review and read and approved the final version of the do manuscript. G Carapinheiro: contributed to the design, analysis, and interpretation of data; drafting of the paper and its critical review; read and approved the final version of the do manuscript. MC Schveitzer: performed the critical review; read and approved the final version of the do manuscript.