Apprehensions of nurse managers on evidence-based practicea

Camargo, Fernanda Carolina; Goulart, Mayla Borges; Iwamoto, Helena Hemiko; Araújo, Maria Rizoneide Negreiros de; Contim, Divanice

doi:10.1590/2177-9465-EAN-2017-0109

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RESEARCH • Esc. Anna Nery 22 (1) • 2018 • https://doi.org/10.1590/2177-9465-EAN-2017-0109 copy

Apprehensions of nurse managers on evidence-based practice^a a Extracted from the doctoral thesis entitled Analysis of the Production of Nursing Research and Strategy to strengthen its Utilization in the Teaching Hospital of Triângulo Mineiro of the Graduate Program in Health Care of the Federal University of Triângulo Mineiro, defended in 2017.

Inquietudes de enfermeros gerentes sobre la práctica basada en evidencias

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objective:

To analyze the apprehensions of nurse managers in the implementation of the Evidence Based Practice in a Teaching Hospital of Triângulo Mineiro.

Method:

Qualitative research guided by the Theory of the Diffusion of Innovations. Five workshops were conducted per focal group (n = 18 participants), conducted by hermeneutic-dialectic interactions between August and September/2016. Textual records resulting from each workshop were analyzed by semantic categories.

Results:

Aspects conditioning to the implementation of the Evidence Based Practice permeate from elements related to the fragmentation of the care network to the necessary expansion of the governability of the nurse managers to put changes into practice in their sectors. Most importantly, timely access to the results of research conducted at the teaching hospital was mentioned as crucial to guide better practices.

Final considerations:

The approach allowed the recognition of contextual conditions for the implementation of the Evidence-Based Practice, which may coincide with similar scenarios, as well as increase the national scientific production on the subject, which is still scarce.

Keywords:
Evidence-based Nursing; Leadership; Diffusion of Innovations; Teaching Hospitals

1^st workshop: “Fragmentation of the SUS health care network, limitation of financial resources and the improvised act of the nurse”

Nurse managers reported that HPE, as known by all participants in the focus group, was responding to a healthcare demand that extrapolated actions agreed by SUS (macro-regional). The patients originated from uncontracted locations, which entailed the absence of adequate financial transfers. The fragmentation of the care network and the reputation of HPE also emerged in this dynamic. Participants reported that a disorderly, non-exclusive and highly complex demand was met at this institution – at the Hospital Emergency Room, as there was a belief in the population that their health problems would only really be solved at this hospital. These situations were reflected, in particular, in the limitation of inputs. Improvisation, faced with limitations related to some materials, was considered as a recurring act in the nurse's action - interventions that did not violate the patient's integrity and safety. However, the focus group participants questioned, in light of PBE concepts, whether improvisation could not be related to the discovery of a new technique. In general, they conceived that the use of evidence to guide care had a positive value, especially when considering the need to legitimize the nurses' performance.

2^nd workshop: “Enhancement of knowledge and practices: an isolated action”

Regarding knowledge not favorable to EBP, the focus group identified that the act of accommodating to the routines imposed and based exclusively on the knowledge acquired during their graduation, put the professional in a position of "discrepancy" of knowledge. In this regard, they discussed the need for nursing to be a profession that depends on constant updates. They argued that, individually, it would be necessary for nurses to search for updates (in particular, specialization courses were mentioned). Through the group discussion, the practice of improving knowledge should be an action of individual search of each nurse. The hospital institution was not responsible for this practice, although it was linked to a university. At no time was the presence of the students (technical, undergraduate or graduate level) mentioned as an inductive action to increase nurses' knowledge. The focus group understood "the questioning and the opening to the new" as essential positions for the implementation of the EBP. They emphasized that a practice could only be modified against the agreement of the patient assisted and if the nurse presented technical ability to perform the new practice. They pointed out that the monitoring and evaluation of their practices, such as epidemiological analyzes and the systematic reporting of these results would be an important starting point for planning the improvement of care.

3^rd workshop: “Hierarchies, Management verticality and uncertainties in the nurse managers' role”

The overload of work and overlap of tasks to the nurse unit manager were denoted as main barriers to the implementation of the EBP. The focus group presented the experience of a day-to-day afflicted by the volume of attributions imposed on them by the hospital institution. They pointed to an excess of records for which they are responsible and a high volume of administrative meetings in which they must be present. As they act in the dialogue of the decisions of the top management with the assistance teams, the activation of their presence in administrative meetings was not an action usually scheduled. Another aspect mentioned were the administrative demands of the hospital. They stated that any events that took place in the hospitalization unit (including building and equipment maintenance) required their intervention, which eventually generated overload. They pointed to the restructuring that the hospital underwent, as opposed to management by care lines and participatory management units, as a positive alternative to reduce the overload of their activities. Importantly, the focus group participants reported interest in having more time together with nursing care teams for more appropriate bedside planning. Some focal group participants mentioned that nursing teams have little understanding in terms of the role of the unit nurse manager.

4^th workshops: “Local Governance for Change, Requests for Institutional and Academic Support”
In the collective discussions, the focus group presented as an understanding that, in order to reach the performance based on EBP, actions that involve their own governance could be implemented. In general, the interventions identified by the focus group for the implementation of EBP mostly included changes in the organization of the work routine that were available to them, such as: discussing the issue with colleagues in the sector, including other categories; implanting a routine of discussion of cases with the nursing team; reading articles weekly with themes similar to the problems experienced in the daily life; raising basic doubts about the routine. The initiatives identified as dependent on greater organizational deliberation were: greater availability of computers with internet access in the hospitalization units; safeguarding workload for study group; adjusting the institution's work guidelines to support EBP.
5^th workshops: “Research development: disarticulation and non-appropriation by the group”
The greatest manifestation of the focus group was the lack of knowledge regarding the research developed in HPE. In general, the group stated that it felt pressured to authorize the carrying out of research in its units of responsibility, because it was an HPE. However, at the same time, this action generated discomfort, as they felt responsible for the maintenance of the integrity of the nursing team and the patients assisted. They commented on the rare exceptions of professors/researchers from different areas of the university who sought them out to discuss a research proposal and to analyze the feasibility of their development in the sector. Often, they mentioned, they felt like "objects", and this feeling was reflected in the entire nursing team of the corresponding hospitalization unit, because students at different levels of training sought them out to answer questionnaires (most of the time, very extensive), but they never returned to present the results. In general, they felt that the academy (in this case, the university) had an unequal power relation over them. In addition, they mentioned that, if they had timely access to results, they would seek strategies to improve practices.

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[1] Correspondig author: Fernanda Carolina Camargo. E-mail: fernandaccamargo@yahoo.com.br