Implications of Nursing Care Systematization in Brazilian professional practice

1 Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brazil. 2 Universidade Federal da Bahia, Salvador, BA, Brazil. 3 Universidade Federal do Recôncavo da Bahia, BA, Brazil. 4 Faculdade Bezerra de Araújo, Rio de Janeiro, RJ, Brazil. 5 Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brazil. ABSTRACT To analyze the implications of the Nursing Care Systematization in Brazilian professional practice. Theoretical and reflective study, which listed as analytical categories the regulatory framework of systematization, the implications for professional practice, the limits and possibilities. In the legal frameworks, an evolution of understanding about Systematization was identified, which resulted in an update in the resolution that deals with the theme. It is emphasized that the implications for professional practice can be elucidated when the concepts, method, personnel and instruments are better understood, the three pillars of systematization, since they do not have conceptual and operational definitions in the current resolution. The lack of conceptual clarity about the term, as well as the lack of conceptual and operational definitions of its pillars and constituent elements, have made the understanding of the Nursing Care Systematization difficult, impacting the perception of its contribution to professional practice, since it is not rarely used as a synonym for the Nursing Process. The production of knowledge about Systematization must consider its limits and possibilities. Thus, contributing to the demarcation of the production of knowledge that is representative of this epistemological object.


INTRODUCTION
The contemporary expression of the organization of professional work in care contexts, from primary care to hospital environments, which represent what are commonly named nursing services, can also be understood in the light of the Nursing Care Systematization (NCS) regarding the method, personnel and instruments (1) , these being its three pillars.
The advancement of nursing knowledge has allowed this art and science to be practiced in care environments that are increasingly organized and structured.Thus, two aspects are considered: NCS -with the organization of work (1) , which covers the environment in which nursing is performed, the service itself; on the other hand, the Nursing Process (NP), with the guidance of professional care and the registration of clinical documentation (1) , resulting from its implementation.
However, what seems to be marked by simple understanding -that is, NCS organizes the work and the NP guides care (1) -undoubtedly has led to the most different inferences and, at times, a limited and/or mistaken understanding of the term NCS, as well as the use and application of its concept, whether in the scope of intellectual production or in the daily care, which makes it difficult to understand the practical implications of its use, considering its primary function -organization of professional work as method, personnel and instruments (1) .
It is noted that the Brazilian literature has registered different groups of thought considering the NCS, a finding that has persisted in the scientific nursing literature until the present day.One group understands NCS, NP and Nursing Care Methodology as different concepts, another one defines NP and Nursing Care Methodology as synonyms and a third one that understands NCS, NP and Nursing Care Methodology as synonyms (2) .This reflection is anchored in the understanding of the first group of thought, that is, NCS and NP are different concepts and need to be addressed as different research objects in the construction of disciplinary knowledge.
Thus, there are theoretical and practical aspects of NCS and NP that need to be discussed and elucidated, considering the limits and possibilities that each term reserves, since their differentiation difficulties "contribute to the lack of consensus on the concept of these two fundamental components for the nursing practice, with consequent repercussions for the formation of professional identity" (3) .
It is necessary to find an unequivocal purpose for NCS, so that nursing professionals recognize themselves in it, identify and know what their real contribution in professional practice is, when it is credited with the organization of professional work (1) .Considering the NP, it seems to already have better outlined epistemological contours, since "the centrality of our profession is care and the NP is the way to give it scientific rationality capable of showing the specificity of our know-how" (3) .However, when considering NCS, it still lacks discussions and theories that give it a clearer epistemological outline, with regard to its concept, its pillars and the elements that compose it.
In the particular case of Brazil, doubts still remain when discussing NCS and NP.As an example of this question, it is still necessary to produce theoretical advances in order to obtain the answer to the question: What is NCS?An editorial that discussed the purpose of the NP pointed out that its teaching should focus on the main concepts of nursing practice, and lists a number of concepts that should be addressed, among them, sleep, pain, self-care, among others (4) .Thus, it is necessary to identify which knowledge to focus on teaching NCS, since once identified, they would constitute advances for its theoretical-practical demarcation as a field for the production of disciplinary knowledge and application in nursing services.
Considering the teaching of NCS, topics such as the administration of nursing services; organizational structure of nursing services; staff sizing; principles, values and beliefs of nursing services; people management, project management, process management; materials and supplies relevant to nursing services could be addressed.In summary, knowledge supported in the administration and management of health and nursing services.
It should be noted that NP is the methodological instrument that guides care in a procedural way through its five interrelated, interdependent and recurring steps, that is, data collection, nursing diagnoses, planning, implementation and evaluation (1) , and which is based on the scientific method.NCS should not be used in synonym with the Nursing Process, since the idea expressed by the term "it may not be adequate to the phenomenon, since systematizing may mean organizing, but not necessarily using all the steps of the scientific method" (5) .
NCS should not be understood in a similar way to that of the NP, since it does not occur in stages.However, it should be understood from its pillars, method, personnel and instruments -large areas of knowledge that represent the bases known for the use of NCS, as a necessary tool for the organization of professional work.Therefore, it is a critical point to understand the bases that support the materialization of NCS, how the organization of professional work is carried out in practice, as well as how NCS contributes as a management tool in health services.
Having presented the problematic, it is assumed that NCS constitutes a field of production of broad knowledge, which still needs to be delimited, considering its limits and possibilities regarding its application.Thus, the question is: what are the implications of NCS in Brazilian professional practice?
This study is the result of reflections that supported the elaboration of the PhD thesis project, entitled: "Meanings attributed to the Nursing Care Systematization: implications for health care".Thus, the study is presented as a theoretical reflection, of an exploratory nature, which aimed to analyze the implications of NCS in Brazilian professional practice.It is noteworthy that this reflection is anchored in laws, normative resolutions and texts in a national perspective, since NCS is a term used by most nurses in Brazil (5) .That is why analytical categories Regulatory framework of NCS, Implications in professional practice and Limits and possibilities were elaborated.

NCS REGULATORY FRAMEWORK
The construction of NCS comes initially from the need to base nursing care in an organized and systematic way, resulting from the epistemic, technical, normative evolution and the way it has been printed in scientific productions on the subject, within the scope of Brazilian Nursing, throughout the past eighteen years.It is largely due to the advent of the regulation of the legal standard issued by the Federal Nursing Council (Cofen) -Resolution No. 272, of 2002 (6) , subsequently revoked and replaced by the current Resolution No. 358, 2009 (1) , in effect until the current days across the national territory.
Although discreetly, Resolution No. 358 makes conceptual demarcations that leave evidence on the existing differentiation between NCS and NP, presenting them as distinct concepts, supported by the evolution and conceptual maturation on the theme over the years, it is emphasized that this is an issue not addressed in the previous resolution.
Resolution No. 272, of 2002 (6) , treated NCS and NP as synonyms, including the stages that characterized them.In its 3 rd article (6) it was stated that the NCS was composed of: Nursing history; Physical exam; Nursing Diagnosis; Prescription of Nursing Care; Evolution of Nursing Care; Nursing report.It quoted, but did not specify, what the "Nursing Report" would be, likewise, it presented the "Implementation of Nursing care", however, it did not position it as a component of the NP.
In addition to this understanding, Resolution No. 272, of 2002 (6) , stated that NCS was constituted as a "private nurse activity".Considering the evolution of the concept, the participation of mid-level professionals, precisely in NCS, was not specified.This specification can be identified with respect to the pillar of the method, which includes the application of NP.Nurses are credited, as a private activity, with the search and definition of the nursing diagnosis of patients/users and the prescription of nursing actions or interventions, as provided in article 4. As for nursing technicians and assistants, participation in the execution of the NP is attributed, in whatever is their responsibility, under the supervision and guidance of the nurse (1) .
Therefore, it is necessary to seek greater integration among Nurses, Technicians and Nursing Assistants in the implementation of the methodological instrument that guides care and clinical documentation in Nursing -The NP (1) .Thus, it should be discussed what roles nursing practitioners can play, considering the NP in the light of legal issues and in a collaborative manner.
Considering the historical panorama presented with regard to the regulatory framework of NCS, it is possible to make a critical analysis on it and infer that, for the authors of this reflection, the current Resolution (1) resolved the division of roles and activities related to the NP, which already constitutes significant advances considering the nursing care, guidance of professional care, as well as for the expansion of the Nursing subject.
However, with regard to NCS, it does not mention or deepens what refers to the participation of the Nursing technician and assistant.In addition, it does not define its structuring pillars -method, personnel, and instruments, conceptually and operationally -which are essential and indispensable for the operationalization of NCS in the field of professional practice, as well as in the management of nursing services in nursing health institutions.This positioning makes it fragile and incipient, with regard to the substantiated information, about what the NCS is, its pillars, and consequently its constituent elements.
In this topic, it is relevant to highlight the interfaces present in the normative field, the Law No. 7,498 of 1986, Law of Professional Nursing Practice (7) , which in a previous way explains elements of the Nursing Process and the pillars of the NCS, regulated in resolution for the entire national territory (1) .Thus, the aforementioned Law defines the private activities of the Nurse and structures the fields of professional activity, which allow a glimpse of the organization and management of the Nursing service and is consistent with the "organization of professional work", dealt with in Resolution No. 358, of 2009 (1) .
It is necessary to consider the interrelations of Resolution No. 358 (1) with Law No. 7,498, of 1986 (7) .This presents private activities of the Nurse that can be divided into two major areas.The first one with regard to the activities of organization and management of the Nursing service, which, in the authors' understanding, are related to the "organization of professional work", dealt with in Resolution No. 358, of 2009 (1) .Thus, it demarcates what activities should be performed by nurses for the proper organization and management of nursing services.They are, as explained in article 11 of the aforementioned Law: "direction of the nursing organ that is part of the basic structure of the health institution, public and private, and head of service and nursing unit; organization and direction of nursing services and their technical and auxiliary activities in companies providing these services; planning, organizing, coordinating, executing and evaluating nursing care and consulting services, auditing and issuing opinions on nursing matters" (7) .Therefore, it is understood that the activities previously described have important relationships with the NCS, and also with the personal pillars and instruments.
The second area is related to that cited in Resolution No. 358/2009 (1) , with regard to the "orientation of professional care" to the Nursing Process for the private activities of nurses, which due to their characteristics are directly related to the nursing care.According to article 11 of the aforementioned Law, they comprise "Nursing Consultation" and "prescription of nursing care" (7) .
The Nursing Consultation, in the different care contexts, allows the meeting between Nurses and their patients, ideally supported by the profession's own references and others that may be necessary, as long as they are in harmony with the Nursing practice.In addition to providing the opportunity to implement the Nursing Process, focusing on care demands.Thus, the prescription of Nursing, one of the elements of the Nursing Process, is a critical point of reflection.Because, through the Nursing Interventions materialized in the Nursing prescription, the results of clients are influenced, demonstrating the contribution of Nursing art and science in health care.Now we are back to the previous discussion, regarding the need to effectively integrate the Nursing Technician and Assistant in addition to the simple execution of actions.With regard to the Technician in particular, the Law of professional practice indicates in its article 12 the "participation in the planning of nursing care" (7) .Still, the same law highlights that it is especially up to this professional, among other duties, to "participate in the programming of nursing care" (7) .Although it is not the objective of this text to deepen these issues, it points out the need to discuss the points of tension pointed out between the Law of Professional Practice (7) and Resolution No. 358, of 2009 (1) .It is understood that it is essential to discuss that contents in the training of the Nursing Technician must be addressed, in the sense of considering the NCS and the Nursing Process.
With regard to the Nursing Assistant, although the Professional Exercise Law states that this professional: "carries out medium-level activities, of a repetitive nature, involving Nursing assistant services under supervision, as well as participation in the level of simple execution, in treatment processes" (7) .Therefore, it is necessary to consider the contextualization of their actions, since they should consider that their practice is based on singular elements of Nursing, that is, Nursing Diagnostics, Results and Interventions, expanding the look beyond the execution of care actions.
Regarding this, it is considered that the theme of NCS and NP is a transversal phenomenon relevant to the three categories, kept as indicated by the legal limits, specificities, private activities and the contribution of each professional.However, it is necessary to advance and shed light on what Resolution No. 358, of 2009, points out about the performance of Nursing Technicians and Assistants, when it mentions that these professionals "participate in the execution of the Nursing Process, in whatever they may, under the Nurse's supervision and guidance".Thus, it provokes the reflection if the regulation is part of the daily practice of Nursing, from the perspective of insertion, understanding, reasoning and performance of professional Nursing Technicians and Assistants in the application of NCS and NP.
From this matter, a knowledge gap that justifies this reflection is identified.This movement gives rise to the deepening and exercise in identifying, discussing, understanding and unifying knowledge about NCS, in order to embody and consolidate the strengthening of its materialization as a theoretical field, capable of being realized as a research object, real and contributory to the Nursing subject.Thus, thinking, reflection, questioning, criticism, raising doubts about what it is, how to operationalize, what are the theoretical references and the scientific bases that allow the conduct of research, configuring it as an object of questioning emerge, analysis and, consequently, knowledge production in Nursing, delimiting it as a singular epistemological field.
Eighteen years after the approval of the first resolution dealing with the theme of NCS and NP, it should be reflected what gains and advances has the adoption of the concept as an organizing framework for professional work brought to national nursing, since it has as genesis the Brazilian Nursing and, therefore, of a character of its own specificity, also with regard to its health system.It is still considered coherent to inquire in contemporary times: "Nursing Care Systematization: is there an agreement on the concept?" (8) .
Doubts and uncertainties still permeate the direction of actions coordinated by nursing professionals who are at the front line of care to patients/users, as well as those who are at the front of the management of nursing services, whether due to mismatches of information, and due to the scarcity of scientific production that approaches NCS from the perspective of work organization, or even due to the need for conceptual review at the normative level.
Currently, it is understood that NCS "organizes professional work in terms of method, personnel and instruments, making it possible for the NP to become operational" (1) .That said, it should be added that the NP is one, but not the only "methodological instrument that guides professional nursing care and professional practice documentation" (1) , these being the most consolidated evidence regarding the terms presented by the resolution.
Thus, these concepts have in essence different predicates when considering the organization of the service and nursing care.NCS concerns the organizational and administrative issues of the nursing service and care environment.The NP, on the other hand, deals with professional and nursing care resulting from the encounter between the nurse and the person -individual, caregiver, family, group and community in which human responses are identified (9) .Therefore, NCS is the area of knowledge production in Nursing that can represent studies and research that produce knowledge related to the administration and organization of services, that is, with nursing management.Considering the practical implications, this refers to organizational elements, in addition to administration issues, and management of the nursing service, resulting in the organization of professional work.And not in the guidance of nursing care, which is the epistemological focus of the NP.

IMPLICATIONS IN PROFESSIONAL PRACTICE
The category Implications for professional practice carries out the reflexive exercise of making NCS and its pillars -method, personnel and instruments (1) -emerge as a theoretical-practical framework that supports the management of nursing services.These pillars are composed of constituent elements that structure them, characterizing areas of knowledge and fields of research in nursing.
The authors of this reflection infer that there are elements that so far cannot be associated with any particular pillar, however, to some extent they can be associated with NCS, such as: nursing management; care models; care delivery systems; the great Nursing Theories and other theoretical references.These are the ones that will guide the organization of the nursing service and that will support the organizational planning with regard to the mission, philosophy, vision, goals, objectives, policies, procedures and rules of the nursing service in line with those of the organization, and that constitute the elements the planning hierarchy (10) , representing part of the knowledge necessary for the management of nursing services.
With regard to the pillars, when the personal pillar is broken down, nursing practitioners, the organization of nursing staff, the expected professional profile consistent with the public served, the roles and responsibilities (attributions) of each category considering the care context in which they practice nursing, the current legislation, the training of human resources through corporate education and the dimensioning of nursing staff.
In addition, "the index of employee absenteeism and turnover, the group's work morale, productivity and the quality of the service performed" (11) , expressed through its own indicators, can be considered as constituents of the personal pillar.In summary, the personal pillar represents people management, considering nursing management.
Instruments are tools that assist nursing supervision (11) , unfolding into elements that allow structuring professional work in nursing, the best organization of professional care and documentation of practice.Some examples of supervisory instruments are: "the patient's record, the nursing prescription, the supervision plan, the schedule, the script, the nursing service manual with its rules, procedures and routines, the employee development plan" (11) .
The instruments pillar goes beyond the activity of supervising, consisting of numerous elements that support the organization of the care environment and that allow the supervision practice.They are: the nursing manual; the internal regulations of the nursing service; standard operating protocols (POP); the Care Protocols, the bundles; clinical guidelines; the guidelines; clinical assessment scales; checklists; service management indicators; care indicators; clinical nursing forms, material request forms, nursing service record books, as well as daily allocation scales for nursing professionals; in addition to any other instrument that is necessary for the organization of nursing work/care.
The two previous pillars are essential for the implementation of the third one, the method pillar.When decomposing this pillar, constituent elements can be identified, such as the NP itself and the Nursing Theorist (12) , who would support its application in professional practice.In the case of NP, it consists of five stages, and at least three are characterized as unique elements of the practice, being the Nursing Diagnoses, Results and Nursing Interventions (12) , this occurs when considering the guidance of professional care.Nursing, with the advancement of knowledge, structured nursing classification systems for each element, which represent them (12) and can be used when applying the NP.
The Nursing Diagnoses of NANDA-Internacional, Inc. (NANDA-I) (9) , represent the second stage of the NP.The Nursing Outcomes Classification (13) represents, in association with the Classification of Nursing Interventions (14) , the stage of Nursing Planning.In the Nursing Assessment stage, the Nursing Outcomes Classification is used again, therefore, this classification would represent two stages of the NP, as it is used at different times and for different purposes.In addition to the three classification systems in Nursing, there is the International Classification for Nursing Practice (CIPE ® ) (15) .It can be used at times similar to those previously described.It is noteworthy that the NP occurs in the context of the Nursing Consultation and in the daily meetings between the Nurses and the patients in different care situations.
The application of the NP results in a lot of information, that is, the clinical nursing documentation, a consequence of the care provided in the preparation of a care plan/ nursing care, which begins in the Data Collection and is processed in a care continuum, considering the initial perceptions that guided the identification of the human response to the professional approach to nursing.And for which a diagnostic label has been attributed, the basis of the nursing therapy to be instituted, aiming to achieve positive health results, whenever possible, through the implementation of nursing interventions.
Resolution No. 358 of Cofen does not deal with the implementation of NCS, but the implementation of the NP is mentioned.NCS does not deal with the organization of care at the bed, but deals with the organization of the nursing service and the care environment in which the NP will be operationalized.Through its three pillars, it is possible to see how the NCS can contribute to the organization of professional work as this issue is analyzed considering its three pillars -method, personnel and instruments.In summary, the implication of NCS to professional practice is to understand, through its pillars, how organized and structured a given Nursing service is, as the pillars of NCS are the unique elements of the organization of professional work.

LIMITS AND POSSIBILITIES
This category deals with the limits and possibilities considering the NCS as an area of production of disciplinary knowledge applied to professional practice.Thus, we begin to exemplify research that, in the authors' understanding, would be consistent with the epistemological object -Nursing Care Systematization.Emphasis was given to the research objectives or questions of the selected studies.
Research on the dimensioning of personnel and its implications on the quality of care can be considered appropriate to the field of NCS and help to identify the elements that make up the Personal pillar.In this context, we have as an example a study that aimed "to analyze the dimensioning of nursing staff in relation to the quality of care" (16) .
Associated with the dimensioning of personnel, absenteeism is a theme that finds harmony with the theme of NCS and the personal pillar.A study that aimed to "investigate in the literature the available knowledge about the interdependence of agents that trigger hospital nursing absenteeism to infer, from a multicausal perspective, possible management and control actions" (17) can be considered within the scope of research related to NCS and people management.
Another theme that corroborates the personal pillar is the mapping of nursing activities.A study that aimed to "map and categorize, according to the Classification of Nursing Interventions, the specific duties of nurses and identify those shared with physicians and physiotherapists in the emergency services" (18) states that of the actions identified, "45.7% specific to nurses, 14.2% shared with physiotherapists and/or physicians and in 40% (n = 42) there was no consensus on the sharing of duties" (18) .
These results point to the need to discuss the autonomous and collaborative practice, demarcating the scope and contribution of the Nursing subject in health care when considering the collaborative practice, which translates into the interrelationships with other members of the interdisciplinary team.However, the issue still reserves challenges focused on the regulation of professional practices and the adequate distribution of nursing staff in Brazilian health institutions.
The organization of nursing services presupposes the elaboration of instruments that make clinical documentation feasible; these translate into the constituent elements of the instruments pillar and support the method pillar, used by nursing professionals in their practical work.Thus, studies that address the elaboration of instruments and documentation, are relevant and essential to the specific organization of the service and, therefore, adequate to the scope of knowledge production compatible with the theme of NCS.We can mention a study that aimed to "build and implement the Nursing History for planning pediatric intensive care" (19) .
Bundle development can also be considered within the scope of knowledge pertaining to NCS and the instrument pillar.We can mention a study that aimed to "create and apply a bundle in clinical practice and analyze its effectiveness in preventing peripheral vascular trauma to address the process of peripheral venipuncture" (20) .The creation of instruments similar to these can assist in the organization and supervision of care practices and, consequently, in the structuring of the care provided, so that it is qualified and safe, contributing to the scope of mitigating difficulties faced in guaranteeing the reduction of indicators that are detrimental to the quality and safety of care.Therefore, previous research raises the possibilities of epistemological demarcation and of NCS' contribution to the Nursing subject, pointing out its fields of research and application in professional practice.
With regard to the method pillar, which, in the authors' understanding, is associated with the production of knowledge related to the Nursing Process and related themes, here the limits of knowledge production on the theme of NCS are established, since the theoretical position adopted in this text is that of the NP as a distinct concept from NCS.There is a need to develop these concepts, when considering their epistemological basis, the current evolution and contextualization for the consolidation of the structural bases of Nursing science.Thus, Nursing Theories are configured on the basis of support to develop constructs, explain phenomena, analyze and structure the components of NCS and NP, based on varied theoretical and methodological strategies.
In this sense, studies that develop or evaluate Nursing Theories, such as research that aimed to "analyze the Theory of Unpleasant Symptoms according to the model proposed by Walker and Avant" (21) .Likewise, research that presents case studies related to nursing practice.These studies have an impact on the consolidation of Nursing's own knowledge, linking to the NCS and NP concepts.
In this regard, a study that aimed to "present the nursing care of a newborn with lamellar ichthyosis admitted to the neonatal intensive care unit of a public children's hospital, in a city in the state of Parana, Brazil" (22) .In the case study, nursing diagnoses and prescriptions are identified, in addition to describing the care and presenting a theory as a theoretical support to the case, which show possibilities of a real application and basis of professional practice through a theoretical support specific to nursing.
NCS has been used as an object of investigation and research, whether in the construction of operational standards, care protocols, manuals, educational materials, technical guides, as well as in the formation of working groups and national and regional commissions on the subject , in the construction of curricular components/subjects in Undergraduate and Graduate courses latu sensu and strictu sensu, and even in the provision of Cofen resources/financing, to the Graduate Programs in Nursing and Health, who develop studies in the research line on NCS.
Given these findings, attention is drawn to the recognition of NCS, as a potent object of research in the nursing field, which lacks in the current context, greater conceptual and operational refinements so that its limits and possibilities are unveiled considering what the current Resolution No. 358/2009 points out, which confers the character of NCS as organizer of professional work in terms of method, personnel and instruments (1) .
NCS comprises a management tool as its pillars and constituent elements are used to analyze the structure of the nursing service, identify possibilities for improvement and perform the situational diagnosis, the basis of the strategic planning of the nursing service.Through it, it is possible to evaluate the level of organization of a service; on the other hand, through the NP, it is possible to assess the level of organization of the care provided.

FINAL CONSIDERATIONS
The study contributed to the delimitation of the field of knowledge in Nursing with regard to NCS as an object of research, that is, it should be approached preferably as an area of knowledge production that dialogues with the organization and structuring of Nursing services, supported by theoretical references of nursing administration and management.The challenge is to clarify the NCS object in disciplinary research that addresses the theme so that the authors make clear the place of speech or even the theoretical area on which the discussions on NCS are based.
Finally, as NCS is conceptually and operationally understood, its pillars and constituent elements reveal the implications of NCS for professional practice, that is, how it organizes work and how it can be used as a knowledge field that supports the management of nursing services.Knowing each pillar of NCS can favor the identification of the aspects that constitute the organization of professional work, dealt with by the legal device that regulates it.