Surgical center: challenges and strategies for nurses in managerial activities

ABSTRACT

Objective

Analyze the challenges and strategies of nurses performing managerial activities in a surgical center.

Method

Exploratory, descriptive study with a qualitative approach, involving six nurses by means of the Focus Group Technique, between April and August 2013. Data were submitted to thematic content analysis.

Results

The main challenges noted were deficiency of material resources, communication noise, adequacy of personnel downsizing, and relationships with the multidisciplinary team. Key strategies include construction of co-management spaces to promote integration among professionals, conflict resolution and exchange of knowledge.

Conclusions

Managerial activities involve the promotion of dialogic moments to coordinate the different processes in the surgical center to provide inputs to expand safety and quality of services provided.

Perioperative nursing; Hospital administration; Focus groups

RESUMO

Objetivo

Analisar os desafios e estratégias do enfermeiro nas atividades gerenciais em centro cirúrgico.

Método

Estudo exploratório, descritivo, de abordagem qualitativa, realizado com seis enfermeiras, mediante a Técnica de Grupos Focais, entre abril e agosto de 2013. As informações foram submetidas à Análise de Conteúdo na modalidade temática.

Resultados

Os principais desafios apontaram: deficiência de recursos materiais, ruídos de comunicação, adequação de redimensionamento de pessoal e relações com a equipe multiprofissional. As principais estratégias compreendem a construção de espaços de gestão compartilhada para promover a integração entre os profissionais, a resolução de conflitos e o intercâmbio de saberes.

Conclusões

Ponderou-se que as atividades gerenciais envolvem a promoção de momentos dialógicos para articular os diferentes processos existentes no CC, a fim de produzir subsídios para ampliar a segurança e a qualidade nos serviços prestados.

Enfermagem perioperatória; Administração hospitalar; Grupos focais

RESUMEN

Objetivo

Analizar los desafíos y estrategias de enfermeras en las actividades de gestión en la sala de operaciones.

Métodos

Estudio exploratorio, descriptivo, con abordaje cualitativo, realizado con seis enfermeras, por medio de la Técnica de Grupos Focales, entre abril y agosto de 2013. Se sometieron las informaciones al Análisis de Contenido, modalidad temática.

Resultados

Los principales desafíos que se observan: carencia de recursos materiales, ruido, comunicación personal idoneidad de cambiar el tamaño y las relaciones con el equipo multidisciplinario. Las estrategias clave incluyen la construcción de la gestión compartida de los espacios para promover la integración entre los profesionales, resolución de conflictos y el intercambio de conocimientos.

Conclusiones

Se ponderó que las actividades de gestión implica la promoción de momentos dialógicos de articular los diferentes procesos de la CC con el fin de hacer subvenciones para ampliar los servicios de seguridad y calidad.

Enfermería perioperatoria; Administración hospitalaria; Grupos focales

INTRODUCTION

The surgical center (SC) is a hospital unit where elective and emergency anesthetic-surgical procedures, diagnoses and therapeutic procedures are performed. This environment is characterized by invasive interventions and material resources of high precision and efficacy, requiring skilled professionals to meet the different needs of users, considering the high density of technologies and great variety of situations that build singular health care dynamics in this unit. The SC is considered to be a high-risk scenario where working processes are complex and interdisciplinary practices strongly depend on individual and team work under pressure and stress(¹).

A recent study attempted to identify the different care practices performed by nurses in the SC and their links with the institutional context where these practices are performed. The study emphasized the strategies developed by nurses to overcome interaction-related difficulties ensuing from the demand for coordinating patients’ flow, inputs and health teams in the SC during procedures, influencing and being influenced by it(²). Regarding the nurses’ role in managing the nursing team in the SC, a study aimed at analyzing the distribution of their workload in interventions and activities during the transoperative period suggests that the Nursing Interventions Classification would be the most accurate indicator to identify such condition, contributing to improve professionals allotment to meet the SC patients’ needs(³).

The search for safety during the transoperative period is becoming an important managerial activity assigned to nurses. However, a recent study that assessed health professionals’ perceptions about safety culture in the SC noted a certain distance between managers and other professionals, with poor working conditions and weaknesses in the safety culture, recommending strategies like communication between teams and introduction of new managerial tools(¹). In Brazil, some studies on the use of instruments to promote safety and prevent adverse events in the SC found that nursing teams contribute by providing crucial registries to develop actions with safety and the nurse, as a leader, must adopt and foster these initiatives(⁴-⁵).

In this context, nurses face challenges to organize the several interfaces part of their working process, including managing nursing care in the transoperative period. This condition implies coordination between the managerial and care dimensions of the nurses’ work, making management a basic activity to achieve the core activity, i.e., care(⁶).

Nurses’ managerial activities are actions aimed to ensure nursing care quality and the institution’s good work(⁶). The following actions are outstanding in their professional practice: nursing team sizing; exercise of leadership in the work environment; nursing care planning; nursing team capacity-building; material resources management; coordination of care delivery process; delivery of care and/or more complex procedures; and, evaluation of results ensuing from nursing actions(⁷).

It is worth mentioning that activities performed by nurses at health institutions make them essential professionals to coordinate core services to promote continuity to nursing work. In addition, this activity can take on specific characteristics, depending on the work place, such as the SC. Recent publications(²-⁵,⁸) emphasize that professionals in this area should discuss, implement and evaluate their preoperative nursing practices, considering the demands for health systems qualification and safety without placing technological advances ahead the core feature of their work, i.e., care.

Thinking over these aspects, these publications found concerns that refer to managerial skills developed by nurses in the SC everyday work, raising significant questions to the object of investigation: how are the nurses’ challenges and strategies characterized when performing managerial activities in the surgical center?

Therefore, the interest in developing this study was guided by the objective of analyzing nurses’ challenges and strategies to perform managerial activities in surgical centers.

METHOD

This study was based on the dissertation named “Atividades Gerenciais do Enfermeiro em Centro Cirúrgico” presented to the Graduate Program in Nursing of the Federal University of Rio Grande do Sul(⁹). This study is characterized as exploratory, descriptive, and qualitative, which allows broadening knowledge on a given topic and flexibility to explore data. To validate meanings, reasons, values and beliefs of subjects to understand the phenomenon being studied, this study employs a focus that gathers individual and collective meaning of the subjects involved, as proposed by Minayo(¹⁰).

This approach was also selected because of the need for exploring the topic in details, considering the reality of nurses working in the SC of a teaching hospital, gathering information through the focus group (FG) technique. It is operated around the possibility of understanding how different perceptions about nurses’ managerial activities are founded, based on reflections and debates among participants.

The study was carried out at the SC of a high-complexity teaching hospital that provides care to adult and pediatric patients in different surgical specialties of elective, urgency and emergency nature, and which also performs transplantations.

The study sample was made up of six SC nurses, adopting the following inclusion criteria: voluntary adherence; interest in discussing the matter; effective service contract for over six months; and, availability to participate in data collection. The exclusion criteria were having a fixed-term service contract and leaves for several reasons. It is worth mentioning that literature recommends assembling small focus groups when the objective is to broaden discussions on given aspects(¹¹).

The focus group met three times from April to August 2013, at night, in a previously booked room to ensure privacy. The master’s candidate researcher led the discussions as a facilitator, using a script of topics with guiding questions to the debate, assisted by a non-participant observer that collaborated with the logistical aspects of time control, proper and comfortable environment, handling of the recorder and, also, making records of any singularity in verbal and non-verbal communication of the group in a field diary.

The first meeting comprised two moments: introduction of participants, clarifications about the study and establishment of the group setting, in addition to the required detailing of ethical aspects of the study, including the signing of a free and informed consent form. The debates started around the guiding question “What are your insights about your managerial activities as a SC nurse”? In the second meeting, debates were fostered with the following guiding questions: “What are the implications of the SC nurses’ managerial activities?” and “Which managerial strategies are adopted by SC nurses”? The third meeting was held after the transcription and analysis of the material gathered up to then, to validate the summary chart of results prepared by the researcher.

After being fully transcribed, the information obtained from the focus group was submitted to thematic content analysis(¹⁰). This technique comprised the following stages: pre-analysis; exploration of the material designing three thematic charts with the main managerial activities performed by nurses and related to the challenges/limitations and strategies discussed in the focus group; and, finally, the results, interpretation and discussions based on the study’s objectives and literature review.

The study complied with Resolution 466/2012 of the Ministry of Health(¹²), and was approved by the Research Ethics Committee of the Hospital das Clínicas of Porto Alegre, under protocol no. 120471. The confidential nature of the information collected was highlighted, as expressed in the free and informed consent form, and the participants’ anonymity was ensured using the following coding: N1 (Nurse 1), N2 (Nurse 2), N3 (Nurse 3) and so on. The debate excerpts part of the research final report were validated with each participant, individually.

RESULTS AND DISCUSSION

The analysis of the information gathered from the focus group debates regarding the SC nurses’ managerial activities resulted in three thematic categories: management of materials; management of the nursing team; and, coordination of the multi-professional team work. Results are presented in three summary charts of the SC nurses’ managerial activities.

The focus group pointed the coordination between nursing work and the remainder supporting services to provide material resources, as regards the concretization, quality and safety of procedures in the SC, as a challenge posed to nurses. When referring to difficulties in this service flow, nurses specified:

The instruments, there are more problems when something is missing, something is damaged. [...]. When some instrument is missing or damaged, it takes a long time to solve it. (N3)

These examples corroborate studies about the materials used in the SC, and point out factors like poor material resources, deficient equipment and shortage of instruments to meet the demand of procedures as the main causes for cancelling surgeries and conflicts in the multi-professional team(¹³-¹⁴). However, they highlighted how strategic the spaces of collective discussions between different teams working in the SC are to build feasible alternatives to manage material resources, considering the optimization of time and resources available, counting on more efficient communication tools for different services that support the SC.

The focus group debates pointed out difficulties regarding input supply, as shown below:

It is about the material that is missing or that was not sterilized in time, or another hard thing that is the purchase of new materials. (N2)

The nurse, as responsible for managing the patients’ transoperative period, is aware that complications with instruments and other equipment have a direct impact on care quality and safety, as well as on the everyday work of all professionals involved. Inserted in the institutional context, SC professionals depend on the due provision and availability of the inputs required to provide risk-free care to patients(²).

The focus group has also discussed topics related to nurses’ limitations and challenges regarding the nursing team work, as explained in the Chart 2.

Chart 1
– Management of materials in the surgical center: limitations, challenges and strategies. Porto Alegre, 2013

Activities	Limitations / Challenges	Strategies
◾ Provide surgical instruments	◾ Poor coordination between the SC nursing work and the sterilized material center ◾ Damaged, changed or insufficient surgical instruments	◾ Jointly plan the availability and processing of instruments ◾ Reorganize the surgery schedule
◾ Acquire materials and equipment	◾ Delayed procurement of materials by the institution	◾ Jointly plan materials procurement with the multi-professional team
◾ Request maintenance and repairs to surgery equipment	◾ Poor communication between the SC engineering service and the nursing team	◾ Improve the communication process among professionals ◾ Suggest the engineering service to improve records

• Source: research data, 2013.

Chart 2
– Management of the nursing team in the surgical center: limitations/challenges and strategies. Porto Alegre, 2013

Activities	Limitations / Challenges	Strategies
◾ Manage nursing care in the SC	◾ Difficulties to understand care as a whole	◾ Discuss nursing care in dialogic spaces
◾ Train the SC nursing team	◾ Constant technological innovations	◾ Design and carry out capacity-building programs focused on the SC demands
◾ Record nursing care and management at the SC	◾ Unforeseen situations during procedures in the SC	◾ Share information about the SC and procedures made
◾ Hold meetings with the SC nursing team	◾ Exclusive informative character ◾ Communication noises ◾ Insufficient physical space	◾ Comprise dialogic spaces ◾ Redistribute nursing work at the SC ◾ Adjust physical spaces
◾ Prepare the daily schedule for the nursing team according to elective and urgency anesthetic-surgical procedures	◾ Insufficient personnel to meet the demand ◾ Consistent turnover of nursing professionals in transoperative period	◾ Resume discussions about nursing team sizing ◾ Train nursing professionals to work on different SC procedures
◾ Shift surgical procedures against unexpected situations in the SC	◾ Situational demands of personnel management ◾ Context of anxiety and tension	◾ Reorganize the nursing work schedule ◾ Exchange of experience among SC nurses

• Source: research data, 2013.

The discussion about different care-related technologies in the transoperative period is related to the nurses’ appropriation of the processes developed in the SC, as highlighted by the participants of the focus group when debating their everyday work:

We [nurses] are the ones to manage situations. (N3)

And the [surgical] block is not static. Sometimes you can even plan, you came, you got the schedule of the rooms where you’ll work, you have to review, you have to redesign. In a moment you have a complication, it is not uncommon. (N5)

The SC nurses’ managerial activities specially demand: quick decision making; technical-scientific knowledge; organization and planning of activities; teamwork skills; flexibility; and, efficient communication with other professionals. The strategies listed by nurses when discussing their work at the SC pointed out the development of managerial skills.

When referring to scientific knowledge as a managerial strategy, it is worth highlighting that training and permanent education in nursing should follow the modifications, singularities and pluralities of the nurses’ working settings, demanding plans that meet the continuous tensions and changes in the field of health, notably in the SC. This assumption is corroborated by a study about health work that analyzes health management through care ethics, expressed in the management of working technologies jointly with subjectivities, making up the health settings’ complexity(¹⁵). It is worth mentioning that the SC nurse, in addition to working with instruments and equipment, works directly with patients, from admission to transferring from the unit, which allows them to build links of satisfaction, commitment and identification of their work, demanding consistent elaboration of educational actions about the care they deliver.

In the debate about communication-related aspects, participants recognized the important role of communication in decision making, mainly to allow the required coordination of actions to ensure quality to the work performed in the SC. According to the literature, communication is a managerial tool that, when effective, works to safely carry out anesthetic-surgical procedures(¹⁶-¹⁷). However, when either verbal or written communication is poor, it can lead to mistakes and adverse results to users and professionals(¹⁶). Hence, the communication process demands discussion and reflection by all workers in a constant scenario of (re)organization and (re)planning of practices typical to the SC. Nurses have highlighted the following strategies:

And communication is the big issue. As we work with a very large team, a very large multi-disciplinary group, much information is lost on the way or we just don’t get it as we should. So you waste a lot of time seeking for information to plan, to prepare your planning and to perform your managerial duties. (N1)

And you have to work hard on teamwork. [...] Each of us have our room, but we must have an overall view of the [surgical] block. So, I guess this facilitates a lot. (N2)

The results of this investigation allow understanding that dialogic spaces can maximize the integration of nursing professionals, help solving conflicts, promote knowledge exchange, facilitate collective planning and reflect about the work developed. These ideas are in tune with a study on nurses’ leadership that points out that dialogic practice and decentralization of the decision-making process favor trust relationships among people and the elaboration of feasible alternatives to each context(¹⁸).

This discussion fosters the search for qualifying teamwork based on more horizontal relationships among professionals to expand knowledge about their working process. As a member of the nursing team, nurses should try to establish links to build partnerships favorable to transoperative care based on quality and safety, opening rooms for exchange among workers, with debates and recommendations about the SC everyday experiences.

Still regarding communication, it is worth mentioning that information written by nurses on patients’ medical records and on the SC nursing report, in addition to managerial instruments, consists of an important source of data to plan work during the perioperative period; legal documentation; and potential source of research. Building proper communication among nursing professionals, based on their reflections, can improve actions developed considering the demands from different work arrangements in the SC’s complex and unpredictable environment.

The challenge faced by nurses to continuously rearrange the nursing schedule, as required by the SC, was pointed out as a condition that distresses nursing professionals and compromises the safety and quality of procedures. These situations are perceived as repetitive in the everyday work considering the shortage of staff resulting from sick and other leaves and vacation. This is concerning to nurses because of the potential risks when performing the procedures, as stated by the following participants:

And on the next day they call you and say that surgery has changed, or that someone is on sick leave, or someone is late. Then you have to turn the working schedule around and rearrange it. (N1).

And sometimes, in your own shift, you have lots of sick leaves. [...] This results in a heavy overload to the nurses that come to replace the absent nurses. (N5)

You have to move nurses from room to room when you have emission of ionizing radiation. So, although you prepare working schedules and, in principle, they are followed in that shift the way they were prepared, it is now 2pm, 3pm, you have to change the schedule of staff members in the room to meet these demands. [...] You are managing it all the time. (N1).

These indications may be related to a study on the nursing teams’ workload that identified high rates of absenteeism and turnover that suggests inadequate personnel sizing, which could contribute to the incidence of risks to patient safety because of fatigue, disease and turnover of the team(¹⁹). Considering this, nurses daily face the challenge of meeting anesthetic-surgical demands with limited and insufficient nursing personnel, in an attempt to avoid compromising the safety of anesthetic-surgical procedures. The need for discussing the (re)organization of the nursing team sizing is essential when one considers the possibility of readjusting the working processes as a strategic component.

Nurses referred to the multi-professional team as a challenge that requires discussion and the development of strategies to manage the SC, as shown in the Chart 3.

Chart 3
– Coordination of the surgical center multi-professional team’s work: limitations/challenges and strategies. Porto Alegre, 2013

Activities	Limitations / Challenges	Strategies
◾ Inform professionals and organize the SC when transplantations are booked	◾ Some physicians’ difficulties in understanding the SC nursing team’s work	◾ Call on multi-professional teams that are in standby ◾ Define criteria to suspend elective procedures
◾ Attend meetings of the SC multi-professional team	◾ Some professionals have difficulty in understanding the nursing working process	◾ (Re)discuss the political positioning of the nurse in the SC ◾ Improve the communication process
◾ Supervise the surgical rooms’ cleaning	◾ Interference by some medical teams on process of sanitizing and preparing the rooms	◾ Attend meetings with the multi-professional team and the CCIH to discuss control of surgical site infection

• Source: research data, 2013.

In a scenario with demands for a wide range of specific tasks, like the SC, health care is no longer an individualized activity of a given professional; it rather demands a care network with close interface to the management of services performed by nurses. The focus group’s debates pointed out that building multi-professional relationships in the SC work comprises acknowledging the importance of different fields of knowledge to improve actions developed. However, extreme fragmentation of knowledge is still found as a result of the advancement and isolation of subjects, and of corporate interests that lack rationality and place interdisciplinarity in the heart of discussions about science and sanitation practices(²⁰).

Challenges related to multi-professional teamwork in the SC were highlighted in the debates regarding situations involving interpersonal relationships and the SC organization to make transplantations, as it can be observed in the following speeches:

– And when we have to block a room for a transplantation procedure? (N4)

– It’s a battle! (N5)

– You have to stay there explaining why the room is for him [the surgeon]. (N4)

The transplantation procedure and the impact of these situations on the SC nurse’s managerial work were mentioned by the focus group as situations that demand an interface with different professionals and services involved in the reorganization of work, material resources and personnel sizing. According to nurses, the design and use of a managerial tool like the scale of room blockage for elective procedures in surgery specialties for transplantations is an important managerial strategy which is also used to provide care in situations of catastrophe and disasters.

Another aspect discussed by the focus group regards safety of procedures developed in the SC which also passes by the nurse’s supervision in the due process of cleaning and preparing rooms and surgery instruments, related to the difficulties of some medical teams in understanding this condition, as expressed in the debate:

It is something that they [surgical teams] want, they want to get into the room, they want to hasten things, they want to overturn the routines, the due time of each person to assemble a [surgical] table, to arrange the room. (N1).

Regarding these situations, it is worth mentioning that the medical team often comes to conflicts with the nursing team because they are not familiar with the nurses’ working process developed in the SC. Moments of argument among different professionals about infection control measures could be configured as strategies, because the due organization and processing of the environment and instruments are necessary to ensure quality and safety to anesthetic-surgical procedures.

Despite the circumstances of conflict among the different SC professional teams, when approaching the multi-professional teamwork participants have emphasized that reconstructing the labor world in face of the new professional training arrangements and knowledge have allowed the acknowledgment of nurses by the remainder SC workers. This was mentioned in the following speeches:

– I recall a physician who said that physicians should be partners of nursing. (N3)

– It is a different generation. (N5)

– This, our [training] was outpaced, things are different now. (N6)

– Now, this generation in the hospital started changing, because vacancies opened, new physicians were hired, old physicians retired. And generations have changed and this, somehow, aggregates this partnership because people think differently. These things of behavior, multi-professional team and co-work came with the change of generations and technological innovation, not only in the field of health, but of information, and training that is somehow different from what it was in the past. (N1).

The focus group’s discussions highlighted that coordination between nurse and the multi-professional team is facilitated as clearer and more effective communication is established to develop care in the SC, linking it to horizontal relationships among the different working processes in health such as in meetings with different professionals working in that unit. Likewise, the nurse’s technical and political knowledge about their field of work, more specifically as a way of supporting their decision making and acknowledgement by remainder professionals, also contribute with these conditions.

FINAL CONSIDERATIONS

The challenges and limitations found in the SC nurse’s managerial activities result from conditions intrinsic to the environment which is marked by the unpredictability and continuous need for (re)planning and (re)organizing actions. This problem is worsened when added to other hardships like lack of materials and equipment, communication noises, physical and emotional distress of workers, and limited understanding of the medical team about nursing work.

The collective space for discussions posed to the focus group participants fostered the clarification of managerial strategies of nurses in the SC considering the relevance of consistent coordination among the different dimensions of their work. Some suggestions that emerged from data collection are discussed or practiced in the everyday life in the scenario of this study. However, participants recognized difficulties to implement practices that, in addition to technical issues, comprise aspects related to the subjectivity and integration of different technologies tangled with health actions during the perioperative care. Issues of this nature are supported by co-management and constructing of more dialogic spaces to promote integration among professionals, to solve conflicts and exchange the knowledge required to the work in SC.

The context of a teaching hospital aimed to professional training and production of knowledge in health characterizes this study and could be considered as a scope that circumscribes investigation because of its specificity. Another limitation of the study refers to the fact that the problem was discussed only with dayshift nurses.

Although results do not allow for broader generalizations, these provide an overview of the everyday challenges and limitations of SC nurses, raising the knowledge/acknowledgement of managerial practices amidst similarities of such a singular environment as the surgical center; in this sense, it could encourage other studies to build generalizations to these confrontations. Another possibility that should also be added is that the strategies recommended and/or used by the group in this specific situation pave the way to new investigations and trigger dialogues on the multiple faces involving the managerial practices of nurses in surgical centers.

REFERÊNCIAS

• ¹
  Carvalho PA, Göttems LBD, Pires MRGM, Oliveira LMC. Safety culture in the operating room of a public hospital in the perception of healthcare professionals. Rev Latino-Am Enfermagem. 2015 [cited 2016 Feb 26];23(6):1041-8. Available from: http://www.scielo.br/pdf/rlae/v23n6/pt_0104-1169-rlae-23-06-01041.pdf
  » http://www.scielo.br/pdf/rlae/v23n6/pt_0104-1169-rlae-23-06-01041.pdf
• ²
  Santos FK, Silva MVG, Gomes AMT. Understanding the forms of care of nurses in the operating room – a construction based on the grounded theory method. Texto Contexto Enferm. 2014 [cited 2016 Feb 29];23(3):696-703. Available from: http://dx.doi.org/10.1590/0104-07072014001140013
  » http://dx.doi.org/10.1590/0104-07072014001140013
• ³
  Possari JF, Gaidzinski RR, Lima AFC, Fugulin FMT, Herdman TH. Use of the nursing intervention classification for identifying the workload of a nursing team in a surgical center. Rev Latino-Am Enfermagem 2015 [cited 2016 May 09];23(5):781-8. Available from: www.scielo.br/pdf/rlae/v23n5/pt_0104-1169-rlae-23-05-00781.pdf.
  » www.scielo.br/pdf/rlae/v23n5/pt_0104-1169-rlae-23-05-00781.pdf
• ⁴
  Maziero ECS, Silva AEBC, Mantovani MF, Cruz EDA. Adherence to the use of the surgical checklist for patient safety. Rev Gaúcha Enferm. 2015 [cited 2016 May 09];36(4):14-20. Available from: http://www.scielo.br/pdf/rgenf/v36n4/1983-1447-rgenf-36-04-00014.pdf
  » http://www.scielo.br/pdf/rgenf/v36n4/1983-1447-rgenf-36-04-00014.pdf
• ⁵
  Pancieri AP, Santos BP, Avila MAG, Braga EM. Safe surgery checklist: analysis of the safety and communication of teams from a teaching hospital. Rev Gaúcha Enferm. 2015 [cited 2016 May 09];34(1):71-8. Available from: http://www.scielo.br/pdf/rgenf/v34n1/en_09.pdf
  » http://www.scielo.br/pdf/rgenf/v34n1/en_09.pdf
• ⁶
  Hausmann M, Peduzzi M. Articulação entre as dimensões gerencial e assistencial do processo de trabalho do enfermeiro. Texto Contexto Enferm. 2009 [citado 2012 abr 30];18(2):258-65. Disponível em: http://www.scielo.br/pdf/tce/v18n2/08.pdf
  » http://www.scielo.br/pdf/tce/v18n2/08.pdf
• ⁷
  Santos JLG, Pestana AL, Guerrero P, Meirelles BSH, Erdmann AL. Nurses’ practices in the nursing and health care management: integrative review. Rev Bras Enferm. 2013 [cited 2016 Feb 27];66(2):257-63. Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0034-71672013000200016
  » http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0034-71672013000200016
• ⁸
  Spruce L, Van Wicklin SA, Hicks RW, Conner R, Dunn D. Introducing AORN’s new model for evidence rating. AORN Journal. 2014;99(2):243-55.
• ⁹
  Martins FZ, Atividades gerenciais do enfermeiro em centro cirúrgico [dissertação]. Porto Alegre (RS): Escola de Enfermagem, Universidade Federal do Rio Grande do Sul; 2013.
• ¹⁰
  Minayo MCS. O desafio do conhecimento: pesquisa qualitativa em saúde. São Paulo: Hucitec, 2010.
• ¹¹
  Cardoso ASF, Dall’Agnol CM. Processo grupal: reflexões de uma equipe de enfermagem. Rev Esc Enferm USP. 2011 [citado 2013 ago 02];45(6):1412-8. Disponível em: http://www.scielo.br/pdf/reeusp/v45n6/en_v45n6a19.pdf
  » http://www.scielo.br/pdf/reeusp/v45n6/en_v45n6a19.pdf
• ¹²
  Ministério da Saúde (BR), Conselho Nacional de Saúde. Resolução n° 466/2012. Diretrizes e normas regulamentadoras de pesquisa envolvendo seres humanos [Internet]. Brasília; 2012. [citado 2013 set. 06]. Disponível em: http://conselho.saude.gov.br/resolucoes/2012/Reso466.pdf
  » http://conselho.saude.gov.br/resolucoes/2012/Reso466.pdf
• ¹³
  Florêncio ACUS, Carvalho R, Barbosa GS. O impacto do trabalho do Centro de Materiais na qualidade da assistência. Rev SOBECC. 2011;16(1):31-9.
• ¹⁴
  Leite ES, Silva EN, Silva EN, Santos J. Educação continuada na central de material e esterilização: significados e dificuldades enfrentadas pela enfermagem. Rev SOBECC. 2011;16(4):31-9.
• ¹⁵
  Franco TB, Merhy EE. Cartografias do trabalho e cuidado em saúde. Tempus Actas de Saúde Coletiva. 2012;6(2): 151-63. Disponível em: http://www.tempus.unb.br/index.php/tempus/article/view/1120
  » http://www.tempus.unb.br/index.php/tempus/article/view/1120
• ¹⁶
  Organização Mundial da Saúde (CH). Segundo desafio global para a segurança do paciente: cirurgias seguras salvam vidas. Brasília: Organização Pan-Americana da Saúde, Ministério da Saúde, Agência Nacional de Vigilância Sanitária; 2009 [citado 2013 abr. 05]. Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/seguranca_paciente_cirurgias_seguras_salvam_vidas.pdf
  » http://bvsms.saude.gov.br/bvs/publicacoes/seguranca_paciente_cirurgias_seguras_salvam_vidas.pdf
• ¹⁷
  Manzo BF, Brito MJM. Alves M. Influence of communication in the hospital accreditation process. Rev Bras Enferm. 2013 [cited 2013 Aug 02];66(1):46-51. Available from: http://www.scielo.br/pdf/reben/v66n1/v66n1a07.pdf
  » http://www.scielo.br/pdf/reben/v66n1/v66n1a07.pdf
• ¹⁸
  Costa DG, Dall´Agnol CM. Participative leadership in the management process of nightshift nursing. Rev Latino-Am Enfermagem. 2011 [cited 2013 Apr 28];19(6):1306-13. Available from: http://www.scielo.br/pdf/rlae/v19n6/05.pdf
  » http://www.scielo.br/pdf/rlae/v19n6/05.pdf
• ¹⁹
  Magalhães AMM, Dall’agnol CM, Marck PB. Nursing workload and patient safety: a mixed method study with an ecological restorative approach. Rev Latino-Am Enfermagem. 2013 [cited 2013 Apr 28];21(spe):146-54. Available from: http://www.scielo.br/pdf/rlae/v21nspe/19.pdf
  » http://www.scielo.br/pdf/rlae/v21nspe/19.pdf
• ²⁰
  Matos E, Pires DEP, Campos GWS. Work relationships among interdisciplinary teams: contributions for new methods of organization in health work. Rev Bras Enferm. 2009 [cited 2013 Apr 30];62(6):863-9. Available from: http://www.scielo.br/pdf/reben/v62n6/a10v62n6.pdf
  » http://www.scielo.br/pdf/reben/v62n6/a10v62n6.pdf

• Financial support: Fundo de Incentivo à Pesquisa e Eventos (FIPE/HCPA)

• Erratum

  Article “Surgical center: challenges and strategies for nurses in managerial activities”, with number of DOI: 10.1590/1983-1447.2016.04.56945, published in the journal Revista Gaúcha de Enfermagem, 2016 dez;37(4):e56945.
  Pages 1,2,4,6,8
  Where it reads:
  Clarice Maria Dall’Agnoll
  The correct should be:
  Clarice Maria Dall’Agnol

Publication Dates

• Publication in this collection
  2016

History

• Received
  07 July 2015
• Accepted
  18 Aug 2016