PERFORMANCE OF NURSING AUXILIARIES AND TECHNICIANS IN MANAGING PIERCING CUTTING MATERIAL: A NECESSARY STUDY

O presente estudo teve como objetivo analisar o conhecimento da equipe de auxiliares e técnicos de enfermagem no manejo e segregação de perfurocortantes, descrevendo a atuação desses profissionais. Trata-se de estudo qualitativo descritivo, cujos sujeitos foram três auxiliares e doze técnicos de enfermagem de uma instituição de saúde de médio porte, totalizando quinze sujeitos entrevistados por meio de roteiro semiestruturado. A análise dos depoimentos foi realizada pela técnica de análise de conteúdo. Os resultados apontaram que, embora os sujeitos tenham conhecimentos teóricos sobre cuidados com perfurocortantes, eles não os utilizam, integralmente, expondo-se a diversos riscos, o que revela conhecimento e atuação reprodutivistos. Propõese, aqui, implementação de programas de educação continuada, baseada em abordagens metodológicas construtivistas, visando a prática eficaz no manejo e segregação de perfurocortantes. Dessa forma, pesquisas que esclareçam a apreensão do conhecimento por adultos podem aprofundar os resultados descritos neste estudo.


INTRODUCTION
Current Brazilian prerogatives related to the management of solid residues establish that the production of waste up to its final destination is the responsibility of the institution that produces it.These institutions have to present a Healthcare Waste Management Plan, which needs to be submitted to the appreciation of responsible offices.Healthcare solid waste is classified in groups identified by letters.Due to its importance, piercing-cutting material occupies a specific group denominated group E (1)   .
Among the occupational risks related to the management of piercing-cutting waste contaminated by biological material, the following stand out: hepatitis B risk of about 30%; hepatitis C risk of 3%; and AIDS, transmitted by HIV virus with risk of 0.3%.Regarding the frequency of accidents, percutaneous inoculation is the most evident and represents one third of all accidents, whose main events are: recapping of needles and intravenous catheters and inadequate disposal of piercing-cutting material thrown in common trash, or in incorrectly assembled sharps disposal boxes (2) .
In the hospital context, exposure to occupational risks and work accident-related injuries is higher in the nursing team because of 24-hour contact with patients, delivering care (3) in a practical perspective.
An additional study addressing accidents involving nursing professionals and piercing-cutting material may seem unnecessary since there are several studies on the characterization of workers contaminated by accidents and related disorders (4)(5) , as well as continuing education practices focusing on knowledge of standard precautions (6)(7) , which shows the theme's relevance.
However, studies addressing the performance of nursing professionals and the construction of their knowledge on the management of piercing-cutting material are scarce."Health workers know the risks posed to their health in a generic way […] which points to the need for a strategy to change this situation" (8) .
Therefore, this study is justified by the need to understand adequate management of piercingcutting material, reduction of accident frequency and risks of infectious diseases, in addition to environmental problems, contributing to the knowledge construction of nursing professionals as from their daily practice.
In this perspective, nursing auxiliaries' and technicians' performance and knowledge on the theme were investigated, mainly because they reflect the performance of nursing professionals in the process of knowledge construction.
The overall study perspective is focused on continuing education of nursing professionals and its connection with knowledge acquired on the management of piercing-cutting material, aiming to relate these results with current findings in the area of Adult Education."Adults' continuing education has increasingly valued modalities that favor people's abilities to construct their own knowledge as from the review of their own attitudes and values based on their learning" (9) .
Therefore  Collected data were sorted and two general categories and respective subcategories emerged.The analysis followed the theoretical framework of content analysis, including the following phases: "pre-analysis, material exploration, treatment of obtained results and interpretation" (10) .

METHODOLOGICAL PROCEDURES
The first category, nursing team's performance in the management of piercing-cutting material, described the way nursing auxiliaries and technicians handle piercing-cutting waste according to the participants' theoretical-practical knowledge.
The following subcategories were generated: care in the management of piercing-cutting material and disposal of piercing-cutting waste by the nursing team.
The category nursing team's knowledge on the management of piercing-cutting material was about aspects related to information incorporated in the management of piercing-cutting waste and their performance with this material, generating the following subcategories: the meaning of piercingcutting material for the nursing team and management of piercing-cutting material: proposals to improve practice.

RESULTS AND DISCUSSION
The nursing team's performance in the management of piercing-cutting material Aiming to characterize the performance of nursing auxiliaries and technicians in the management of piercing-cutting material, we discussed the way this material is handled, relating it not only to the importance these individuals attribute to its disposal but also to the Ministry of Health recommendations on its adequate management.
In this perspective, it is pertinent to describe The Ministry of Health recommendations on the handling and disposal of piercing-cutting waste were used in the subcategory care in the management of piercing-cutting material as parameters of analysis, so as to compare participants' answers on the care taken to adequately manage piercing-cutting material.
The adoption of standard precautions aims to minimize risks of accidental exposure and emphasizes specific care during the handling and disposal of piercing-cutting waste.The majority of measures was mentioned in the obtained answers.
Among the recommendations to be complied with, the following stand out: paying maximum attention during procedures, not using finger as shield, not recapping, twisting or removing needles with hands, not using needles to hold papers and discarding any piercing-cutting material in lidded container resistant to perforation (11) .
The mere mention of these measures, Most piercing-cutting accidents occur when these measures are neglected, that is, during inadequate discarding and recapping of needles and scalps.This procedure violates standard precautions.
Nursing auxiliaries and technicians are appointed in this case as those who most frequently perform this procedure inadequately (3) .
It is important, however, to heed to the fact that piercing-cutting waste should be separately discarded where it is generated right after its use or in case it needs to be discarded.Rigid and lidded containers, resistant to perforation and appropriately identified, should be used.The completion of the container should not exceed 2/3 of its capacity and it is expressly forbidden to empty it for reuse (12) .
Another important fact is related to the availability of disposal boxes used for discarding piercing-cutting waste.Most times, they are not readily available for replacement in places of easy access, which leads to filling them above established limits (3) .
The difficult access to sharps disposal boxes for ready replacement, as well as their incorrect assembly without placing internal reinforcements or plastic bags, increases the risk of percutaneous exposure due to the box overcrowding and fragility caused by inadequate assembly (13) .
Conflicting situations related to the filling limits of the disposal boxes were observed among participants.Despite their claim that boxes should not be overcrowded, there were doubts regarding their limits, as can be inferred by the following statement: These attitudes reveal that, even though institutions encourage continuing education and competitions, and instructions are also available on the container itself, professionals are not incorporating the knowledge necessary for effective practices.
Occupational risks have been underestimated because professionals know most recommendations for adequate management of piercing-cutting material.
In practice, however, they do not properly value the most important step of the process: its disposal, which contributes to a significant increase in the risk of accidents.
The nursing team's knowledge on the management of piercing-cutting material In this item, the study focuses on professionals' knowledge about the handling and disposal of piercing-cutting material, based on the meaning nursing auxiliaries and technicians attribute to its residues, so as to verify the level of incorporation of specific knowledge, the participants' education and contribution of continuing education.
In t e r m s o f c a r e d e l i ve r y, n u r s i n g technicians have the responsibility, during their p r o f e s s i o n a l p r a c t i c e , n o t t o p o s e r i s k s t o themselves, to the health team and to clients, through the use of biosafety protocols (14) .In this perspective, issues related to workers' health and to general principles of biosafety are addressed in the subjects Health Promotion and Occupational Safety and Biosafety Promotion in Health Actions, with 30 and 40 hours, respectively, in the curricula of the Nursing Technician Course (15) .

Concepts and the classifications of
Resolutions n. 306 and n. 358 were used in the subcategory: meaning of piercing-cutting waste so as to compare them with participants' answers on their understanding regarding piercing-cutting waste (1,16) .
We observed during the analysis of answers that only 26.7% of the participants defined piercingcutting waste, 46.7% were able to exemplify it, 26.6% associated them to the risk of contamination and accidents.A1 specifically confounded it with organic matter.This way, we perceived that the majority of the individuals has some notion of piercing-cutting material, notion of conceptualization, exemplification or relation with occupational exposure.
In the subcategory: piercing-cutting management: proposals to improve practice, we aimed to identify the individuals' knowledge on the handling of piercing-cutting waste through suggestions that can contribute to the improvement of their performance.The reports are: using gloves (A1, A2, T8); more information (T2, A2, T4, T5, A3, T9); disposal box at the nursing ward (T3, T8); ideal place only for vein puncture (T3, T12); more attention (A2, T6); greater awareness (A2, A3); more care (T5, T6); taking risks more seriously (T7); more importance to its disposal (A3); creating a flow chart and teams to orient in case of accidents (T11).
According to answers, the most recurrent suggestion was the need for more information related to the management of piercing-cutting waste addressing risk factors, prevention mechanisms and conducts to be adopted in case of accidents with the material, emphasizing the need for continuing education.
One of the participants suggested putting disposal boxes near beds in nursing wards.This practice has already been implemented at the Hospital Alemão Osvaldo Cruz in São Paulo, which has demonstrated a reduced number of accidents in the transportation of piercing-cutting material (13) .The same participant acknowledges however that, in the case of a pediatric hospital, this measure has to be reconsidered: a box in each nursing ward would be ideal, but we work with children, so where would we put it?We cannot put it high, there was a case of an employee who was sued because she put a box high and a short employee got pierced (T3).Nurses usually administer updating courses offered in hospitals, which suggests there are essential weaknesses in teaching and learning processes of these professionals in study.Thus, there is a lack of more complex rationales involving selfreflection and construction of critical knowledge.
"Historically, technical staff is trained to do without thinking, as they are alienated in compiling techniques and in applying them uncritically as soon as they receive an order" (17) .
We also believe there are other factors compromising a change of attitude in these professionals.Among them, we can name the lack of continuing education, focused on nursing auxiliaries' and technicians' real needs, including planning, previous knowledge, adequate language, evaluation, supervision and follow-up in the work environment.
Coupled to these factors, culture and history of the nursing profession also reflect the problem, "it is the role of graduate nurses, whose training is focused on teaching and administration of nursing care, to manage care delivery, distributing and delegating specific tasks to the remaining nursing workers" (18) .

Current teaching proposals for technical health courses are based on Brazilian Curricular
Guidelines with new perspectives for these workers' education, which require: "cognitive, abstract, techniques" (14) .
Current perspectives appoint a great challenge for nurses responsible for teaching these professionals because there are dichotomies between the education of nurses and technicians.The latter, being "manual workers", perform functions in which there is no control of the process or end product and remain alienated […] nurses are also salaried employees, their education is intellectual and they manage care delivery" (18) .
The teaching proposal based on the Curricular Parameters and Guidelines involves the need to promote changes in the teaching-learning process.It attempts to sensitize individuals to perform safe practice and to privilege standard precautions for their protection, even in situations of stress and work overload, emphasizing the importance of self-esteem and self-care" (18) .In this context, the identification of problem situations that can be addressed through training is essential, so as to face the challenges and alternatives necessary to break the ties of the technicist model.
The development of research addressing the reason why strategies developed so far do not promote significant changes in health professionals' practice, which is the focus of this study, is crucial.In this perspective, there are prospects in current studies addressing adult education.
, the results presented are based on the following questions: what is the performance of nursing auxiliaries and technicians in the management of piercing-cutting material?What is the knowledge of nursing auxiliaries and technicians on the handling and disposal of piercing-cutting material?The goal is to analyze the knowledge of nursing auxiliaries and technicians in the handling and disposal of piercing-cutting material and describe their performance.
symbolic analysis, communication and inter-relation abilities with clients and co-workers; initiative and creativity; ability for cooperative teamwork and mutual training in the work environment, competence to evaluate the result of their work and implement measures to improve the quality of their work, mastering planning and work organization This way, nurses, in the role of health educators, should value the Ministry of Health recommendations so as to contextualize teachinglearning conditions of nursing auxiliaries and technicians through continuing education, enabling education strategies that permit trainees to make the link between the empirical and scientific practice without getting lost in intuitive experiences, especially in conditions of risk, like in the case of piercing-cutting management.CONCLUSIONSThis study appoints the need for adjustments in nursing teams' work with a view to constructing critical and reflexive knowledge on daily practice.For that, nurses, in the role of educators and managers of nursing care, should conduct the continuing education process, taking into account the knowledge of nursing auxiliaries and technicians, aiming at a transformed practice.Therefore, in view of the countless potential occupational risks posed by inadequate management of piercing-cutting material, personal and institutional investments are needed, valuing workers' experience and aiming to strengthen their performance, so as to promote effective daily practices and adherence to biosafety measures.