SciELO - Scientific Electronic Library Online

 
vol.73 issue3Social representations of transsexual women living with HIV/AIDSTransformational leadership: journal club for emergency and intensive care nurse managers author indexsubject indexarticles search
Home Pagealphabetic serial listing  

Services on Demand

Journal

Article

Indicators

Related links

Share


Revista Brasileira de Enfermagem

Print version ISSN 0034-7167On-line version ISSN 1984-0446

Rev. Bras. Enferm. vol.73 no.3 Brasília  2020  Epub Apr 03, 2020

http://dx.doi.org/10.1590/0034-7167-2018-0453 

ORIGINAL ARTICLE

Nurse as an integrator in healthcare management of children with chronic condition

Enfermero como integrador en la gestión del cuidado al niño con condición crónica

Deborah Dinorah de Sá MororóI 
http://orcid.org/0000-0002-0936-0761

Rejane Maria Paiva de MenezesII 
http://orcid.org/0000-0002-0600-0621

Ana Angélica Rêgo de QueirozII 
http://orcid.org/0000-0003-1807-8191

Carlos Jordão de Assis SilvaII 
http://orcid.org/0000-0002-9575-9030

Wanesca Caroline PereiraII 
http://orcid.org/0000-0003-2129-4004

IHospital Universitário Onofre Lopres. Natal, Rio Grade do Norte, Brazil.

IIUniversidade Federal do Rio Grande do Norte, Natal, Rio Grande do Norte, Brazil.


ABSTRACT

Objectives:

to understand the practice of the nurse in healthcare management of children with chronic condition in the hospital setting.

Methods:

analytical study of qualitative approach with theoretical and methodological reference of institutional ethnography. Developed in the pediatric unit of a university hospital, in a municipality in Northeastern Brazil. Data collections techniques were: participant observation, documentary analysis and semi-structured interview. Participants of the study totaled twenty professionals, including nurses, social workers, psychologists, pharmacists, nutritionists, physiotherapists, and doctors. For data analysis, it was used the Bardin's Content Analysis with interface of the Atlas.ti software.

Results:

categories of analysis were “Nurse as mediator of healthcare management”; “Nursing process as a mechanism of healthcare management”.

Final

considerations: the nurse proved to be essential for healthcare management of the child with chronic condition, acting as mediator of the relationship between the doctor, the members of the health team, the user and their family.

Descriptors: Nurses; Child; Healthcare Management; Child Care; Chronic Disease

RESUMEN

Objetivos:

comprender la práctica del enfermero en la gestión del cuidado al niño con condición crónica en el contexto hospitalário.

Métodos:

estudio analítico de abordaje cualitativo, con referencial teórico y metodológico de la etnografía institucional. Desarrollado en la unidad pediátrica de un hospital universitario, en un municipio del Nordeste brasileño. Se utilizaron técnicas de recolección de datos, como observación participante, análisis documental y entrevista semiestructurada. Participaron del estudio un total de veinte profesionales, siendo ellos enfermeros, asistentes sociales, psicólogos, farmacéuticos, nutricionistas, fisioterapeutas y médicos. Para el análisis de los datos, se utilizó el Análisis de Contenido de Bardin con interfaz del software Atlas.ti

Resultados:

las categorías de análisis fueron “enfermero como mediador de la gestión del cuidado”; “Proceso de enfermería como mecanismo de gestión del cuidado”.

Consideraciones finales:

el enfermero se reveló fundamental para la gestión del cuidado al niño con condición crónica, actuando como mediador de la relación entre el médico, los integrantes del equipo de salud, el usuario y su família.

Descriptores: Enfermeros; Niño; Gestión en Salud; Cuidado del Niño; Enfermedad Crónica

RESUMO

Objetivos:

compreender a prática do enfermeiro na gestão do cuidado à criança com condição crônica no contexto hospitalar.

Métodos:

estudo analítico de abordagem qualitativa, com referencial teórico e metodológico da etnografia institucional. Desenvolvido na unidade pediátrica de um hospital universitário, em um município do Nordeste brasileiro. Foram utilizadas técnicas de coleta de dados, como observação participante, análise documental e entrevista semiestruturada. Participaram do estudo vinte profissionais, sendo eles enfermeiros, assistentes sociais, psicólogos, farmacêuticos, nutricionistas, fisioterapeutas e médicos. Para análise dos dados, utilizou-se a Análise de Conteúdo de Bardin com interface do software Atlas.ti.

Resultados:

categorias de análise, bem como “Enfermeiro como mediador da gestão do cuidado”; “Processo de enfermagem como mecanismo de gestão do cuidado”.

Considerações finais:

o enfermeiro revelou-se fundamental para gestão do cuidado à criança com condição crônica, atuando como mediador da relação entre o médico, os integrantes da equipe de saúde, o usuário e sua família.

Descritores: Enfermeiro; Criança; Gestão em Saúde; Cuidado da Criança; Doença Crônica

INTRODUCTION

The Brazilian Unified Health System (SUS - Sistema Único de Saúde) brought advances to Brazilian public health and the expectation of building a universal system. And despite the past thirty years, it has encountered difficulties, mainly related to integral care, which still remains a challenge(1).

In this context, healthcare management is understood as “the provision of health technologies according to the unique needs of each person, in different moments of their life, being carried out in six dimensions: individual, family, professional, organizational, systemic and corporate “(2).

Among these dimensions, it stands out the organizational as essential for reaching the integrality of the healthcare, since this dimension occurs in each unit of the Healthcare Network (RAS - Rede de Atenção à Saúde) from the organization of the work processes that must constitute an interprofessional team and adoption of shared devices capable of providing a collaborative action(2).

The hospital, in this setting, assumes a complementary position to Primary Health Care (PHC) and should be clear about its mission of care, the skills of professionals and work processes that favors the reception of users, building links, constructing Unique Therapeutic Projects (UTP) and connecting with the components of the network through formal referral and counter-referral processes(2-3).

In this background, it is the Healthcare of the Child and Adolescent, that over the last century has been experiencing an epidemiological transition countrywide and worldwide, due to the increase of the chronic health conditions among child population(4).

Chronic conditions are characterized by gradual onset, with uncertain prognosis, long or indefinite duration, and clinical conditions that change over time and can generate disabilities, requiring continuous care and interventions through the use of soft, hard/soft and hard technologies. This new profile of health and illness imposes an expanded care model consistent with the proposal of SUS(5-6).

Given this, it becomes essential to organize the RAS of the person with chronic condition. In this, specialized care is a set of points with different technological densities for actions and services of urgency and emergency, specialized and hospital outpatient clinics, supporting and complementing basic care services in a resolute and timely way.(7).

The nurse has relevant insertion in this setting, both as coordinator of the nursing team and as articulator of the care organization, since it occupies a strategic position, due to its proximity to the child and its family, as well as its relationship with professionals of the health team. Thus, their interaction with the interprofessional team to enable the organization of care and its continuity in the domicile is of essential importance. Based on these assertions, the following research question is presented: What is the nurse role in healthcare management of children with chronic condition in the hospital setting.

OBJECTIVES

To understand the practice of the nurse in healthcare management of children with chronic condition in the hospital setting.

METHODS

Ethical aspects

Data collection began after submission and approval of the Research Ethics Committee of the Hospital Universitário Onofre Lopes of the Universidade Federal do Rio Grande do Norte (CEP/HUOL-UFRN) by means of a favorable. The interviews were preceded by the signing of the Free and Informed Consent Form and voice recording authorization, in accordance with the ethical and legal principles established by Resolution 466, of December 12, 2012, of the Brazilian Health Board (Conselho Nacional de Saúde)(8).

Theoretical-methodological framework

It was used as theoretical-methodological framework the Institutional Ethnography (IE), built from the examination of work processes in order to understand the actors' actions in that space and from the perspective of the involved ones, because IE explored the experiences directly involved in the institutional environment. Nonetheless, it is not the persons or institution that constitute the object of research, but the problems experienced and the relevant aspects of the institution's day-to-day life.(9).

Type of study

This is a descriptive and analytical study of qualitative approach.

Methodological procedures

As an initial approach, we began to attend the environment and observe the dynamics of the service, with the purpose of conducting a direct, continuous and systematic participant observation, as well as identifying administrative and clinical protocols, patient access flows, medical charts and minutes of meetings; all of these documents being aimed at the nurses' practice in healthcare management of children with chronic conditions. For the observation and documentary analysis, a script was elaborated in order to objectively identify the structure and organization of care in the unit.

Study setting

It was carried out in the pediatric unit of a university hospital, in a municipality in northeastern Brazil. The hospital is a member of the Brazilian Company for Hospital Services (EBSERH - Empresa Brasileira de Serviços Hospitalares) and is categorized as medium-sized, having 243 beds, integrating the RAS, in medium and high complexity. The pediatric hospitalization unit has 31 beds distributed in the specialties. It is, therefore, a reference for the population from zero to 16 years of age and attends to children and adolescents with chronic health conditions.

According to the hospital's information system, the main chronic conditions met are: epilepsy, cardiopathy, microcephaly, genetic syndrome, nephrotic syndrome, Chronic Renal Failure (CRF), Systemic Lupus Erythematosus (SLE), diabetes mellitus, cystic fibrosis, pneumopathy chronic, immunodeficiency and chronic liver disease.

The following flow of these children in the RAS after hospital discharge occurs as follows: When the child needs continuity of care at home, the nurse calls the social service that makes contact with the managers of the municipalities and mobilizes the Home Healthcare Service (SAD - Serviço de Atendimento Domiciliar), or even the Family Health Strategy (FHS). At the same time, the doctor schedules follow-up appointment for these children directly at the hospital's pediatric specialty clinic.

Data source

The population of the study totaled twenty health professionals at the unit: nurses, social workers, psychologists, pharmacists, nutritionists, physiotherapists and doctors.

The inclusion criterion was: to be a higher level professional; develop healthcare management actions for hospitalized children and adolescents with a chronic condition in the pediatric hospitalization unit of the university hospital during the research period. It was not included professionals in medical or maternity leave or removed from the service during the period of data collection.

Data collection and organization

After two months of participant observation and more detailed knowledge of the field of research, health professionals of the pediatric hospitalization unit that met the inclusion criteria were invited to participate in the study. With no refusal, they participated in a semi-structured interview, held in the meeting room of the pediatric unit - an enclosed place to provide comfort and privacy.

Data collection took place in the four-month period between May and August of 2017, at a frequency of three days a week, at different times: morning (7am-1pm), evening (1pm-7pm), and night (7pm-10pm). When data from participant observation and interviews met the sufficiency criterion, widely responding to the study objectives, the data collection was closed(10-11).

Participant observation was performed through a script that guided, at the same time, the aspects to be observed and the documentary analysis. After each field observation, the manuscript was recorded in the field diary, followed by its scanning to Word, for a total of 44 sections described.

The interview script, organized based on the research objectives, contained open questions about the organization and practice of nurses in healthcare management of children with a chronic condition, according to the following guiding questions: What do you understand for healthcare management?; Tell me how you see the nurse participation in healthcare management of children with chronic health condition. The interviews, conducted by the researcher herself, a PhD student from a postgraduate program and with experience in child health, were recorded on an MP3 player with the written permission of the participants.

Data analysis

With the interface and instrumentation of the software Atlas.ti, the analytical process of this study followed the steps of the Bardin content analysis, which consists of pre-analysis, at the point the construction of the research corpus occurs, through selection of the documents to be analyzed(12).

The following phase, exploration of the material, represents the technique of coding the corpus by means of clipping in order to identify units of record (meaning) and context (understanding), and then regroup them, from the semantic similarities of these codes, and classify them into analysis categories(12). In this step, the information collected and transcribed were inserted and organized through the use of the Scientific Software Atlas.ti version 8.0, under the license No. 8572B-1980A-7C494-MWOW1-00AYP, constituting a single New Project containing all the research data.

After defining the categories, the results were processed, culminating in inferential interpretations of the information, constituting a moment of reflexive and critical analysis(12).

RESULTS

Nurse as mediator of healthcare management

To understand nurses' healthcare management of the child with a chronic condition in a hospitalization unit, it started with his own conceptions about the phenomenon to understand which conceptual structures and symbolic meanings support the instrumentalization of its practice(13). Thus, through the nurses' reports, several meanings about healthcare management were identified:

Actions developed [...] aimed at improving the development of the sector or an infirmary and are people that the other components of the group have as reference. (Nr3)

It is a very broad thing that involves regulation, care lines, basic, middle and high complexity care [...] so that we have the way of the citizen as its access to health services. From prevention, treatment, rehabilitation, to palliative care, if applicable. (Nr4)

Means to see the patient as the whole, both what it brings to the picture at the moment and what it will need in the future. It is not only the patient here in the hospitalization unit as such. This management goes through nursing, communication with the medical team and covers all the multidisciplinary team that the child may need. (Nr6)

Diversities of views about healthcare management were apprehended. Some testimonies demonstrate limited understanding of the institutional scope; and others, bring a systemic conception, when considering the itinerary of the user in the network and the interprofessional practice for healthcare management.

Allied to these conceptions through participant observation, it was possible to identify the practice of nurses in healthcare management of children with chronic conditions. It was observed, in addition to activities of management and tutoring, the sharing of care with the nursing technicians, since the nurse admit more complex procedures, besides attending directly the child in critical condition.

Thus, an approximation of the nurse with the practice of care that outlined its care profile was visualized:

I see the nurse very committed. [...] most are very caring. We usually go to the very bedside. If it is to pass the probe, we pass. If it is to make a dressing, we do. (Nr2)

I think the basis of our profession is care, so we deal with care directly. Not neglecting any of the professions because each has the role of caring in a different view, but we deal more directly with patient care so we have a fundamental participation. (In14)

Confirming the observation, the nurses, in their testimonies, self-describe a care professional who goes to the bedside both to interact with the child and its companion - in order to gather information necessary to compose the history and the evolution of nursing - and to experience the process of caring, which is understood as the basis of the profession.

In addition, the nurse recognizes that her practice in healthcare management of the child with chronic condition occurs in situations in which she establishes cooperative relationships with the team, expressed in the following speech:

[...] participates in healthcare management when I am with the team discussing the best way of care for that child. Therefore, we are all there, leaning, studying the best way to move the treatment and care of the child. (In4)

Care management is related to the interprofessional discussion in order to seek the best way of caring, with a view to follow up the child, understanding that managing healthcare is inherent to the nurse's role, as well as highlighting the importance of communication in this process.

Nevertheless, the participation of nurses in multidisciplinary visits, routine activities of the service, depends on the dynamics of the unit, as stated in the following report:

[...] when it is viable, the nurse participates in multidisciplinary visits. In these last times, it is being viable because it has fewer patients, the scale is with a better number of nurses and this favors one or the other to participate, not all, because there always have to be some nurse in care, the telephone rings direct and always look for the nurse. Therefore, you cannot always participate. (Nr16)

From what the nurse emphasizes, it conditions the availability for visits to the structure of the sector. If the environment is “calm” and if it has a more suitable dimensioning, it becomes possible to participate. However, in situations of greater agitation, she cannot make herself present. There is also a proviso about its central position in the unit, because whenever one of the nurses leaves for the visit, even if it happens in the hall, it is necessary to leave another in the sector to meet the demands of the service, considering that the nurse is often requested.

In this sense, the following report highlights the need to modify the logistics of visits to make it easier the participation of nurses and other staff members.

[...] the visit has to be really multidisciplinary and not only medical, I think that changing it already improves a lot because it happens to have several professionals discussing together. We nurse sometimes wait for them to finish talking, and when they finish, we say, “No, the dressing is like this, the injury is like that and so, it did not get better even with the antibiotic.” When there is this interaction, this connection improves a lot [...] I think it has to improve this logistics. Sometimes we even restrict ourselves to talk due to the sovereign presence of the medical professional and this sometimes makes it difficult to talk, interfere and be distrusted [...]. (Nr16)

This testimony reveals a broad and random participation in the visits and expresses the difficulty of the nurses to intervene on these occasions, because the sovereign presence of the doctor makes them afraid to state their opinion and be disliked.

In addition, during her exercise in healthcare management, the nurse identifies herself as a mediator between the various professional categories, as mentioned below:

[...] it turns out that the nurse links the doctor's request with the laboratory, the pharmacy, the issue of provision of medicines, supplies, and nutrition. Sometimes, when an opinion is requested, it is the nurse who makes this link, not only in relation to specialties but also in relation to, for example, psychology, social service. (Nr8)

If you had a sustaining element in healthcare management for the chronic patient, it would be the nurse. [...] The internal client seeks the nurse, whether he is a pharmacist, a doctor or a resident. In addition, the external client, because the family, the patient, always goes after the nurse to know what to do from there, how they go home, how to use that little bomb. [...]. I understand that he is the coordinator of this situation. (Nr11)

The nurse refers itself as central player in the relationship of intermediation between the doctor and the other members of the health team to provide the material conditions of organization of care.

When referring to the patient with a chronic condition, the nurse believes to be an element in the maintenance of healthcare management and identifies itself as an articulator of the whole situation. The child and its family constantly request it, especially at the time of discharge from hospital and in view of the need to continue home care.

Corroborating the nurses' speeches, the health team professionals identify the nurse as the person responsible for healthcare management, according to the following statements:

I think the nurse might be the organizer. He gets involved in everything [...]. It is closer to the patient, feels more the problems and even the needs to convey to the attending doctor, the need for that patient. It might be a bigger bridge between the patient and the doctor. (Do15)

I see that the nurse is more connected to healthcare management, since it is the one who manages, be examination, medication, hygiene care or feeding. He is the one involved in this and I managed everything that is done for the patient [...]. An example of this: today I went to the nurse because I had a broken scale. I figured the nurse would be in charge of administration [...]. But that is precisely what is missing here, this communication, this discussion of the role of each one. (Nt1)

Professionals from different categories directly associate healthcare management with nurses, because of their proximity to the patient. As such, he is assigned a responsibility beyond the healthcare manager, as he relates it to the organization of the sector and to the provision of the conditions of health professionals to run their practices. Some see it as a link between the doctor and the patient; others believe to be him, the “unit administrator.”

From this perspective, during the participant observation period, it was possible to experience situations in which the nurse presented himself as mediator between the doctor, the staff and the relative.

As an example, there was the case of a newly admitted child whose companion had just left the social work room looking for the nurse, carrying a document about the authorization of his food in the unit, due to his stay to accompany a child under six months of age. As requested by the social worker, the companion asked the nurse to contact the nutritionist to ensure the feeding in the bed.

Faced with the expectation of the team and their own beliefs, the nurse seeks alternatives to exercise the position of “manager” and “mediator” among the different professional categories:

[...] I see myself as a manager in the moment of organizing healthcare and dealing with different categories, because we have internal clients: nutrition, psychology, reception [...]. We have to attend the laboratory and other services and we have to be attentive to everything. For example: today we organized the service and a colleague stayed in administration, solving all the problems and the rest were in the direct assistance. (Nr13)

[...] we tried several times, to leave one nurse in the bureaucracy and the others in the assistance, but we are not able to perform. It is as if a link was missing, a spring to move on. Everything is programmed, but we cannot perform, so the management gets a fault. (Nr3)

The reports express the nurses' need to organize daily their work in order to divide the management from care and to make available a professional exclusively oriented to attend to the administrative demands of the sector, which implies the professional dimensioning.

On the other hand, other reports from the team, as shown below, attribute a prominent position of nurses in healthcare management due to their proximity to the patient in the processes of hospitality, education, and care:

The nurse, I believe is the one who participates most in the management. He is always there managing the patients, always present, listening to what we have to say, both the nurse and the technician. (Ps10)

I think the nurse is the key, since he is the gateway, either in care of hospitalized patient or in outpatient clinic, […] he must be aware of this role because he is the one who welcomes the patient[…] he has the role of educator, embracer, caregiver […] it is he who gives security to the patient and the relative. It is who opens the doors, as if it were a home. It is a home where he [the child] will spend a few or many days, or even months, if he is a chronic patient. (Do12)

In this respect, it is emphasized the importance of the nurse in the process of healthcare management, from the hospitality and follow-up of the patient, who in the case of the child with chronic condition can spend days or months hospitalized. Its constant presence and closeness to the child leads it to be seen as a healthcare manager as it monitors its evolution, offers psychological support and provides pathways for the child who needs home care, as follows:

The nurse is fundamental in healthcare management of chronic children because it is the professional who is more present, closer to the patient, integrally in the 24 hours, monitoring their evolution and the necessary parameters to evaluate and improve the progression of the treatments that are established. It gives great backup in the psychological support, comfort and viability of ways so that parents can claim for benefits, when you have a chronic patient needing home care. [...]. (Pm5)

The testimony reaffirms the nurses' strategic position in childcare, not as a bridge between the categories, but especially because of their constant presence throughout care. From this perspective, it is evident in the following report the explicit need for theoretical discussions about healthcare management:

I see that the nurse participates a lot, he gets very involved. What may be needed [...] is to understand more about this issue of healthcare management. If I speak from the practical point of view, I think we all do, with limitations, but we do healthcare management, since we work for results. It may be needed the people to understand that they do healthcare management and prove this by effectively tracking the results and aligning planning and outcome. (Nr11)

The nurse admits to take an important part of responsibility in care for the child and considers himself a participant and involved. Nevertheless, it emphasizes the need to understand, conceptually, healthcare management to base its practice and make it evident through the evaluation and alignment between what was planned and actually achieved.

Nursing Process as a tool to manage care

During the activities in the research field, it was observed in the pediatric hospitalization unit the adoption of the Nursing Process (NP) as a methodological device for the SNC, of which is performed in all stages. In this context, through participant observation and documentary analysis, it was identified an organized physical structure to perform the nursing process and other professional records in the patient's electronic record.

In this setting, NP is systematized as follows: in the morning, the nurse in possession of the clinical information of the child, collected and registered by nurses in the afternoon and night hours, performs the evolution adding its own evaluation through the which outlines the diagnosis and the prescription of nursing, attaching it to the medical prescription at the moment of the appointment of the medication schedules.

Thus, the nurse intends to integrate the two prescriptions and make it easier for the nurse technician to access, because when he seeks the medical prescription for the preparation of the medications, he will have access to the nursing prescription simultaneously. Medical residents, in turn, know about the nursing prescription and are informed that care is prescribed by the nurse, but despite that, prescribes it. Therefore, at the time of the medication scheduling, the nurse reports by text in the medical prescription that these behaviors are included in the nursing prescription, as a strategy to define their space.

These repetitions of care in the medical prescriptions do not seem to interfere directly in the practice of the NP, since it was observed through the documentary analysis the check of the prescriptions of the nurses by the nursing technicians, at all the schedules. In addition, during the participant observation, it was not possible to identify the lack of motivation on the nurses' side to continue to carry out the stages of the NP, even during the interviews, moment that the professional reaffirmed to practice it fully:

We nurses, we have practiced the SNC at all stages, this is a tool that helps in healthcare management. The nurse who is introduced to this work environment is obliged to practice it, since it is already an institutionalized practice. Then he goes to the bedside, take physical examination, talk to the mother, to fill the instruments. He is obliged to get close to the patient, I think this is another tool that helps in healthcare management. (Nr2)

It is revealed the Systematization of Nursing Care (SNC) as a facilitator of nursing care management, which through the fulfillment of the NP provides in all its stages an approach of the nurse to the children and their companion to organize care focused on their needs. This demonstrates the joy in the achievements with institutionalization of the NP instruments:

The SNC instruments are very good. I am proud to say that we practice it. Knowing that we do all the steps, that we have a daily evolution in the patient's chart made by the nurse. This is very good, because there are places that the nurse can not access the patient's chart and here we can develop procedures, in general, and make the bureaucracy. (Nr2)

In addition, the NP makes it possible to monitor and evaluate the actions implemented, as emphasized in the following statement:

Systematization is a tool that has an impact on healthcare management by bringing this scientific method [Nursing Process]. [...] We start from the data collection that subsidizes the planning until the very evolution that would be the evaluation stage [...]. We planned, implemented, and were able to monitor the execution and evaluate the outcome of the patient's response, for example, whether the pain wore off or a responded to a particular change in position. So, this is healthcare management. But we still need to generate indicators [...]. We have data, but we do not yet generate indicators. (Nr11)

It is reaffirmed the impact of SNC on the nursing care management as it subsidizes planning, based on the needs of the user and allows the evaluation through the definition of indicators. Nevertheless, according to the testimony, although the nurses from the unit have implemented all stages of the NP, it has not yet been possible to generate indicators to assess the provided care.

DISCUSSION

From the objective of the study that aim to understand the practice of the nurse in healthcare management of children with chronic condition in the hospital setting, it was initially intended to apprehend the nurses point of view regarding healthcare management. Some testimonies showed limited understanding of the institutional organization; and others, brought a systemic conception, when considering the itinerary of the user in the network and the interprofessional practice. This fragmented and limited notion of care space may be related to the influence of a hospital-centered culture that has dominated and still prevails in health service organizations(14).

Although it is revealed a trend toward overcoming healthcare management from a fragmented perspective to a more complete practice focusing on the needs of the child with chronic condition - not only the immediate ones, but those going beyond hospitalization - such actions require the nurse the articulation with the RAS and the interactive relations between the dimensions of its work process in caring, educating, managing and investigating(15).

In this context, nursing care management is understood as “articulation and integration between care and management actions, through exercising the leadership and the interactive, communicative and cooperative relationships assumed by the nurse towards the nursing team, health professionals and the user(16). It then involves a dialectical relationship between the know-how to manage and the know-how to take care; and should focus on the needs of the human being(17-18).

In this sense, nurses' work essentially encompasses two dimensions that are interdependent and complementary to one another, care and management.(19). These two dimensions must be developed in an articulated and integrated way. Nevertheless, it was observed in this study the perpetuation and historical and social reproduction of nurses as organizers of the service, which conditioned him to identify himself culturally as the administrator not only of care, but of unity, creating difficulties of articulation between actions of care and management.

Accordingly, other studies have revealed the inclination of the nurse to fragment her work process by dividing the tasks of management with those that involve direct care for the sick person(20). Thus, nurses' administrative practices tend to be progressively distant from nursing care and approach institutional expectations(21).

However, the complexity of healthcare for children with a chronic condition requires that care management be thought out and organized from the perspective of the RAS in order to promote actions and services in a continuous and integral way(5). For this, it is necessary a broad look and use of tools that improve interaction, dialogue and sharing of knowledge and practices. Among these tools are the shared discharge and the UTP that address to the prospective discussion of a given situation and/or case to be developed by the involved professional core in an integrated way, considering the needs of the user(22).

In this context, nurses must act beyond hospitalization, assuming the main role as networking in order to ensure longitudinality and continuity of care, which are requirements for the follow-up of children and adolescents with chronic health conditions. In this perspective, it is fundamental to participate in the process of planning hospital discharge, together with the doctor and other knowledge centers, both in the sense of preparing the child and his companion to continue care in their homes as well as to reference them in the RAS or ensure the follow-up in outpatient clinic(23-24).

Nevertheless, in this research, the role of the nurse to ensure continuity of care for the child or adolescent with a chronic condition was focused on the guidance and training of the companion/family member, aiming to achieve relative autonomy and empowerment for continuity of care at home. Thus, it is a practice restricted to the hospital environment with little participation in the networking process.

This fact seems to be associated to the hospital culture, whose care model focuses on the hospital and specialties. Thus, the nurse is inserted in a cultural system of specialized unit that in the Brazilian health system is marked by the predominance of fragmented practices and points of attention that do not interact and forget to guarantee the longitudinality of care.(14).

It is also observed the influence of the cultural and organizational system of the unit under the attributes of communication and interprofessional interaction, essential for the collaborative practice in healthcare. In this direction, it is highlighted “the implications of the organizational culture of health for the practices of collaborative care and the importance of the nurse as an integrator in the instances of work in health institutions through their protagonism in leadership and communication”(25).

So it is reaffirmed the importance of the nurse in these moments of interprofessional interaction considering that, as coordinator of the therapeutic activities and care actions offered by the nursing team, it becomes crucial to develop a collaborative work(25).

And to compose a professional profile that is consistent with this position of the nurse, as well as articulation, leadership and interdisciplinarity are indispensable attributes.(16). The instrumentalization of the nurse to act in healthcare management must begin from his professional training, which must focus on fostering an expanded view of care, and on the incorporation of management skills and competences based on cooperation, articulation and interdisciplinarity(19).

In addition, lifelong education is considered an essential tool for changing and transforming nursing care management practices as it allows reflexivity about care they want to offer, the organization of work processes and their practice.

In this background, the NP is considered a fundamental methodological and technological tool to develop healthcare management, insofar as it organizes, directs and qualifies care, as well as registering the professional practice of the nurse(19).

In the study setting, it was observed that the NP is fully developed and recognized by the nurses team as crucial for healthcare management. However, it was identified there was little recognition of the team about the importance of the nurse's prescription of care. Regarding this issue, the literature points to the need for NP interaction with the interprofessional team through dialogic attitudes that allow it to become efficient and visible beyond nursing(26).

In an interdisciplinary perspective, the diagnosis and prescription of nursing care need to be discussed and negotiated with the health team. Thus, it is pointed out the importance of the nurses positioning themselves before the team about the NP, which involves the identification of the needs of child care, materialized by the definition of nursing diagnoses, prescription of care, intervention and evaluation.

Nonetheless, according to the testimony, although the nurses team of the unit have already implemented all stages of the NP, it has not yet been possible to generate indicators to assess the provided care. These indicators are the empirical references that measure the quality of care offered and subsidize their improvement and decision making; and can be represented by “indicators of patient safety, quality of interprofessional interaction, effective communication, integration and articulation”. Since healthcare management involves, above all, the organization of a safe environment(16).

Study limitations

It refers to the short time of insertion of some research subjects as professionals of the pediatric unit and also the absence of the nursing technician as participant, that can reflect in the understanding of the context and the phenomenon of study.

Contributions to Nursing

It is highlighted the importance of the knowledge built by the study to promote changes in nurses' training in order to instrumentalize them for healthcare management, from his professional training, from fostering an expanded view of care, and on the incorporation of management skills and competences based on cooperation, articulation and interdisciplinarity.

FINAL CONSIDERATIONS

The nurse proved to be essential for healthcare management of the child with chronic condition, acting as mediator of the relationship between the doctor, the members of the health team, the user and their family. It was identified a nurse with a care profile that recognizes and uses the NP as a mechanism to manage care, but still requires theoretical instrumentalization to base its practice on this management. Moreover, even in the face of advances in the institutionalization of the NP in the unit, opportunities for improvement in their practice are seen, especially with regard to the evaluation of care.

There are also difficulties in articulating the dimensions of management and care, since the nurse's performance is under the expectation of the team and the dynamics of the unit that assign responsibilities beyond healthcare management, attributing them the role of “administrator” of everything that involves the patient. Thus, although it is recognized the importance of an interprofessional work to develop full healthcare management, the nurse is often faced with the overload of activities, making it difficult for them to participate in the multidisciplinary visits of the unit.

FUNDING

This study was financed in part by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - Brasil (CAPES) - Finance Code 001.

REFERENCES

1 Paim JS. Sistema Único de Saúde(SUS) aos 30 anos. Ciênc Saúde Coletiva [Internet]. 2018 [cited 2018 Nov 30];23(6):1723-8. Available from: http://dx.doi.org/10.1590/1413-81232018236.09172018Links ]

2 Cecílio LCO. Apontamentos teórico-conceituais sobre processos avaliativos considerando as múltiplas dimensões da gestão do cuidado à saúde. Interface Comunicação Saúde Educação [Internet]. 2011[cited 2018 Jun 05];15(37):589-99. Available from: http://www.scielo.br/pdf/icse/v15n37/a21v15n37.pdfLinks ]

3 Ministério da Saúde (BR). Conselho Nacional de Saúde. Resolução nº466, de 12 de dezembro de 2012[Internet]. 2012[cited 2018 Nov 30]. Available from: https://bvsms.saude.gov.br/bvs/saudelegis/cns/2013/res0466_12_12_2012.htmlLinks ]

4 Araújo JP, Silva RMM, Collet N, Neves ET, Tos BRGO, Viera CS. História da saúde da criança: conquistas, políticas e perspectivas. Rev Bras Enferm [Internet]. 2014 [cited 2018 Nov 30];67(6):1000-7. Available from: http://dx.doi.org/10.1590/0034-7167.2014670620Links ]

5 Ministério da Saúde (BR). Diretrizes para o cuidado das pessoas com doenças crônicas nas redes de atenção à saúde e nas linhas de cuidado prioritárias. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Brasília: Ministério da Saúde, 2013b. [ Links ]

6 Merhy EE. Saúde: a cartografia do trabalho vivo. São Paulo: Hucitec, 2007. [ Links ]

7 Ministério da Saúde (BR). Portaria nº 483, de 1 de abril de 2014. Redefine a Rede de Atenção à Saúde das Pessoas com Doenças Crônicas no âmbito do SUS e estabelece diretrizes para a organização das suas linhas de cuidado. [ Links ]

8 Ministério da Saúde (BR). Resolução nº 466, de 12 de dezembro de 2012. Conselho Nacional de Saúde. Brasília, 2012. [ Links ]

9 Smith DE. Institucional etnography: a sociology for people. Toronto: Altamira Press, 2005 [ Links ]

10 Streubert HJ, Carpenter DR. Investigação Qualitativa em Enfermagem: Avançando o Imperativo Humanista. 2. ed. Camarate: Lusociência, 2002. [ Links ]

11 Triviños AN. S. Introdução à pesquisa em ciências sociais: a pesquisa qualitativa em educação. São Paulo: Atlas, 2009. p. 137-158. [ Links ]

12 Bardin L. Análise de conteúdo. São Paulo: Edições 70, 2011. [ Links ]

13 Geertz C. A interpretação das culturas. Rio de Janeiro: S. A., 1989. [ Links ]

14 Mendes EV. Interview: The chronic conditions approach by the Unified Health System. Ciênc Saúde Coletiva [Internet]. 2018 [cited 2018 Oct 11];23(2):431-436. Available from: http://dx.doi.org/10.1590/1413-81232018232.16152017Links ]

15 Proshnow AG, Leite JL, Erdmann AL. Teoria interpretativa de Geertz e a gerência do cuidado: visualizando a prática social do enfermeiro. Rev Latino-Am Enfermagem [Internet]. 2005 [cited 2018 Jun 05];13(4):583-90. Available from: https://www.revistas.usp.br/rlae/article/view/2122/2211Links ]

16 Mororo DD de S, Enders BC, Lira ALBC, Silva CMB, Menezes RMP. Análise conceitual da gestão do cuidado em enfermagem no âmbito hospitalar. Acta Paul Enferm [Internet]. 2017[cited 2018 Jun 05];30(3):323-32. Available from: http://www.scielo.br/pdf/ape/v30n3/en_1982-0194-ape-30-03-0323.pdfLinks ]

17 Koerich C, Santos FC, Meirelles BHS, Erdmann AL. Gestão do Cuidado de enfermagem ao adolescente que vive com HIV/AIDS. Esc Anna Nery [Internet]. 2015[cited 2018 Jun 05];19(1):115-23. Available from: http://www.scielo.br/pdf/reben/v71n1/pt_0034-7167-reben-71-010142.pdf Links ]

18 Christovam BP, Porto IS, Oliveira DC. Gerência do cuidado de enfermagem em cenários hospitalares: a construção de um conceito. Rev Esc Enferm USP [Internet]. 2012[cited 2018 Jun 05];46(3):734-741. Available from: http://www.scielo.br/pdf/reeusp/v46n3/en_28.pdfLinks ]

19 Senna MH, Lívia Crespo Drago LC, Kirchner AR, Santos JLG, Erdmann AL, Andrade SR. Significados da gerência do cuidado construídos ao longo da formação profissional do enfermeiro. Rev Rene [Internet]. 2014 [cited 2018 Jun 05];15(2):196-215. Available from: http://repositorio.ufc.br/bitstream/riufc/11546/1/2014_art_mhsenna.pdfLinks ]

20 Lanzoni GMM, Magalhães ALP, Costa VT, Erdmann AL, Andrade SR, Meirelles BHS. Tornando-se gerente de enfermagem na imbricada e complexa fronteira das dimensões assistencial e gerencial. Rev Eletr Enf [Internet]. 2015[cited 2018 Jun 05];17(2):322-32. Available from: https://www.fen.ufg.br/revista/v17/n2/pdf/v17n2a16.pdfLinks ]

21 Montezelli JH, Peres AM, Bernardino E. Demandas institucionais e demandas de cuidado no gerenciamento de enfermeiros em um pronto socorro. Rev Bras Enferm [Internet]. 2011 [cited 2018 Jun 05];64(2):348-54. Available from: http://www.scielo.br/pdf/reben/v64n2/a20v64n2.pdfLinks ]

22 Araújo TAM, Vasconcelos ACCP, Pessoa TRRF, Forte FDS. Multiprofissionalidade e interprofissionalidade em uma residência hospitalar: o olhar de residentes e preceptores. Interface(Botucatu) [Internet]. 2017[cited 2018 Oct 11];21(62):601-613. Available from: http://www.scielo.br/pdf/icse/v21n62/1807-5762-icse-1807-576220160295.pdfLinks ]

23 Nóbrega VM, Reichert APS, Viera CS, Collet N. Longitudinality and continuity of care for children and adolescents with chronic diseases. Esc Anna Nery [Internet]. 2015 [cited 2018 Oct 11];19(4):656-63. Available from: http://www.scielo.br/pdf/ean/v19n4/en_1414-8145-ean-19-04-0656.pdfLinks ]

24 Holz CB, Menezes LP, Begnini V, Sarturi F. Hospital na Rede de Atenção à Saúde: uma reflexão teórica. Rev Espaço Cienc Saúde [Internet]. 2016. [cited 2018 Oct 11];4101-15. Available from: http://revistaeletronica.unicruz.edu.br/index.php/enfermagem/article/view/5254Links ]

25 Waldow VR. Cuidado colaborativo em instituições de saúde: a enfermeira como integradora. Texto Contexto Enferm [Internet]. 2014[cited 2018 Jun 05];23(4):1145-52. Available from: http://www.scielo.br/pdf/tce/v23n4/pt_0104-0707-tce-23-04-01145.pdfLinks ]

26 Backes DS, Koerich MS, Nascimento KC, Erdmann AL. Nursing care systematization as a multidimensional and interactive phenomenon. Rev Latino-Am Enfermagem [Internet]. 2008 [cited 2018 Jun 05];16(6):979-985. Available from: https://www.revistas.usp.br/rlae/article/view/2496/2949Links ]

Received: August 08, 2018; Accepted: May 11, 2019

EDITOR IN CHIEF: Antonio José de Almeida Filho

ASSOCIATE EDITOR: Mitzy Danski

Corresponding author: Deborah Dinorah de Sá Mororó, E-mail: deborahsa1@hotmail.com

Creative Commons License This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.