doi:10.17533/udea.iee.v33n3a03

Care management in nursing within emergency care units

Gestión del cuidado de enfermería en las unidades de cuidados de emergencia

Gerência do cuidado de enfermagem em unidades de pronto atendimento

Roberta Juliane Tono de Oliveira¹; Patrícia Madalena Vieira Hermida²; Fernanda Hannah da Silva Copelli³ José Luís Guedes dos Santos ⁴;Alacoque Lorenzini Erdmann⁵;Selma Regina de Andrade⁶

¹Nurse, Master. Federal University of Santa Catarina - UFSC, Florianópolis, Santa Catarina, Brazil. email: roberta_tono@hotmail.com.

²Nurse, Ph.D. candidate. UFSC, Florianópolis, Santa Catarina, Brazil. email: patymadale@yahoo.com.br.

³Nurse, Master. UFSC, Florianópolis, Santa Catarina, Brazil. email:fernandacopelli@hotmail.com.

⁴Nurse, Ph.D. Assistant Professor UFSC, Florianópolis, Santa Catarina, Brazil. email: joseenfermagem@gmail.com.

⁵Nurse, Ph.D. Full professor, UFSC. Grant holder 1ª, CNPq, Florianópolis, Santa Catarina, Brazil. email: alacoque@newsite.com.br.

⁶Nurse, Ph.D. Assistant professor, UFSC, Florianópolis, Santa Catarina, Brazil. email:selma.regina@ufsc.br.

Receipt date: February 20, 2015. Approval date: September 1, 2015

Article linked to research: Management practices of nursing care in the emergency care units of Florianópolis, conducted through the Scientific Research Program (PIBIC) coordinated by Ph.D. Professor Alacoque Lorenzini Erdmann.

Subventions: National Council for Scientific and Technological Research (CNPq) and the Federal University of Santa Catarina (UFSC).

Conflicts of interest: none.

ABSTRACT

Objective.Understand the conditions involved in the management of nursing care in emergency care units. Methodology. Qualitative research using the methodological framework of the Grounded Theory. Data collection occurred from September 2011 to June 2012 through semi-structured interviews with 20 participants of the two emergency care units in the city of Florianopolis, Brazil. Results. Hindering factors to care management are: lack of experience and knowledge of professionals in emergency services; inadequate number of professionals; work overload of emergency care units in the urgent care network; difficulty in implementing nursing care systematization, and need for team meetings. Facilitating factors are: teamwork; importance of professionals; and confidence of the nursing technicians in the presence of the nurse. Conclusion. Whereas the hindering factors in care management are related to the organizational aspects of the emergency care units in the urgency care network, the facilitating ones include specific aspects of teamwork.

RESUMEN

Objetivo.Comprender las condiciones que intervienen en la gestión del cuidado de enfermería en las Unidades de Cuidados de Emergencia. Metodología. Investigación cualitativa que utiliza el marco metodológico de la Teoría Fundamentada. La recolección de datos se llevó a cabo desde septiembre 2011 a junio 2012, mediante entrevistas semi-estructuradas con 20 participantes de las dos Unidades de Cuidados de Emergencia en Florianópolis, Brasil. Resultados. Los factores que dificultan la gestión del cuidado son, entre otros: la falta de experiencia y de conocimiento de los profesionales en situaciones de emergencia; el déficit de profesionales; la sobrecarga de estas unidades en la atención a la red de emergencia; la dificultad en la implementación de la sistematización de la Atención de Enfermería, y la necesidad de las reuniones del equipo. Los factores facilitadores de la gestión son: el trabajo en equipo; la importancia de la formación profesional y la seguridad del personal de enfermería en la presencia del enfermero profesional. Conclusión. Los factores que dificultan la gestión están relacionados con aspectos de organización de las Unidades de Cuidados de Emergencia en la atención urgente de la red, mientras que los facilitadores se dirigen a aspectos específicos del trabajo en equipo.

Palabras clave: gerencia; atención de enfermería; servicios de enfermería; enfermería de urgencia; administración de los servicios de salud.

RESUMO

Objetivo.Compreender as condições intervenientes na gerência do cuidado de enfermagem em Unidades de Pronto Atendimento. Metodologia. Pesquisa qualitativa que utilizou o referencial metodológico da Teoria Fundamentada nos Dados. A coleta de dados ocorreu de setembro de 2011 a junho de 2012, por meio de entrevistas semiestruturadas com 20 participantes das duas Unidades de Pronto Atendimento do município de Florianópolis, Brasil. Resultados. Os fatores dificultadores da gerência do cuidado são: ausência de experiência e de conhecimento dos profissionais em urgência; déficit de profissionais; sobrecarga das Unidades de Pronto Atendimento na rede de atenção às urgências; dificuldade na implantação da Sistematização da Assistência de Enfermagem e, necessidade de reuniões de equipe. Os facilitadores da gerência são: trabalho em equipe; importância das capacitações profissionais e segurança da equipe de enfermagem na presença do enfermeiro. Conclusão. Os fatores que dificultam a gerência estão relacionados aos aspectos organizacionais das Unidades de Pronto Atendimento na rede de atenção à urgência, enquanto os facilitadores voltam-se para aspectos específicos do trabalho da equipe.

Palavras chave:gerência; cuidados de enfermagem; serviços de enfermagem; enfermagem em emergência; administração de serviços de saúde.

INTRODUCTION

From the perspective of complexity, a new management model emerges, principally from a new individual, a questioning, inquiring subject, who seeks knowledge to overcome his or her limitations.⁵ The challenges to care management are to extrapolate the institutionalized limits of traditional care and/or that founded on administrative proceedings based on positivist and deterministic bases, and find a new support, a new center, and/or a new order able to cope with uncertainties and contradictions. It is necessary to understand the connections and the network of interactions mobilized in scenarios where the user and the professional meet to realize the care process. Thus, the complexity of management practices is evidenced in nursing, which blend both multiple professional interactions, different organizational systems, and the complexity of care.⁵ Care management, defined as the relationship between the caring and the management dimension of nursing work, mobilizes actions, interactions, and associations among members of the organic complex care system composed of nursing and health teams, carriers at their core of knowledge, skills, and attitudes that enhance teamwork and participate in the care management exercised by the nurse.^6.7

To overcome the traditional model of management it is necessary to review the role of nurses in the services and share new ways to manage in nursing. Because there is no single way forward for such overcoming, it requires the development of strategies consistent with the contexts in which the nurses exercise their practice.² This contemporary logic of care management is shared in Latin American countries like Chile, Mexico and Cuba. In 2007, the Chilean Ministry of Health approved care management as part of the structure of health services, as it is a responsibility of nurses and an inherent and exclusive function of nursing, ⁸ which highlights the autonomy legally granted to the profession in the management of the care implemented. In Brazil, studies have been developed to clarify the definition of the term "care management".^5,9,7 For some authors, care management means managing the nursing service in its multiple dimensions or its organizational policies, and it is the nurse who assumes that management and constitutes the communication and feasibility link of health care policies focused on personal and collective interests, since nursing is the engine that moves, connects, and mobilizes the network of complex interactions that make up the care system.⁵

Specifically in the context of an ECU, an earlier study found that the nurses' activities involve the use of technological knowledge in everyday problem solving, thereby enabling the infrastructure to carry out the care.³ Thus, it is considered relevant to nurses' professional practice in the ECU to advance the discussion about the particularities of the nursing work within this performance scenario, particularly with regard to care management. Hence, in light of the concept of care management, and considering the ECUs to be a new performance scenario for the nurses, the question that arises is: what are the conditions involved in nursing care management in the ECUs? This study aims to offer an answer.

METHODOLOGY

The research took the form of a qualitative study guided by the Grounded theory, also known in Brazil as the Data-based theory (DBT).¹⁰ The study site comprised two ECUs located in the South and North districts of the city of Florianopolis, Brazil, inaugurated respectively in 2008 and 2009. Data collection was carried out from September 2011 to June 2012. The theoretical sample was composed of three sample groups (SGs), defined according to the relevance of the participant's work in relation to the investigated phenomenon, namely care management. Thus, the guiding question was: How do nurses experience and what meaning do they attach to their care management practice in ECUs? The first SG was composed of eight nurses. The data collection and analysis of this group defined new participants, who were the second and third SG. The second included six health team professionals: three physicians, two nursing technicians, and a social worker, according to the replies submitted by the first SG. The third SG was made up of six users, taking into account the question: What motivated you to seek the services offered in this ECU? The sample size was determined by theoretical saturation data, totaling 20 participants. The inclusion criteria of the subjects of the first and second SGs were: minimum experience of three months in the sector and availability to participate in the study. Inclusion criteria for the selection of users were: having used the services provided by ECUs, being served in one of the units, as well as availability to participate.

Data were collected through semi-structured interviews with the subjects in individual meetings. The interviews were recorded and transcribed soon after they were made, and analyzed concurrently, following the methodological framework. The analysis was careful in order to find the empirical indicators defined as codes. The encoding comprises all operations for data analysis, being classified into open, axial, and selective coding.¹⁰ Open coding, the first stage of the analysis, entails separating, examining, comparing, and conceptualizing the data obtained, which are analyzed line by line, so that each respondent's speech is transformed into a code. The codes are grouped by similarities and differences, forming subcategories, labeled according to the subject addressed. The second stage, axial coding, is the set of procedures in which the data are again grouped, giving rise to the categories. In the last step, called selective coding, the search and development of the central category is performed, around which all other categories revolve.¹⁰

To organize the process of agglomeration of categories and subcategories, we used the data analysis paradigm,¹⁰ in terms of context, causal conditions, consequences, action strategies, and intervening conditions. From the categorization process emerged the phenomenon: "Managing nursing care and health in Emergency Care Units for a specialized and differentiated care," which is supported by six categories: "Organization and structuring of the ECU for emergency services" (context ); "Perception of nurses, by themselves and the health team, as professionals responsible for care management" (causal condition); "Revealing the enabling conditions for Nursing Care Management" and "Identifying hindering conditions for Nursing Care Management" (intervening conditions); "(Re)organizing the flow of care and the care process" (strategies); and "Providing a differentiated service" (result).

Given the importance of understanding the intervening conditions in nursing care management in ECUs, this study presents and discusses only the categories relative to these as they relate to the phenomenon of nursing care management, insofar as intervening conditions are responsible for including the facilitating and hindering aspects of the phenomenon.¹⁰ The study was approved by the Ethics Committee of the Federal University of Santa Catarina (UFSC), under opinion N° 1991/96. All participants signed an informed consent form. To ensure confidentiality and privacy, respondents were identified with the letter "I" followed by an Arabic numeral.

RESULTS

Intervening conditions for the management of nursing care were revealed in the following categories: Revealing the enabling conditions for the management of nursing care" and "Identifying the hindering conditions for the management of nursing care," which together consist of eight subcategories, three facilitating and five hindering ones. The following emerged as facilitating subcategories: Working as a team; Assigning importance to professional training; and Feeling confident in the nurse's presence. The hindering subcategories were: Realizing the lack of experience and knowledge of emergency professionals; Citing the deficit in the number of professionals; Realizing the burden of ECUs in the emergency healthcare network; Identifying difficulties in the implementation of Nursing Care Systematization (NCS); and Recognizing the need for team meetings.

Facilitating conditions for the management of nursing care

The Working as a team subcategory was understood to mean working together, counting on one another and collaborating. This work emerges linked to the idea of ​​collaboration among professionals when one of them has difficulties: Team work for me is when a colleague needs to turn his back to do something and the other can pick up where the first one left [...]. Team work is being able to count on each other and have this collaboration, and here I have enough of it [...] (I13).

The Assigning importance to professional training subcategory points out the need for relevant training regarding the work process of the ECUs, constituted in a permanent education space: When the direction changed that was one of the things I discussed because I thought it was relevant [training]. Why does this space happen in all units and why couldn't we be doing this in the ECU, with the employees and the team? (I1).

The Feeling confident in the nurse's presence subcategory denotes that the safety perceived by nursing technicians in the nurse's presence is characterized by the support he or she gives, especially in times of uncertainty, and openness to dialogue, which can be seen in the following excerpts: The nurse for me is my compass; [...] it is he who guides the shift. I never do anything that is not in my power [...] without first passing it by the nurse. Even some medical procedures [...] I'm in doubt about I talk to the nurse. They [nurses] have this importance within the team (I13). An active nurse is something else, he stabilizes all the shift and conveys tranquility for the technician. You know you can rely on him if you need (I14).

Hindering conditions in the management of nursing care

The Realizing the lack of experience and knowledge of emergency professionalssubcategory occurs mainly due to the lack of professionals in ECUs, a deficit supplied by professionals who generally have experience in PC. Learning about urgent care is realized in practice to meet the demands of this service, either with nurses or even nursing technicians, as reported: Some [professionals] came from health centers, working public health care [...] and have no experience in urgent / emergency, but are learning from the technicians who have worked longer, or nurses who are on shifts (I1). The other [professionals] who came to the ECU [...] and who were from the Health Unit and never worked anywhere else have to learn from those with more experience [...] and often aren't as effective and then they are dependent on that nurse who has the experience, but the right thing would be training (I3).

Another subcategory, Citing the deficit in the number of professionals, reveals that this deficit compromises the care provided by the nurses, who cannot carry out the activities that have been designated as unique to them, the reception, and those regulated as integral parts of their professional practice, such as direct care to patients in life-threatening conditions. A relevant aspect pointed out to the management of nursing care refers to absenteeism due to medical certificates, which produces gaps in the nursing service schedules and burden to the professionals who take over the work of those who are missing in addition to their own. Some testimonials illustrate this point: So we [nurses] cannot be full-time screening, that would be ideal, but there is no staff nor technicians, many people are lacking, we do not have the full team yet (I2). We have some responsibilities that are specific to the nurse, such as the reception [...] and in this condition of being alone we cannot be 100% of the time in the reception (I6). [...] That which interferes much at work is the number of medical certificates on the part of the nurses [...] that will therefore throw off the on-duty schedule which will be depleted because we cannot cover all the holes and overloads (I4).

The Identifying difficulty in the implementation of Nursing Care Systematization (NCS)subcategory shows that professionals understand that due to the inherent characteristics of the service it is not possible to develop this systematization in the ECU, and while recognizing that some type of prescription is performed, it is understood as informal. The difficulty in planning nursing care through the NCS is justified by the absence of a proper theoretical framework of nursing in the service, because there are no inpatients in the ECU, nor a specific instrument for records. In addition, the nurses do not perceive any encouragement from the institution to adopt a specific model of registration and nursing prescription, which is pointed out in the following excerpts: There's no way to plan like at the UH [University Hospital], which has a routine based on the Wanda Horta system, which prescribes the nursing care and everything. Here, because we do not have inpatients, there's no way to use this prescription, unless the patient stays longer [...] (I2). It is not a formalized prescription, but it is a nursing prescription because it has constant and daily guidance. We have no instruments here even because the service does not allow us to have a prescription (I4).

Another subcategory identified was Recognizing the need for team meetings. The professionals, besides perceiving the need for meetings, are able to point out the contributions that these could bring to the job in the Units studied, such as service organization, routine creation, work in multidisciplinary teams, and hence integration of work into the ECU, which is evidenced in the following statements: [...] There are no meetings. No gatherings, neither by category, nor with teams and not even only the coordination, no, there isn't that, and that is missing. I think it [the meeting] is a way of organizing the service, creating a routine (I10). [...] this movement would be interesting if only to have the spirit of working in a multidisciplinary team [...] so that everything works in an integrated way (I12).

DISCUSSION

The analysis of the conditions intervening in the management of nursing care in the studied ECUs revealed both difficulties and facilitators for the professional practice of nurses. In this scenario, teamwork is emphasized as a facilitator, together with the idea of collaboration and support in the adverse conditions of professional nursing practice. A recent research study shows that to addressing work issues in the emergency setting requires a cohesive, integrated team, from the moment of conception to the implementation of actions.⁶ Teamwork is also involved in the management of nursing care in other performance scenarios of the nurses.¹¹

The importance of training, conveyed by the professionals, refers to the characteristics of the nurse's managerial work, which involves actions of managing, caring, and educating; caring, managing, and educating; and educating, caring, and managing.⁵ This dynamic between managing, caring, and educating can permeate and connect the hospital and para-hospital services in hospital quality care.⁵ A similar study points out that the nurse who trains the team contributes to the acquisition of knowledge, professional development, and self-organization capacity, enabling the construction of better care practices.⁷ In the environment of the ECUs, constantly permeated by complex situations, knowledge is essential not only to produce interpretations, criticisms, and meanings, but also to participate in the dynamic reality of this context.¹² Our results emphasize that the nursing technicians of the ECUs trusts the nurses' work, seeing them as their "safe haven". Confidence, though subjective, facilitates care practices, care management, and nursing training, since promoting nursing care requires focusing on creating environments that foster trust. The nurse stands out in emergency services for being the professional responsible for the work environment organizaition.^13,14 .

As for complicating aspects of the care management performed by nurses in the ECUs, the lack of experience and knowledge of professionals regarding emergency care is related to the origin of these workers, coming from PC and experienced only in that level of health care. Some research works corroborate the unpreparedness of the PC team in coping with emergencies.^15,16 However, the authors emphasize that in order to effectively meet the urgent and emergent demands in primary care, one must consider a number of factors, including the professionals' technical expertise,¹⁴ a condition found lacking in this study. As recommended by the NPEC, acute injuries should be accepted at any level of the health care system, so that both PC and specialized services must be prepared to accept and refer users to other levels of the system when the possibilities of complexity of each service are exhausted.¹⁷ Research shows that learning of urgent and emergent care of the professionals in ECUS becomes concrete in the practices that meet the demand for the health services, which may be why the respondents value capacity-building, treated in the study as a facilitating condition for the management of nursing care.

Besides compromising care, the deficit evidenced in the number of professionals, which cause exclusive nursing duties to be done by other nursing professionals, causes wear in the whole team. The nursing work process has produced occupational illnesses due to a significant number of patients in ECUs and hospital emergency departments. According to some authors, ¹⁸ the relationship between the nursing work process and the exposure of workers to work overloads results in a high absenteeism rate. The deficiency in human resources is configured as an improper work condition, threatening the health of workers, hindering service and relations between workers and users, who show their dissatisfaction with the services received.¹⁸ The work overload of the ECUs in the emergency healthcare network is corroborated in another work, which also blames it on the spontaneous demand unconnected from PC, and the incomplete teams.¹⁹ A study pointed out that the demands met in the ECUs can delimit some "knots" of the network, mainly those located in PC.²⁰ In Florianopolis, for example, where this research was conducted, it was identified that the reception and the PC organization mechanism is incipient as operational technology, which makes a significant quantity of families enrolled in PC use the emergency care services as a source of regular care.²¹ The PC problems reflect the ongoing health care overload in levels with a higher technological density.²²

Our research revealed difficulties for the nurses' performance in terms of the management of care (the NCS) the patients' length of stay in the units, and the drafting of a formal instrument, which requires adaptations of this methodology to the reality of ECUs. The implementation of the NCS involves a series of steps including: recognition of the institutional reality, customer analysis, creation of the Nursing Process instruments, and adaptation of the nursing method to different scenarios of professional practice.²³ What draws attention in this study is that professionals associate the difficulties in implementing the NCS with the management of nursing care, which is relevant if we consider that this methodology allows care and management interventions simultaneously, thereby being an assistance tool with a managerial connotation.⁴ The team meeting can be an extremely important condition intervening in the management of nursing care. The lack of meetings between the teams pointed out by the respondents requires reflection insofar as comprehensive care, free from fragmentation, is a matter being constantly addressed. These meetings, and the cooperation between the different professional categories in responding to emergency situations, promote an exchange of different knowledges for the benefit of a risk free quality care, and establish a relationship of interchange, cooperation, and improved communication between professionals.¹⁷

This notion points to the understanding that the hindering conditions are more in the governance of the institution or the network in general, especially for some subcategories, such as overload in the ECUS and the deficit in the number of professionals. However, some hindering conditions, which could be understood as being of shared responsibility (the nurse and the institution's), such as the difficulty in implementing the NCS and the need for team meetings, lead us to reflect on the nurse's position in the face of these difficulties.

This study allowed us to understand the conditions involved in the management of nursing care in ECUs by revealing the difficulties and facilitators in care management in the scenario of the emergency healthcare network. Thus, the enabling conditions in care management in the professional nursing practice, focused on team work, emphasize interpersonal relationships, which in a way are subjective, as in the case of the Working as a team and Feeling safe in the nurse's presence subcategories. The Assigning importance to training subcategory concerns education in the work environment, which may be explained by the lack of knowledge and experience in the context of emergency care. It is noteworthy that the challenges faced in the management of nursing care are overcoming the hindering factors and strengthening the facilitators evidenced in this study. To that end, the management must be reinforced as a dynamic, situational, and systemic activity, characterized by the connections between know-do-manage, know-do-care and know-do-educate, involving a dialectical, and not a dichotomous relationship.

The results have limited generalizability inasmuch as the research was conducted in only one municipality and only part of the ECU professionals were included. To improve understanding of the phenomenon in question, further research on the subject is suggested involving other subjects in the context of the ECUs, and other scenarios of the emergency care network. It is hoped that this will ensure a quality nursing care that safely meets the needs of users of ECUs.

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