CONCEPTIONS OF NURSES ON THE MANAGEMENT OF CARE IN AN EMERGENCY SERVICE: DESCRIPTIVE-EXPLORATORY STUDY

José Luís Guedes dos Santos¹, Maria Alice Dias da Silva Lima², Patrícia Klock³, Alacoque Lorenzini Erdmann⁴

1,3,4Postgraduate Federal University of Santa Catarina – UFSC;
2 Federal University of Rio Grande do Sul - UFRGS.

ABSTRACT

Objective: To analyze the conceptions of nurses in a hospital emergency service on care management. Method: exploratory-descriptive study with qualitative approach carried out with nurses of the Emergency Department of a university hospital in southern Brazil. Data were collected through semi-structured interviews between June and September 2009 and analyzed using thematic analysis. Results: three conceptions of care management were evidenced: management as organization and optimization of working in emergency; management as an instrument for the best practices of care; and management of the nursing staff. Conclusion: nurses' conceptions express the complementarity between the management and care dimensions, which enhance the role of a nurse and enable the smooth progress of work in the unit, setting priorities for care and developing strategies to overcome the present difficulties in the daily work in the emergency department.

KEYWORDS: Nursing, Patient Care Management; Management; Role of Nursing Professional; Hospital Emergency Service.

INTRODUCTION

In emergency hospital services, nurses' work is considered, often by the nurses themselves and other health professionals, as restricted to the implementation of assistential activities and procedures to support the diagnosis and medical interventions. However, studies have punctuated that the scope of activities performed by these professionals, covers in addition to assistance activities, a series of actions related to management of care through the coordination of care process, management of material resources, management of the nursing staff and articulation of actions of health professionals^(1,2).

Historically, care for and manage are the main dimensions of nursing work, however, they are characterized as poorly articulated processes. Currently, there is the existence of an emerging paradigm, which refers to management focused on nursing care, from a perspective that articulates the management and care, with the centrality of health service users and care in an approach that goes beyond the technicalities toward comprehensive care⁽³⁾.

In this sense, the term care management refers to the articulation between the management and care dimensions of the work of nurses, so that management can be considered a support activity that creates and implements appropriate conditions for the target activity: care^(4-5). The nurse manages the care while he plans it, while he delegates it or do it, when he predicts and provides resources, empowers his team, educates the user, interacts with other professionals, occupies spaces of articulation and negotiation between people that make up the nursing staff and health on behalf of the procurement and implementation of improvements in care^(6;7).

Depending on the scenario of professional practice of the nurse, the management of care can take on different characteristics. In hospital emergency services, nurses work in the attendance of serious situations that require fast and accurate interventions, pressed by the time in view of the high demand for labor and often with limited resources to support or guide the diagnosis and care of patients. To manage care given these peculiarities, nurses need to develop skills and abilities for the sake of boosting patient care and provision of safe and qualified care, which requires overcoming difficulties as, for example, overcrowding and lack of beds to accommodate patients^(2;8).

Despite the structural changes in the organizational model of the Brazilian health system and the formulation of specific policies aimed at the organization of care in a regionalized, hierarchical and regulated way, the emergency services are still the place to which converge the unsolved and undiagnosed problems in other levels of care. For most of the population, hospital emergencies are the main alternative for access, as the common sense prevails that these services have a pool of resources that make them more resolute, such as: visits, medicines, nursing procedures, laboratory exams and hospitalization^(8-9).

As a result, the hospital emergency services receive patients who arrive by their own means, by the mobile pre-hospital care, as well as outpatient referrals by the hospital itself and basic health units. The significant number of care provided by the health team results in permanent overcrowding, especially of patients with non-urgent needs, from the biomedical point of view^(8,9).

Starting from the picture above, the interest in developing this study, focusing on the concepts of care management in an emergency department in order to contribute to the work of nurses, from the understanding of the perspectives that guide the actions, decision-making, relationships, the characteristic challenges and peculiarities of the practice of these professionals. To this end, we delimited the following question: what are the concepts that guide the work of nurses in care management in the context of a hospital emergency service?

Thus, the objective of this study was to analyze the conceptions of nurses in a hospital emergency service about care management.

METHODOLOGICAL PATH

This is an exploratory descriptive study with qualitative approach.The research scenario was an emergency department of a university hospital located in southern Brazil, which is characterized by 24 hours patient care in clinical specialties, surgery, gynecology (up to 20 weeks of gestation) and pediatrics, mainly originating from the county seat and the metropolitan area. It has five service areas: Home to Risk Rating, Short Stay Room, Observation Room 1 and 2, Vascular Unit and Semi-intensive and Pediatric Unit, which account for a capacity to care for 78 patients between beds, stretchers and chairs. The professional staff of nursing that works in the emergency department consists of a head nurse, 32 nurses and 101 nursing technicians.

Data were collected between June and September 2009, using the technique of semi-structured interviews with 20 nurses that had as a guiding question: what is for you the nursing care management in an emergency? The selection of these participants was intentional among those nurses who agreed to participate and worked for more than six months in the emergency department. The definition of this period of time was based on the criterion that six months is enough time for the professional to get adapted to the routines of the sector and the work team, and may thus contribute in a more effective way to the investigation.

The interviews were recorded on an audio electronic device, comprising between 10 and 50 min., and later transcribed. The number of interviews was set based on the criterion of data saturation, ie, when the information obtained began to repeat itself, enabling the identification of convergences between the evidence and the establishment of a linkage between them.

For the analysis of the empirical material, we used the technique of content analysis, of the type thematic analysis, which consists of three steps: pre-analysis, material exploration and processing of obtained data, inference and interpretation⁽¹⁰⁾. The pre-analysis included the organization of the material collected and systematization of the main ideas by means of floating reading, identifying the main ideas and relevant issues based on the criteria of completeness, representativeness, consistency and relevance. That done, we proceeded to the exploration of the material in order to highlight the log units, transform raw data into core understanding of the text and build the empirical categories responsible for the specification of the themes. In the final phase, we proceeded with the treatment of results and interpretation from the relationship between the structured empirical material and theoretical framework, emerging categories and subcategories.

The project was approved by the Ethics Committee of Hospital de Clínicas de Porto Alegre under number 09-151, and the study participants signed an informed consent, as recommended by Resolution CNS 196/96. The interviews were coded by acronyms composed the letter E, associated to numbers assigned in the order in which they were made (E1, E2,..., E20).

RESULTS

The results presented in this article formed the category “conceptions about nurses in emergency care management", which was subdivided into three subcategories: management as an organization and optimization of work in emergency; management as an instrument for the best practices of care; and management of the nursing staff.

Management as an organization and optimization of the work in emergency

In the context in which the study was developed, the process of managerial work of nursing is organized into positions and hierarchical levels. The heads of nursing of the emergency service establish the guidance for the work of nursing assistants, which, in turn, are responsible for operationalization of management, implementing and ensuring compliance with rules and routines. However, nurses do not restrict their practice to the completion and fulfillment of what is prescribed and seeks to create new ways of acting to perform the care.

Thus, nurses perceive that the care management involves the organization of work and development of intervention strategies aiming at solving the problems that arise due to overcrowding and the constant demand for care that characterize the daily work in an emergency.

Management is to develop interventions in order to solve the problems in emergency [...]. (E6)

It is the dynamic organization of the work through actions that enable improving care, adapting, optimizing the work under the conditions that we have, because it's no use to complain [...]. (E12)

The efforts of the nurses in order to solve problems and enhance the work according to the conditions of existing service in the emergency department allows us to infer the effort and commitment of these professionals to perform a management that enables the improvement of nursing care, without envisioning conflicting situations as impediments to work. To achieve this goal the nurses used as a strategy to establish service priorities.

[...] We have to prioritize the problems of those who really are an emergency [...]. (E6)

[...] Amid this turmoil, of so many people, you can organize this service prioritizing those who mostly need it. (E16)

In addition to establishing service priorities, the nurses also try to speed up assistance actions that can be performed more quickly, recognizing that this is a managerial assignment that they bear in the context of work organization in the emergency department.

Everything we can do for the things to go faster is a management favoring the patient. As it is overcrowded, and there are always people who have to enter, you have to speed up everything you can, especially the procedures. (E17)

In this sense, some nurses believe that the care management encompasses the execution of actions aimed at the proper functioning of the unit, which requires a vision and action on the "whole" of the emergency, I mean, both the assistance and the organization of the unit in general.

The nursing management covers everything; you have to get the whole covered, which is both the care and the service organization. (E4)

[...] We must have a vision of the whole, with a general objective all the assistance to the population that you're assisting. (E6)

Management of the sector in itself for anything [...]. (E18)

Management as a tool for the best practices of care

To the extent that nurses associate management to the organization and optimization of work in an emergency, we perceived a second design that points to the understanding of the close relationship between care and management in nursing, so that management becomes a important instrument for the achievement of better care practices and a more qualified and humanized assistance in emergency.

The management is that assistance that should be made before every situation. You give all the assistance, encompassing all the care to the patient. (E5).

[...] it is humanized care as much as possible and with quality [...]. (E13)

[...] it is mostly the care management; to see if the patient is being well served, if care is being provided correctly, if we have the medication [...]. (E18)

The management performed by nurses is focused on meeting the needs of patients and quality of nursing care provided in the unit. The close relationship that nurses build between management and assistance was very well illustrated in the following quote, in which they appear as two complementary actions that can be performed concurrently:

[...] I manage along with the activities I'm doing. When I go around, I organize everything rearranging what is out of place, seeing what we have to do with another patient; as I call and warn the technician to do things, warning that there are patients to go up for examination. I don't stop to think and manage things; I don't separate what is management from what assistance is. (E19)

Management of the nursing team

In the hospital context, one of the main activities performed by nurses is concerned with coordinating the work of nursing staff. Thus, some nurses when expressing their views on care management, focused the management of the nursing team, which involves the distribution/delegation of activities and management of interpersonal relationships and conflicts inherent to work in health and nursing.

[...] it is managing the team, interpersonal relationships, conflicts that arise in everyday life [...]. (E2)

[...] Nursing works with people, [...] then you have to know how to work with these people; knowing how to manage these people in a friendly way is the key point of nursing. (E7)

It is to delegate and distribute tasks among nursing technicians, working in partnership with them (E19).

The nurses feel responsible for the management of interpersonal relations, seeking to establish a cooperative relationship with and among the nursing staff. In this sense, the construction and maintenance of good relations with co-workers were considered key strategies for the management of care in the emergency department.

[...] keeping a good relationship with your working group is essential for the management of any sector, because eventually, or better, frequently you will need help. [...] And the group involves not only technicians, but it also involves the medical staff, the secretaries, the issues of bed you have to talk to the secretary, [...] it includes the collector, hygiene personnel, because when the emergency box is a mess, I need him to clean it, so if I don't talk to people nicely they will not work well with me, they will not work the way I want them to work [...].(E1)

[...] having a good relationship with colleagues, because what you know you pass on, they know they'll pass on to you, if not you will not survive. Union is everything. If you don't join them, you cannot work. (E14)

Although they highlight the importance of a collaborative and interactive work, nurses revealed the ambiguity embedded in the word manage: treat them with respect, seek partnership and at the same time demand work, after all they are nurses and occupy a higher rank, as it is explicit in following statement:

You know that you'll have to demand work and this is something that has to be clear! I may really like the guy, sitting down to make yerba mate, and even have a more intimate relationship, but when necessary [emphasis], I am a nurse and he is the technician, and if I want to charge, demand, question, this has to be clear and has nothing to do with personal relationships. (E1)

DISCUSSION

After analysis of the conceptions of nurses, it was found that the management of emergency care is a dynamic process in which the nurse coordinates the management and care in his professional practice for the realization of better care practices through the organization and optimization of the assistance process and management of nursing staff in the emergency service.

In the daily work of nurses in the emergency service, they do not reserve a specific period of their working shift for the development of management activities. They are carried out simultaneously or intercalated with care activities, as nurses identify demands that require their intervention, through a dynamic and interactive process with the nursing staff. The idea that management is an integral part of care and an instrument that favors the production of care corroborates the findings of an earlier study that investigates the performance of nurses in the management of care in the hospital context⁽⁴⁾. Care as the focus of nursing management is also one of the findings of a study on managerial work developed by nurses from the emergency room of Curitiba⁽¹¹⁾.

The routine of the work of nurses, marked by excess demand for care, means that they are always choosing priorities as a strategy to cope with daily demands and deliver the care that patients need. Setting priorities is important in light of the turbulent context that characterizes the work in emergency, which can help nurses to fulfill their daily tasks and prepare themselves for the surprises that may happen, that are unpredictable⁽¹²⁾.

By mentioning that they seek to speed up those assistance actions that can be performed faster, nurses show concern and commitment to care management and patient recovery. A similar result was reported in a study in which nurses stand out by the search for solutions to problems that arise in everyday work in an emergency, knowing that if they do not take an action or provide that someone does it, patient care may be impaired⁽¹²⁾.

The views of nurses that nursing management in the emergency service includes the administration of the sector for anything and everything points to the performance of these professionals as articulators of actions involving the organization of work and, consequently, the production of health care and nursing. The vision of the "whole" is often used to characterize the work of nurses. It is a skill that has been historically constructed and encouraged, because the spaces and practices of nurses in the organization of health care work and nursing have as objectives to ensure the functioning of the institutions and to follow up medical instructions, as well as meet the needs of patients⁽¹³⁾.

Health work in the hospital, is a collective process undertaken by different professional categories that encapsulate their knowledge and practices in order to meet the needs of patients/users, and while the nurse is present most of the time in everyday health services, we may consider that it is precisely his role to articulate and integrate the parts of the "whole" that comprise and influence the production of care. From the perspective of the rational model of management, still strongly present in the practice of nursing management, the vision about the "whole" can take on the character of direction and control over the efforts made in all areas and levels of an organization or health service. However, efforts to understand the management from a historical and social view point to the visualization of the "whole" as a form of coordination and integration between agents and their practices in the organization of work processes in health.

The managerial work of the nurse cannot be moved from personal relationships, for health work, including therein the managerial activities, is essentially a subjective and relational process, based on partnerships between different professionals working towards the same goal. From this perspective, contrary to what was mentioned by one of the nurses interviewed, the decision making process is hampered by the notion that interpersonal relations cannot overcome the barriers of domination, subordination and formality conferred by the hierarchical level of each worker.

The care management goes beyond the reductionist administrative actions and focuses on mobilizing people as subjects of relationships, interactions and associations of the complex system of care in their nursing teams and health in general. The skills or management skills are increasingly related to the management of people, teams, which requires from the nurse the constant exercise to relate and build bridges of integration with credibility and respect, aiming at a team work that enables higher functional and relational performance⁽⁴⁾.

FINAL CONSIDERATIONS

This study showed three concepts of care management among nurses in a hospital emergency service: management as an organization and optimization of work in emergency; management as a tool for better care practices; and management of the nursing team. These conceptions express the complementarity between the management and care dimensions of nursing work, which enhances the performance of this professional and enables the smooth progress of work on the unit, as well as setting priorities for care and the development of strategies to overcome difficulties present in the daily work in the emergency service.

The statement of the nurses that care management encompasses the vision and action on the "whole" of the emergency is noteworthy because it shows the extent and specificity on which rests the practice of nursing, which includes, besides the management of the care process, the organization of work in the unit in general. Management, from a historical-social perspective, enables you to view the materialization of the "whole" cited by the nurses from the coordination and integration between agents and their practices in work organization in health and nursing. Nurses recognize their responsibility in the joint between the actions of professionals and coordination of the nursing staff, which reinforces the notion that care management focuses on people as mobilizing subjects of relationships, interactions and associations of the complex system of care in their nursing staff and health.

These results may help with the work of nurses in emergency, enabling them to discuss and reflect on their practices and advance in the understanding of care management as a tool for improving care and the practices of health care in hospital emergency services.

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Contribution of authors: Bibliographical research and collection of research data: José Luís Guedes dos Santos; Conception and design of the article: everybody; Analysis and interpretation of results: everybody; Writing of the article: everybody; and, Critical review and final approval of the article: Maria Alice Dias da Silva Lima and Alacoque Lorenzini Erdmann.

Received: 08/23/2011

Approved: 02/29/2012