Apprehensions of nurse managers on evidence-based practice^a

Inquietudes de enfermeros gerentes sobre la práctica basada en evidencias

Abstract

Objective:

To analyze the apprehensions of nurse managers in the implementation of the Evidence Based Practice in a Teaching Hospital of Triângulo Mineiro.

Method:

Qualitative research guided by the Theory of the Diffusion of Innovations. Five workshops were conducted per focal group (n = 18 participants), conducted by hermeneutic-dialectic interactions between August and September/2016. Textual records resulting from each workshop were analyzed by semantic categories.

Results:

Aspects conditioning to the implementation of the Evidence Based Practice permeate from elements related to the fragmentation of the care network to the necessary expansion of the governability of the nurse managers to put changes into practice in their sectors. Most importantly, timely access to the results of research conducted at the teaching hospital was mentioned as crucial to guide better practices.

Final considerations:

The approach allowed the recognition of contextual conditions for the implementation of the Evidence-Based Practice, which may coincide with similar scenarios, as well as increase the national scientific production on the subject, which is still scarce.

Keywords:
Evidence-based Nursing; Leadership; Diffusion of Innovations; Teaching Hospitals

Resumen

Objetivo:

Analizar las inquietudes de enfermeros gerentes sobre la implementación de la Práctica Basada en Evidencias en Hospitales de Enseñanza del Triángulo Minero.

Método:

Investigación cualitativa orientada por la Teoría de la Difusión de Innovaciones. Se realizaron cinco talleres por grupo focal (n = 18 participantes), conducidos por interacciones hermenéutico-dialécticas, entre agosto y septiembre/2016. Los registros textuales resultantes de cada taller fueron analizados por categorías semánticas.

Resultados:

Los aspectos condicionantes para implementar la Práctica Basada en Evidencias permearon desde los elementos relacionados a la fragmentación de la red asistencial hasta la necesidad de ampliar la gobernabilidad de los enfermeros gerentes para que realicen cambios en sus sectores. Mayoritariamente, el acceso oportuno a los resultados de las investigaciones realizadas en el hospital de enseñanza fue mencionado como crucial en la orientación de prácticas más calificadas.

Consideraciones finales:

El abordaje permitió reconocer condiciones contextualizadas para implementar las Práctica Basada en Evidencias, en escenarios similares; y también, incrementar la producción científica nacional, aún escasa, sobre el tema.

Palabras-clave:
Enfermería basada en evidencias; Liderazgo; Difusión de Innovaciones; Hospitales de enseñanza

Resumo

Objetivo:

Analisar apreensões de enfermeiros gerentes frente a implementação da Prática Baseada em Evidências em Hospital de Ensino do Triângulo Mineiro.

Método:

Pesquisa qualitativa orientada pela Teoria da Difusão de Inovações. Foram realizadas cinco oficinas por grupo focal (n = 18 participantes), conduzidas por interações hermenêutico-dialéticas, entre agosto e setembro/2016. Registros textuais resultantes de cada oficina foram analisados por categorias semânticas.

Resultados:

Aspectos condicionantes à implementação da Prática Baseada em Evidências permearem desde elementos relacionados à fragmentação da rede assistencial até a necessária ampliação da governabilidade dos enfermeiros gerentes para efetuarem mudanças nos seus setores. Majoritariamente, o acesso oportuno aos resultados das pesquisas realizadas no hospital de ensino foi mencionado como crucial para orientação de práticas mais qualificadas.

Considerações Finais:

A abordagem permitiu reconhecer condições contextualizadas para a implementação da Prática Baseada em Evidências, que podem ser coincidentes a cenários similares. Como, também, incrementar a produção científica nacional sobre o tema, ainda escassa.

Palavras-chave:
Enfermagem baseada em evidências; Liderança; Difusão de Inovações; Hospitais de ensino

INTRODUCTION

The Evidence-Based Practice (EBP) in Nursing supports clinical and managerial decision-making regarding the application of knowledge resulting from safe research to guide action in everyday practice. Integrating scientific evidence of quality into nurses' practice, associating it with the professional expertise and preferences of individuals, families and communities assisted by health services; however, it is still a complex issue for contemporary Nursing.^1-4

Although this concept has been discussed for more than two decades by the Nursing Associations of the Anglo-Saxon countries - such as the American Nursing Association and the American Association Nursing College - this perspective is still incipient with regard to nurses from Latin American countries and the Caribbean.¹ The experiences for the implementation of EBP and the publications that address this issue in Brazil are scarce.⁵ However, the implementation of EBP in Nursing presents itself as a worldwide challenge, because it faces some dilemmas related to the nature of research and to the support of the health institutions, besides the competence of the nurses to act with this practice.^1-3

The competencies for EBP among hospital nurses have been discussed by renowned authors in theme 3. The aspects under discussion include: identifying practical problems of nursing; formulating research questions; performing the systematic search for evidence, anchored by results of quality research; involving the stakeholders (among the nursing team and other professionals who can contribute to the critique and implementation of the intervention proposal in the care setting, leadership of the institution, other groups that may benefit from the care change); integrating the evidence with the nurse's expertise and the preferences of the people assisted, so that the best clinical decision is adopted; assessing the impact of the intervention and disseminating its findings to the people assisted and policymakers.^3,4 The incorporation of evidence into the internal protocols with the purpose of generating the best practices in the hospital environment, and the support to other working groups in the conduction of EBP can also be included.³

As they are typical institution, where partnerships for teaching-service integration are traditionally celebrated, the Hospitais Públicos de Ensino (HPE - Public Teaching Hospitals) have, as part of their mission, the development of the teaching-research binomial to achieve qualified training and assistance. HPEs support the university vocation as a scenario with a differentiated potential for the quality of care, in order to facilitate the reconciliation of nursing practice, teaching, research and technological development.^6,7 The engagement of Nursing coordination, as indicated by contemporary scientific productions, presents as a crucial strategy to make the hospital context favorable to EBP. This is due to the fact that the Nursing leaders present themselves capable of encouraging and supporting the assistance teams in the change of practices - an organizational change, therefore,^8,9 provides the undertaking of strategies that increase the cooperation and engagement of the workers as important elements for the implementation of EBP - in particular to avoid discontinuance of this practice in the organization.^1,8,9

In this perspective, the Rogers Innovations Diffusion theory¹⁰ has been undertaken to achieve leadership engagement and induction of hospital organizational culture in favor of EBP implementation among nurses. International models that guide the implantation of EBP in the hospital scope also adopted Rogers' conception. It is worth noting that the Ottawa Model of Research Use (OMRU) model addressed the question of the EBP that would occur in the face of adopting a referential capable of influencing innovation adepts.¹¹ The Iowa model was the first to point out the need for hospital institutions if they were to support the adoption of EBP among nurses. This model adopted Rogers' theory as a reference for mobilizing the EBP organization assertively.¹² Experience with model implementation, The Clinical Scholar, also used the Theory of Diffusion of Innovations.¹³

According to Rogers's theory,¹⁰ the diffusion of innovation would depend on the basic elements: innovation itself, communication of this innovation, the channels and time. It points out that the perceived novelty of ideas would be the facilitator of the process, not just the objective novelty, and the engagement of people who encourage others to adopt innovation is crucial to this process. In general, the Rogers Theory presents four phases for the diffusion and incorporation of an innovation. They are: phase 1, which corresponds to the knowledge phase, aiming at understanding the variables of the social system regarding the need for change and incorporation of innovations; phase 2, of persuasion, concerns the relative advantages brought about by change and the adoption of innovation; phase 3, of the decision, when considering the adoption or rejection of the proposed change and the incorporation of innovations; and phase 4, of confirmation, regarding the diffusion of the results obtained and the reordering of the system for change and incorporation of the innovations.^4,10

One of the characteristics of Rogers's theory¹⁰ was to explain, in a Gaussian curve, how people adhere to innovation. Overall, the innovators accounted for 2.5% of the quota - by this model they were termed "out of the box thinkers" - capable of recognizing the potential for innovation precociously. In a sequence, the opinion leaders, composed of 13.5%, were presented as people who would encourage others to adopt the innovation (stakeholders). 34% of the contingents were considered as people who follow the guidelines of opinion leaders. Therefore, the curve comprised a late majority (also 34%). And finally, a contingent of 16% of people showed behavior linked to a traditional action, presenting greater difficulties for the adoption of changes. Eventually, the last contingent would adopt the innovation, but only if it had visible practical results.

Above all, in the EBP proposition in hospital institutions, many efforts could fail when focusing on the late majority of the contingent of workers, or on that portion of people who would be more resistant to change. From this perspective, the following question emerges: How do the encouragers of the adoption of innovation, in this case, hospital nurses, seize the EBP? In this way, the present research aims to analyze the apprehensions of nurse managers facing the implementation of EBP in a HPE of the Triângulo Mineiro.

METHOD

This is a qualitative approach research. Qualitative research, usually, shows interest in accessing experiences and interactions; with this, it seeks to express particularities. Researchers, themselves, have been considered an important part of the development process of the qualitative research. Their own personal presence as researchers and the immersion in the analyzed scenario, the experiences in the field and their capacity for reflection influence the production of qualitative research data.¹⁴

Five focus group workshops were held in the period from August 09, 2016 to September 16, 2016, each workshop lasting 120 minutes. The study scenario was a large general public and teaching hospital (332 beds) - a macro-regional reference of high complexity in the Triângulo Sul de Minas Gerais pole.¹ The results presented refer to a detail of phase 1 of the Rogers' theory: the phase of knowledge.⁹ An intentional sample, consisting of all the nurses managers of the Unidades de Internação do Hospital Público de Ensino (UI-HPE - Inpatient Units of the Public Teaching Hospital) (n = 18), was composed, excluding those on vacation or leave. A questionnaire was applied for socio-demographic characterization of the participants (elaborated by the authors), and the details of this intervention are presented in recent publications.^1,4

The socio-demographic characterization of the workshop participants was: mean age 35.1 years (SD = ± 2.7 years), majority of women (95%) in a stable union (85%) who declared themselves as white-skinned (60%). On average, they finished Nursing Graduation 11.1 years ago (SD = ± 3.9 years),⁴ worked as nurses for 10.5 years (SD = ± 3.8 years) and worked in HPE for 9.5 years (SD = ± 4 years).¹ All of them had a lato sensu postgraduate course, six of them with completed masters1. As for participation in the workshops, the average was 16.2 participants per workshop (SD = ± 2.7).^1,4

The collective constructions of the UI-HPE nurse managers regarding the interactions of the researcher were the aspects that allowed the production of the data, so that the focal group consisted of the main apparatus for generating the data to be analyzed. It was observed that the actions of intervening and producing the research data were in harmony with each other. The analysis considered a hermeneutic-dialectical approach. The data production reflected the interactions and understanding in terms of how the phenomenon occurred in the context, pointing to further development of dimensions by the characterization of the specificity of the case.^14-16

Above all, the production of data through the hermeneutic-dialectical conception has valued the power of reflection of the research participants.^14-16 Under the aegis of this perspective, the hypothesis of an eternal reconstruction was worked out, due to the interaction of the subjects with the world and the subjects with each other. This means that, although context-bound and committed, the research participants - IU-HPE nurse managers - would be able to cope with relative autonomy for change. Infinite and open possibilities have been potentially generated by all discursive practices, which have had hermeneutic-dialectical composition for the production of research data. Moreover, through communicative interactions, it has been possible to conduct a subtle process of dissemination for change.^14-16

Workshops have been theoretical-methodological strategies used in different contexts, along with various populations, for reflections on different themes in Nursing; therefore, they are a modality of shared learning, guided by hermeneutic-dialectical interventions.^1,17 The concept of focal group considered was the exercise of focusing on a specific theme and seeking the conduction of discursive propositions against the intersubjective value elaborated by a specific group of people.^1,18

The workshops were attended by two observers who registered, verbatim, their operationalization. The analysis of the records took place at the end of each workshop, by joint reading among the observers. At the end of each workshop, a single textual record was drawn up with the intention of portraying the apprehension of the group as a whole, not just the isolated speech of the participants. The elaborated textual record followed the structure of content analysis proposed by Minayo,^15,16 seeking to identify, in addition to the semantic structures, the interactions they presented with the context of the sociological structures of message production. In that sense, the transcripts of the textual records of the seizures of the focal group were transcribed in their entirety. It was also analyzed, through the propositions of each workshop, the way the group of nurse managers UI-HPE seized the EBP - to be diffused among the nurses of this hospital.

Regarding the ethical aspect, resolution CNS 466/2012 (12) was respected, and this research was approved by the Research Ethics Committee of the Federal University of Triângulo Mineiro, in 2016, under opinion no.1.1618.872. Data were collected after signing the Informed Consent Term by the participants.

RESULTS

The teaching hospital has 18 nursing heads for inpatient care units. The UI-HPE nurse managers were characterized by being stable workers in the institution, who received additional salary for the exercise of this function. The choice of the manager of the hospitalization unit was presented by a vertical definition in this institution - deliberated by the HPE superintendency.

Speeches by the focus group exceeded expressions of conformity with the contextual situation or even expressions of apparent cordiality or agreement with the group task for fear of potential retaliation. These characteristics were understood as positive and as desired reach factors in the mediation of group operation. First of all, the focus group participants were HPE workers with a historical relationship building. Because they belonged to the same professional category and at the same level in the hierarchy of the hospital, they experienced common dilemmas and corresponding experiences. Besides, they were not unknown to each other, and these aspects facilitated group integration.

During the first workshop, the seized content could be referred to as "fragmentation of the SUS care network, limitation of financial resources and the improvised act of the nurse", with "fragmentation of the SUS health care network" and "financial resource limitation" as inhibitors of the effective EBP, while "the improvised act of the nurse" was perceived as the intermediary of an innovation, or even, the discovery of a new technique (Table 1).

Table 1
Description of the group apprehension from the 1^st workshop (excerpts from the register). Uberaba, Minas Gerais, 2017.

1st workshop: “Fragmentation of the SUS health care network, limitation of financial resources and the improvised act of the nurse”

Nurse managers reported that HPE, as known by all participants in the focus group, was responding to a healthcare demand that extrapolated actions agreed by SUS (macro-regional). The patients originated from uncontracted locations, which entailed the absence of adequate financial transfers. The fragmentation of the care network and the reputation of HPE also emerged in this dynamic. Participants reported that a disorderly, non-exclusive and highly complex demand was met at this institution – at the Hospital Emergency Room, as there was a belief in the population that their health problems would only really be solved at this hospital. These situations were reflected, in particular, in the limitation of inputs. Improvisation, faced with limitations related to some materials, was considered as a recurring act in the nurse's action - interventions that did not violate the patient's integrity and safety. However, the focus group participants questioned, in light of PBE concepts, whether improvisation could not be related to the discovery of a new technique. In general, they conceived that the use of evidence to guide care had a positive value, especially when considering the need to legitimize the nurses' performance.

In the second workshop emerged the apprehension "improvement of knowledge and practices: an isolated action". According to the discussions, EBP's technical-scientific improvement would be an individual search initiative for each nurse, outside the hospital. In the HPE setting, nurse managers actively participated in a variety of academic activities. However, they did not conceive of these daily activities originated by the teaching-service integration as capable of delivering the improvement of competences and extension of knowledge to the EBP. They also evidenced the need to send systematic reports to UI-HPEs that consolidate the daily records related to care, and this initiative is considered by the focus group as an important starting point for the planning of EBP care and implementation (Table 2).

Table 2
Description of the group apprehension from the 2^nd workshop (excerpts from the register). Uberaba, Minas Gerais, 2017.

2nd workshop: “Enhancement of knowledge and practices: an isolated action”

Regarding knowledge not favorable to EBP, the focus group identified that the act of accommodating to the routines imposed and based exclusively on the knowledge acquired during their graduation, put the professional in a position of "discrepancy" of knowledge. In this regard, they discussed the need for nursing to be a profession that depends on constant updates. They argued that, individually, it would be necessary for nurses to search for updates (in particular, specialization courses were mentioned). Through the group discussion, the practice of improving knowledge should be an action of individual search of each nurse. The hospital institution was not responsible for this practice, although it was linked to a university. At no time was the presence of the students (technical, undergraduate or graduate level) mentioned as an inductive action to increase nurses' knowledge. The focus group understood "the questioning and the opening to the new" as essential positions for the implementation of the EBP. They emphasized that a practice could only be modified against the agreement of the patient assisted and if the nurse presented technical ability to perform the new practice. They pointed out that the monitoring and evaluation of their practices, such as epidemiological analyzes and the systematic reporting of these results would be an important starting point for planning the improvement of care.

Faced with the apprehensions of the third workshop, "hierarchies, management verticality and uncertainties in the nurse manager's role" were conceived as the main barriers to the implementation of EBP. The vertical transmissibility of activities such as ordinal management practice in HPE and the overlap of tasks attributed to the nurse manager were denoted as situations that caused work overload and distance from the performance of this category in relation to care planning. In general, the group presented the desire to be more present and close to the care provided in the hospitalization units. However, they expressed the excess of records and forms to be filled and the need to constantly deliberate activities related to property maintenance and equipment (Table 3).

Table 3
Description of the group apprehension from the 3^rd workshop (excerpts from the register). Uberaba, Minas Gerais, 2017.

3rd workshop: “Hierarchies, Management verticality and uncertainties in the nurse managers' role”

The overload of work and overlap of tasks to the nurse unit manager were denoted as main barriers to the implementation of the EBP. The focus group presented the experience of a day-to-day afflicted by the volume of attributions imposed on them by the hospital institution. They pointed to an excess of records for which they are responsible and a high volume of administrative meetings in which they must be present. As they act in the dialogue of the decisions of the top management with the assistance teams, the activation of their presence in administrative meetings was not an action usually scheduled. Another aspect mentioned were the administrative demands of the hospital. They stated that any events that took place in the hospitalization unit (including building and equipment maintenance) required their intervention, which eventually generated overload. They pointed to the restructuring that the hospital underwent, as opposed to management by care lines and participatory management units, as a positive alternative to reduce the overload of their activities. Importantly, the focus group participants reported interest in having more time together with nursing care teams for more appropriate bedside planning. Some focal group participants mentioned that nursing teams have little understanding in terms of the role of the unit nurse manager.

Concerning the fourth workshop, the focus group apprehensions concerned "local governance for change, institutional and academic support claim". Most of the alternatives presented by the group for the induction of EBP could be initiated by small modifications in the organization of their work processes. However, they emphasized the need for high hospital management to recognize the dilemmas they experienced in their daily lives, and to induce the University to develop more proactive research projects to solve their daily demands (Table 4).

Table 4
Description of the group apprehension from the 4^th and 5^th workshops (excerpts from the register). Uberaba, Minas Gerais, 2017.

4th workshops: “Local Governance for Change, Requests for Institutional and Academic Support”
In the collective discussions, the focus group presented as an understanding that, in order to reach the performance based on EBP, actions that involve their own governance could be implemented. In general, the interventions identified by the focus group for the implementation of EBP mostly included changes in the organization of the work routine that were available to them, such as: discussing the issue with colleagues in the sector, including other categories; implanting a routine of discussion of cases with the nursing team; reading articles weekly with themes similar to the problems experienced in the daily life; raising basic doubts about the routine. The initiatives identified as dependent on greater organizational deliberation were: greater availability of computers with internet access in the hospitalization units; safeguarding workload for study group; adjusting the institution's work guidelines to support EBP.
5th workshops: “Research development: disarticulation and non-appropriation by the group”
The greatest manifestation of the focus group was the lack of knowledge regarding the research developed in HPE. In general, the group stated that it felt pressured to authorize the carrying out of research in its units of responsibility, because it was an HPE. However, at the same time, this action generated discomfort, as they felt responsible for the maintenance of the integrity of the nursing team and the patients assisted. They commented on the rare exceptions of professors/researchers from different areas of the university who sought them out to discuss a research proposal and to analyze the feasibility of their development in the sector. Often, they mentioned, they felt like "objects", and this feeling was reflected in the entire nursing team of the corresponding hospitalization unit, because students at different levels of training sought them out to answer questionnaires (most of the time, very extensive), but they never returned to present the results. In general, they felt that the academy (in this case, the university) had an unequal power relation over them. In addition, they mentioned that, if they had timely access to results, they would seek strategies to improve practices.

The result of the fifth workshop was "Research development: disarticulation and non-appropriation by the group". On this occasion, they reported their greatest weaknesses in terms of the knowledge and ability to analyze research (lack of knowledge regarding the methodologies and the analyzes undertaken). The professionals showed little engagement with the researchers who undertook their investigations in HPE, and discussions about the viability of research projects in the units they lead are rare. Moreover, in most cases, the researchers did not share the results achieved by the research developed there (Table 4).

DISCUSSION

Studies that used the workshops as a research tool presented important results in relation to the elaborations seized by the participants.¹⁷ These elaborations were not restricted to a rational reflection, but involved subjects integrally, their ways of thinking, feeling and acting.^2,17,19 Horizontality in the relations undertaken in workshops by focus group has facilitated individual expressions and intergroup communication, as motivating elements for the discussion of content.^17,19 It is worth mentioning that the focus group itself has already been presented as a stimulus technique. It was considered that in nursing teams there are group processes that need to be known by the members themselves, so that, together, they can re-signify their actions, in order to modify realities.^1,17-19 Facing this reality, the enterprise of the oriented workshop strategy by focus group allowed reaching contextualized dimensions in the experiential dynamics of the daily work of the nurse managers studied.

Concerning the apprehensions reached in the first workshop, the underfunding of health and the fragmentation of health care networks have been complex and persistent realities that are required to solve the Sistema Único de Saúde (SUS - Unified Health System) in Brazil.²⁰ The design of the Redes de Atenção à Saúde (RAS - Health Care Networks), as a model for the organization of SUS in the territories, recent in the management of universal access health services, has sought to overcome this fragmentation in the Brazilian context. Through the RAS, active participation of managers is perceived, bringing them closer to health professionals, users and community realities, instituting a culture of sharing and reciprocity.²⁰ However, the realization of the RAS still stands as a challenge to health managers and when issues related to the financing of social security, which integrates the health area in Brazil, are presented as problematic trajectories - especially when the current context of globalized economies is analyzed with significant constraints faced from the 2000s.²¹

Above all, the organizational culture could support or not the development of EBP - as pointed out in the apprehensions of the second workshop. Publications that guide the implementation of EBP indicate primarily that the use of research (development and/or incorporation of the resulting evidence) should be an action inherent in the practice of hospital nurses and, therefore, health organizations should support this practice.^3,10-12 In this way, the hospital organization's support for the implementation of the EBP should be designed as a guideline, which would include the provision of continuous training to nurses or specialized advisory services, so that they would increasingly present improved skills to perform this action in their daily life.^10-12

However, the level of organizational maturation, functionality and decision-making harmony of its structures, availability of resources, decentralized commands, and openness and autonomy to new projects would be areas that facilitate the incorporation of innovations^22,23 such as EBP. The strictly hierarchical hospital organizational practices, in the traditional model of management and production, would lead to individualistic and competitive work relations, fragmenting care. These characteristics of the traditional organizational culture would hinder integration and sharing among the teams, implying the lack of motivation of the workers and reduction of commitment to the quality of care.^22,23

Inpatient units were characterized, above all, as potential places to respond to the needs of the people assisted. However, it has been observed that the management of these units coexists with the absence of planning, difficult coordination of care and administrative processes, communication problems and lack of participatory planning, and also with the lack of systematization of information to measure performance at these websites.²⁴

It is noteworthy, taking into account the results of the third and fourth workshops, that the success of the EBP implementation has been related to the leadership profile undertaken by the nurse manager. As it presented the result of a research developed in a general hospital in the South of Minas Gerais, there are difficulties of the nursing team in understanding the role of the managerial nurse in the hospitalization units. Often, nurses' managerial practice was represented as bureaucratic and preponderantly distanced from care.^25,26 In this way, the need to invest in aspects of nurses' work involving the exercise of transformational leadership based on cooperation, vision inspiring and the committed to share the importance of applying scientific evidence in care.^4,25,26

The investments made in a new administrative work structure, which is based on the availability of resources and the realignment of activities for the use of evidence, were also identified as processes favoring the incorporation of innovations such as EBP.^25,26 In addition, the perceived work overload among nurses has been a barrier to the implementation of the EBP at an international level, which generates the need for the development of guidelines on performance priorities, in order to reduce the overlap of tasks worldwide.²⁶

Although nurses are expected to use scientific evidence, with a view to the evolution of Nursing and health practice, not always the application of research knowledge to guide practice is considered as one of the activities of this professional in the work process. Taking into account the apprehensions of the 5^th workshop, when the EBP is discussed in the space of teaching-service integration, it is important to highlight that health services are instances of caregiving generated by daily encounters between researchers, teachers, students and workers in the health area.^27,28 However, one of the major challenges is to place research and scientific evidence in an inventive way in this space, where daily reproduction and repetition of the established environment prevails.^27,28

In general, innovations, such as EBP, play an important role in organizations, when they indicate the internal opportunities that benefit their development in a sustainable way, and generate benefits or responses that can meet the needs of the specific context.²⁹ Thus, organizational leaders - in the present study, UI-HPE nurse managers - have a crucial role to play in the implementation of new approaches, provided that: they identify unmet contextual needs; be able to manage social relations, especially with regard to governance and participation; and, consequently, disseminate improvements to be obtained in the scenario.^9,29

Above all, the hermeneutic-dialectic intervention carried out in the workshops organized by focus group with the nurses managers of the UI-HPE allowed, in the context of the dissemination of EBP as an innovation in the hospital, an analysis to understand the conditions that permeate the implementation of this practice. Leadership has a role to play in identifying context needs in order to support the resolution of these demands and to broaden cooperation among others to be affected by the implementation of innovation.²⁹

It is important to emphasize that the methodology used prevents generalizations, and that the sample was selected for the convenience of the researchers, in addition to the limitation of the number of participants. However, the participants composed almost the entire interest group of this research, and the interactions of the focus group provided access to contextual meanings, allowing the visibility of aspects that condition the implementation of EBP in HPE, which, through discussion of the results, have the potential to correspond to similar scenarios.

However, in accordance with the disposition for phase 1 of the Rogers Theory, the hermeneutic-dialectic interactions undertaken allowed recognition on the contextual aspects that influence the social system of HPE in relation to the adoption of EBP, according to the perspective of the change animators - nurse managers IU-HPE.

FINAL CONSIDERATIONS

EBP has been presented as a challenge to the performance of hospital nurses worldwide. The engagement of nursing leaders, such as nurses who manage inpatient units, has been discussed as a suitable factor for the implementation and sustainability of this innovative practice. The workshops oriented by focus groups, allowed the unveiling of contextual aspects conditioning the diffusion of EBP among nursing teams. These aspects are related to the macro context of the Unified Health System, such as the fragmentation of attention and underfunding; the hospital management model that is traditionally organized by a rigid hierarchy and verticality regarding decision making; the great responsibility attributed to the work of the nurse managers in the hospitalization units, which often distance them from the care planning; and both the research and the resulting evidence are perceived as an act detached from everyday work.

In general, the hermeneutic-dialectic approach undertaken allowed the recognition of aspects that condition the implementation of EBP in that scenario, and this recognition is an important contribution to the dissemination of EBP as an innovation and its promotion among nurses. The presented results contribute to the development of researches that aim to implement this practice in similar scenarios, as well as to increase the national scientific production on the subject, still scarce.

• a
  Extracted from the doctoral thesis entitled Analysis of the Production of Nursing Research and Strategy to strengthen its Utilization in the Teaching Hospital of Triângulo Mineiro of the Graduate Program in Health Care of the Federal University of Triângulo Mineiro, defended in 2017.

REFERENCES

• ¹
  Camargo FC, Iwamoto HH, Monteiro DAT, Goulart MB, Garcia LAA, Augusto ALDS, et al. Techniques undertaken to disseminate the evidence-based practice among hospital nurses. Rev Min Enferm [Internet]. 2017 Jul; [cited 2017 Jul 22]; 21:e-1003. Available from: http://www.reme.org.br/artigo/detalhes/1139
  » http://www.reme.org.br/artigo/detalhes/1139
• ²
  Bick D, Chang Y. Implementation of evidence into practice: complex, multi-faceted and multi-layered. Rev Esc Enferm USP [Internet]. 2014 Aug; [cited 2017 Mar 16]; 48(4):578-83. Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0080-62342014000400578 DOI: 10.1590/S0080-623420140000400001
  » https://doi.org/10.1590/S0080-623420140000400001» http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0080-62342014000400578
• ³
  Melnyk BM, Gallagher-Ford L, Long LE, Fineout-Overholt E. The establishment of evidence-based practice competencies for practicing registered nurses and advanced practice nurses in real-world clinical settings: proficiencies to improve healthcare quality, reliability, patient outcomes, and costs. Worldviews Evid Based Nurs [Internet]. 2014 Feb; [cited 2017 Mar 16]; 11(1):5-15. Available from: http://onlinelibrary.wiley.com/doi/10.1111/wvn.12021/epdf DOI: 10.1111/wvn.12021
  » https://doi.org/10.1111/wvn.12021» http://onlinelibrary.wiley.com/doi/10.1111/wvn.12021/epdf
• ⁴
  Camargo FC, Iwamoto HH, Monteiro DAT, Lorena LT, Pereira GA. Assessment of an intervention for the diffusion of evidence-based nursing in a teaching hospital. Rev Gaúch Enferm [Internet]. 2016; [cited 2017 Mar 18]; 37(esp):e68962. Available from: http://www.scielo.br/pdf/rgenf/v37nspe/0102-6933-rgenf-1983-14472016esp68962.pdf DOI: http://dx.doi.org/10.1590/1983-1447.2016.esp.68962
  » http://www.scielo.br/pdf/rgenf/v37nspe/0102-6933-rgenf-1983-14472016esp68962.pdf» http://dx.doi.org/10.1590/1983-1447.2016.esp.68962
• ⁵
  Camargo FC, Garcia LAA, Santos AS, Iwamoto HH. Evidence-Based Practice: bibliometric review of national journals in nursing journals. REFACS [Internet]. 2017; [cited 2017 Nov 6]; 5(3):429-39. Available from: http://seer.uftm.edu.br/revistaeletronica/index.php/refacs/article/view/2137 DOI: 10.18554/refacs.v5i3.2137
  » https://doi.org/10.18554/refacs.v5i3.2137» http://seer.uftm.edu.br/revistaeletronica/index.php/refacs/article/view/2137
• ⁶
  Macedo APMC. Nursing Supervision: Studying the "Case" of the phenomenon of interorganizational articulation Nursing School and Hospital. Rev Esc Enferm USP [Internet]. 2014 Dec; [cited 2017 Mar 18]; 48(esp2):190-6. Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0080-62342014000800190 DOI: 10.1590/S0080-623420140000800028
  » https://doi.org/10.1590/S0080-623420140000800028» http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0080-62342014000800190
• ⁷
  Brehmer LCF, Ramos FRS. Teaching-service integration: implications and roles in experiences of Undergraduate Courses in Nursing. Rev Esc Enferm USP [Internet]. 2014; [cited 2017 Mar 18]; 48(1):118-26. Available from: http://www.scielo.br/pdf/reeusp/v48n1/pt_0080-6234-reeusp-48-01-118.pdf DOI: 10.1590/S0080-623420140000100015
  » https://doi.org/10.1590/S0080-623420140000100015» http://www.scielo.br/pdf/reeusp/v48n1/pt_0080-6234-reeusp-48-01-118.pdf
• ⁸
  Galvão MC, Sawada NO. A liderança como estratégia para a implementação da prática baseada em evidências na enfermagem. Rev Gaúcha Enferm [Internet]. 2005 Dec; [cited 2017 Mar 18]; 26(3):293-301. Available from: http://seer.ufrgs.br/index.php/RevistaGauchadeEnfermagem/article/view/4559/2486
  » http://seer.ufrgs.br/index.php/RevistaGauchadeEnfermagem/article/view/4559/2486
• ⁹
  Hauck S, Winsett RP, Kuric J. Leadership facilitation strategies to establish evidence-based practice in an acute care hospital. J Adv Nurs [Internet]. 2013 Mar; [cited 2017 Nov 6]; 69(3):664-74. Available from: https://www.ncbi.nlm.nih.gov/pubmed/22697406 DOI: 10.1111/j.1365-2648.2012.06053
  » https://doi.org/10.1111/j.1365-2648.2012.06053» https://www.ncbi.nlm.nih.gov/pubmed/22697406
• ¹⁰
  Rogers EM. Diffusion of innovations. Nova York: Free Press; 2003. 576 p.
• ¹¹
  Kitson AL, Rycroft-Malone J, Harvey G, McCormack B, Seers K, Titchen A. Evaluating the successful implementation of evidence into practice using the PARiHS framework: theoretical and practical challenges. Implement Sci [Internet]. 2008 Jan; [cited 2017 Mar 18]; 3(1):1. Available from: https://implementationscience.biomedcentral.com/articles/10.1186/1748-5908-3-1 DOI: 10.1186/1748-5908-3-1
  » https://doi.org/10.1186/1748-5908-3-1» https://implementationscience.biomedcentral.com/articles/10.1186/1748-5908-3-1
• ¹²
  Titler MG. Nursing science and evidence-based practice. West J Nurs Res [Internet]. 2011; [cited 2017 Mar 18]; 33(3):291-5. Available from: http://journals.sagepub.com/doi/pdf/10.1177/0193945910388984 DOI: 10.1177/0193945910388984
  » https://doi.org/10.1177/0193945910388984» http://journals.sagepub.com/doi/pdf/10.1177/0193945910388984
• ¹³
  Strout TD, Lancaster K, Schultz AA. Development and implementation of an inductive model for evidence-based practice: A grassroots approach for building evidence-based practice capacity in staff nurses. Nurs Clin North Am [Internet]. 2009 Mar; [cited 2017 Nov 6]; 44(1):93-102. Available from: https://www.ncbi.nlm.nih.gov/pubmed/?term=Development+and+implementation+of+an+inductive+model+for+evidence-based+practice%3A+A+grassroots+approach+for+building+evidence-based+practice+capacity+in+staff+nurses
  » https://www.ncbi.nlm.nih.gov/pubmed/?term=Development+and+implementation+of+an+inductive+model+for+evidence-based+practice%3A+A+grassroots+approach+for+building+evidence-based+practice+capacity+in+staff+nurses
• ¹⁴
  Andrews T. Ontological issues in qualitative research in nursing. Texto Contexto Enferm [Internet]. 2016 Oct; [cited 2017 Mar 18]; 25(3):1-2. Available from: http://www.scielo.br/pdf/tce/v25n3/0104-0707-tce-25-03-editorial.pdf DOI: 10.1590/0104-0707201600453editorial
  » https://doi.org/10.1590/0104-0707201600453editorial» http://www.scielo.br/pdf/tce/v25n3/0104-0707-tce-25-03-editorial.pdf
• ¹⁵
  Minayo MCS. Scientificity, generalization and dissemination of qualitative studies. Ciênc Saúde Coletiva [Internet]. 2017 Jan; [cited 2017 Mar 18]; 22(1):16-7. Available from: http://www.scielo.br/pdf/csc/v22n1/en_1413-8123-csc-22-01-0016.pdf DOI: 10.1590/1413-81232017221.30302016
  » https://doi.org/10.1590/1413-81232017221.30302016» http://www.scielo.br/pdf/csc/v22n1/en_1413-8123-csc-22-01-0016.pdf
• ¹⁶
  Minayo MCS, Gualhano L. Pesquisa qualitativa para pensar e atuar no campo da saúde. Ciênc Saúde Coletiva [Internet]. 2016 Aug; [cited 2017 Mar 18]; 21(8):1. Available from: http://www.scielo.br/scielo.php?script=sci_arttext_pr&pid=S1413-81232016010900001&lng=es&nrm=iso&tlng=pt
  » http://www.scielo.br/scielo.php?script=sci_arttext_pr&pid=S1413-81232016010900001&lng=es&nrm=iso&tlng=pt
• ¹⁷
  Spink MJ, Menegon VM, Medrado B. Using workshops as a research strategy: theoretical and methodological articulations and ethical-political applications. Psicol Soc [Internet]. 2014; [cited 2017 Mar 18]; 26(1):32-43. Available from: http://www.scielo.br/pdf/psoc/v26n1/05.pdf DOI: 10.1590/S0102-71822014000100005
  » https://doi.org/10.1590/S0102-71822014000100005» http://www.scielo.br/pdf/psoc/v26n1/05.pdf
• ¹⁸
  Nóbrega DO, Andrade ERG, Melo ESN. Research with focal group: contributions to the study on social representation. Psicol Soc [Internet]. 2016; [cited 2017 Mar 18]; 28(3):433-41. Available from: http://www.scielo.br/pdf/psoc/v28n3/1807-0310-psoc-28-03-00433.pdf DOI: 10.1590/1807-03102016v28n3p433
  » https://doi.org/10.1590/1807-03102016v28n3p433» http://www.scielo.br/pdf/psoc/v28n3/1807-0310-psoc-28-03-00433.pdf
• ¹⁹
  Lucchese R, Calixto BS, Vera I, Paula NI, Veronesi CL, Fernandes CNS. Group teaching in nursing/teaching group nursing practices guided by the Pichon-Rivière theoretical framework. Esc Anna Nery [Internet]. 2015 Apr/Jun; [cited 2017 Mar 18]; 19(2):212-9. Available from: http://www.scielo.br/pdf/ean/v19n2/1414-8145-ean-19-02-0212.pdf DOI: 10.5935/1414-8145.20150027
  » https://doi.org/10.5935/1414-8145.20150027» http://www.scielo.br/pdf/ean/v19n2/1414-8145-ean-19-02-0212.pdf
• ²⁰
  Lapão LV, Arcêncio RA, Popolin MP, Rodrigues LBB. The role of Primary Healthcare in the coordination of Health Care Networks in Rio de Janeiro, Brazil, and Lisbon region, Portugal. Ciênc Saúde Coletiva [Internet]. 2017 Mar; [cited 2017 Mar 18]; 22(3):713-24. Available from: http://www.scielo.br/pdf/csc/v22n3/en_1413-8123-csc-22-03-0713.pdf DOI: 10.1590/1413-81232017223.33532016
  » https://doi.org/10.1590/1413-81232017223.33532016» http://www.scielo.br/pdf/csc/v22n3/en_1413-8123-csc-22-03-0713.pdf
• ²¹
  Vieira FS. Impact of recent decisions and discussions on the Brazilian Public Health System financing. Saúde Debate [Internet]. 2016 Jun; [cited 2017 Mar 18]; 40(109):187-99. Available from: http://www.scielo.br/pdf/sdeb/v40n109/0103-1104-sdeb-40-109-00187.pdf DOI: 10.1590/0103-1104201610915
  » https://doi.org/10.1590/0103-1104201610915» http://www.scielo.br/pdf/sdeb/v40n109/0103-1104-sdeb-40-109-00187.pdf
• ²²
  Carvalho MC, Rocha FLR, Marziale MHP, Gabriel CS, Bernardes A. Work values and practices which characterize the organizational culture of a public hospital. Texto Contexto Enferm [Internet]. 2013 Jul/Sep; [cited 2017 Mar 18]; 22(3):746-53. Available from: http://www.scielo.br/pdf/tce/v22n3/en_v22n3a22.pdf DOI: 10.1590/S0104-07072013000300022
  » https://doi.org/10.1590/S0104-07072013000300022» http://www.scielo.br/pdf/tce/v22n3/en_v22n3a22.pdf
• ²³
  Rocha FLR, Marziale MHP, Carvalho MC, Cardeal Id SF, Campos MCT. The organizational culture of a Brazilian public hospital. Rev Esc Enferm USP [Internet]. 2014 Apr; [cited 2017 Mar 18]; 48(2):303-9. Available from: http://www.scielo.br/pdf/reeusp/v48n2/0080-6234-reeusp-48-02-308.pdf DOI: 10.1590/S0080-6234201400002000016
  » https://doi.org/10.1590/S0080-6234201400002000016» http://www.scielo.br/pdf/reeusp/v48n2/0080-6234-reeusp-48-02-308.pdf
• ²⁴
  Lorenzetti J, Gelbcke FL, Vandresen L. Management technology for hospital inpatient care units. Texto Contexto Enferm [Internet]. 2016 Jul; [cited 2017 Mar 18]; 25(2):e1770015. Available from: http://www.scielo.br/pdf/tce/v25n2/0104-0707-tce-25-02-1770015.pdf DOI: 10.1590/0104-07072016001770015
  » https://doi.org/10.1590/0104-07072016001770015» http://www.scielo.br/pdf/tce/v25n2/0104-0707-tce-25-02-1770015.pdf
• ²⁵
  Lima RS, Lourenço EB, Rosado SR, Fava SMCL, Sanches RS, Dázio EMR. Representation of nurse's managerial practice in the inpatient unit: nursing staff perspective. Rev Gaúcha Enferm [Internet]. 2016 Mar; [cited 2017 Mar 18]; 37(1):e54422. Available from: http://www.scielo.br/pdf/rgenf/v37n1/0102-6933-rgenf-37-1-1983-144720160154422.pdf DOI: 10.1590/1983-1447.2016.01.54422
  » https://doi.org/10.1590/1983-1447.2016.01.54422» http://www.scielo.br/pdf/rgenf/v37n1/0102-6933-rgenf-37-1-1983-144720160154422.pdf
• ²⁶
  Heydari A, Mazlom SR, Ranjbar H, Scurlock-Evans L. A study of Iranian nurses' and midwives' knowledge, attitudes, and implementation of evidence-based practice: the time for change has arrived. Worldviews Evid Based Nurs [Internet]. 2014 Oct; [cited 2017 Nov 6]; 11(5):325-31. Available from: https://www.ncbi.nlm.nih.gov/pubmed/?term=A+study+of+Iranian+nurses'+and+midwives'+knowledge%2C+attitudes%2C+and+implementation+of+evidence-based+practice%3A+the+time+for+change+has+arrived.+Worldviews+evid.+based+nurs DOI: 10.1111/wvn.12052
  » https://doi.org/10.1111/wvn.12052» https://www.ncbi.nlm.nih.gov/pubmed/?term=A+study+of+Iranian+nurses'+and+midwives'+knowledge%2C+attitudes%2C+and+implementation+of+evidence-based+practice%3A+the+time+for+change+has+arrived.+Worldviews+evid.+based+nurs
• ²⁷
  Lamarra NF. Universidad, sociedad y conocimiento reflexiones para el debate. Avaliação (Campinas) [Internet]. 2014 Nov; [cited 2017 Mar 18]; 19(3):663-87. Available from: http://www.scielo.br/pdf/aval/v19n3/08.pdf DOI: 10.1590/S1414-40772014000300008
  » https://doi.org/10.1590/S1414-40772014000300008» http://www.scielo.br/pdf/aval/v19n3/08.pdf
• ²⁸
  Fortuna CM, Mishima SM, Matumoto S, Pereira MJB, Ogata MN. The research and association between teaching and care in the consolidation of the Brazilian National Health System. Rev Esc Enferm USP. [Internet]. 2011 Dec; [cited 2017 Mar 18]; 45(spe.2):1696-700. Available from: http://www.scielo.br/pdf/reeusp/v45nspe2/10.pdf DOI: 10.1590/S0080-62342011000800010
  » https://doi.org/10.1590/S0080-62342011000800010» http://www.scielo.br/pdf/reeusp/v45nspe2/10.pdf
• ²⁹
  Correia SEN, Oliveira VM, Gomez CRP. Dimensions of social innovation and the roles of organizational actor: the proposition of a framework. Rev Adm Mackenzie [Internet]. 2016 Dec; [cited 2017 Mar 18]; 17(6):102-33. Available from: http://www.scielo.br/pdf/ram/v17n6/1678-6971-ram-17-06-0102.pdf DOI: 10.1590/1678-69712016/administracao.v17n6p102-133
  » https://doi.org/10.1590/1678-69712016/administracao.v17n6p102-133» http://www.scielo.br/pdf/ram/v17n6/1678-6971-ram-17-06-0102.pdf

Publication Dates

• Publication in this collection
  2018

History

• Received
  20 Apr 2017
• Accepted
  30 Sept 2017