Patient care system: bringing health care practice, knowledge and legislation together

Abstracts

OBJETIVOS: Analisar a Sistematização da Assistência de Enfermagem (SAE) utilizada em dois hospitais de grande porte, um público e um privado, sob o olhar do pensamento complexo; Compreender o significado da SAE para os profissionais da equipe multiprofissional da saúde nessas duas instituições. MÉTODOS: Utilizou-se a Teoria Fundamentada nos Dados com entrevista semi-estruturada com 15 participantes. RESULTADOS: O tema Vislumbrando a SAE como Fenômeno interativo e complexo foi identificado como central, pois perpassa os dois fenômenos: Verificando a possibilidade de um cuidado interativo, complementar e multiprofissional e Percebendo a desarticulação entre o saber fazer e o legislar. Discutiremos o segundo fenômeno. CONCLUSÃO: Apesar de ser recomendada pelas teóricas, orientada pelo ensino formal e exigida pela legislação profissional, a implementação da SAE ainda é incipiente, sugerindo-se inová-la à luz do pensamento complexo e da interdisciplinaridade, trazendo novas possibilidades.

Pesquisa em enfermagem; Prática profissional; Planejamento de assistência ao paciente

ORIGINAL ARTICLE

Patient care system: bringing health care practice, knowledge and legislation together^*

Sistematización de la asistencia: aproximando el saber académico, el saber-hacer y el legislar en salud

Magda Santos Koerich^I; Dirce Stein Backes^II; Keyla Cristiane do Nascimento^III; Alacoque Lorenzini Erdmann^IV

^IStudent of the Nursing Graduate Program, Assistant Professor of the Pathology Department at the Health Sciences Center at Federal University of Santa Catarina - UFSC - Florianópolis (SC), Brazil. Member of the NUPEQUIS and GEPADES research groups at UFSC

^IIStudent of the Nursing Graduate Program at the Federal University of Santa Catarina - UFSC - Florianópolis (SC), Brazil; Holder of a scholarship from the "National Counsel of Technological and Scientific Development" (CNPq). Brasília (DF), Brazil. Member of the GEPADES Research Group at UFSC

^IIIStudent of the Nursing Graduate Program at the Federal University of Santa Catarina - UFSC - Florianópolis (SC), Brazil; Holder of a scholarship from the Coordination for the Improvement of Higher Education Personnel (CAPES) Brasília (DF), Brazil. Member of the GEPADES Research Group at UFSC

^IVPhD in Nursing. Full Professor of the Nursing Department at Federal University of Santa Catarina - UFSC - Florianópolis (SC), Brazil; Researcher of the National Counsel of Technological and Scientific Development" (CNPq). Brasília (DF), Brazil. Coordinator of the GEPADES Research Group at UFSC

^{Corresponding Author}

ABSTRACT

OBJECTIVES: To analyze the NAS used in two hospitals based on complexity' thinking, one public and one private; Understanding the meaning of the NAS for the staff of the multi-professional team of health care in both institutions.

METHODS: The methodology was the Data Fundamental Theory with interview of 15 people. As a result of the central theme: Realizing that the Nursing Assistance Systematization as a complex and interactive phenomenon, derived from two different phenomena as follows: Verifying the possibility of the multi-professional, complementary and interactive patient care and Identifying the lack of articulation among health care practice, knowledge and legislation. This article addresses the second phenomenon.

CONCLUSION: The results showed that the implementation of the NAS is still incipient despite its strategies are recommended by theorists, as well as it is addressed in academic disciplines and demanded by professional legislation. It was suggested the use of the thinking complexity and the interdisciplinary for its novelty.

Keywords: Nursing research; Professional practice; Patient care planning.

RESUMEN

OBJETIVOS: Analizar la SAE utilizada en dos hospitales de primer nivel, uno público y otro privado, bajo la óptica del pensamiento complejo; Comprender el significado de la SAE para los profesionales del equipo multiprofesional de la salud en esas dos instituciones. Métodos: Se utilizó la Teoría Fundamentada en los Datos con entrevista semi-estructurada a 15 participantes.

RESULTADOS: El tema Vislumbrando la SAE como Fenómeno Interactivo y Complejo fue identificado como central, pues atraviesa los dos fenómenos: Verificando la posibilidad de un cuidado interactivo, complementario y multiprofesional y Percibiendo la desarticulación entre el saber el hacer y el legislar. Discutiremos el segundo fenómeno.

CONCLUSIÓN: A pesar de ser recomendada por las teóricas, orientada por la enseñanza formal y exigida por la legislación profesional, la implementación de la SAE aun es incipiente, sugiriéndose innovarla a la luz del pensamiento complejo y de la interdisciplinaridad, trayendo nuevas posibilidades.

Descriptores: Investigación en enfermería; Práctica profesional; Planificación de la asistencia al paciente.

INTRODUCTION

When we observe a specific object, we can describe it from our view angle or varying positions, from bottom to top or top to bottom or, still, in vertical positions with more or less light. We can increase or decrease the distance that separates us from this object. We can also touch, feel, measure, observe its texture, realize its colors and combinations, harmonies and contrasts. If, further to our observations, we exchange experiences with other observers, we will be opening new possibilities of seeing and representing, of various ways, the object/world we see and propose to describe.

The multiple ways and styles of looking at the world are characteristics of art and painting and also can be found in science, research, professional practice, in social and political world perception, in our daily lives as well as in our subjectivity and inner process.

The technical and scientifical progress in post modern times brought the urge of new challenges and discussions in science epistemological and ontological fields, admitting reflexions upon other ways of understanding reality which is complex.

In order to notice the complexity of the world around us and of the objects we want to know, it is necessary to dislocate the focus on looking and on the way of understanding the world, in other words, on the perspective of new and different paradigms. Therefore, it is necessary to (de)construct cultural, subjective and ideological reference patterns.

Thus, whenever we try to know and use care or scientific investigation methodologies we become reviewers or defenders. Once the positions, for or against this or that theory, depend on how we see the world we live in and to what extent we are originals or breeders of a pre-constructed and standardized perception of the varied phenomena and elements around us. Or even on how we fear variation, the new, the bravery of changing history.

Health and education fields, for being dinamically involved with transformations occured in society, are constantly called to respond reflexive and critically to new challenges, searching plausible adequacy in epistemologic and methodologic fields.

Nursing, as the society in general, is evolving with deep and important changes in political and social changes, in technological, interpersonal relationships and, especially, in organizing services and responding new managerial and scientific demands. Since 1950s, it is observed a growing tendency in the profession for the search of organizing and nursing service planning methods/procedures which are more effective and result in a more qualified nursing assistance.

This process was influenced/triggered from the formulation of nursing theories, firstly developed by American theorists and, in Brazil, by Wanda de Aguiar Horta whose work "Contribuição para uma Teoria de Enfermagem" (A Contribution to a Nursing Theory), published in 1979, has been widely discussed and used, especially in academical contexts as a teaching tool. However, it is seen that, practically, the implementation of the Nursing Process is still, in most health services, way under the dreamed by the theorist or the desirable as nursing care system model⁽¹⁾.

Such finding, allied to the understanding that the present moment, post-modern, is a complex, uncertain, multi faceted and multi dimensional reality, has been subject of discussions and reflexions in the Study and Research Group in Nursing and Health Management of Nursing Post Graduation Program of Federal University of Santa Catarina.

By observing reality under the perspective of complex thinking (theorized by Edgar Morin), Nursing Patient Care System (NPCS) could be fitted into traditional processes of producing new knowledge and health, in other words, based on linear and reductionist processes. Would this be the reason why its application as a nursing patient care system is, even nowadays, so not used and incipient? Are nurses qualitatively prepared, by the formal educational system, to innovate their practice and assume the assistance users have as a right? What is the role of profession supervisory organs regarding NPCS implementation in health institutions? Does the system used by nursing integrate all the complexity involved in health assistance? How do the other professionals of health staff notice this nursing system and how are/can be integrated in patient care system models? Is NPCS really to develop Nursing work?

The deeper we go on reading and reflexions on this matter, the more doubts appeared inside our discussions, challenging us to find new answers. So, we developed a qualitative study with two hospital institutions from the south of the country, with the following objectives: to analyze NPCS used in two major hospitals, a public and a private one, from the complex thinking point of view and; understand the NPCS meaning for the health multi professional staff in these two institutions.

METHODS

With the expectation of understanding experiences and meanings professionals give to NPCS, especially inside the hospital environment, a methodology of qualitative investigation was chosen, called Grounded Theory (GT). Idealized by American sociologists Barney Glaser and Anselm Strauss, GT has been widely used in Nursing^(2-7).

The method is characterized by the comparison and constant data analysis, both used to elaborate and improve, theoretically, the categories shown from data. The data comparative analysis is based on environment knowledge; data codification; category formation, followed by a reduction in category numbers or new groupings; identifying the main category; besides modifying and integrating categories.

Therefore, using the interviewees' answers and the observations notes, data became codes and categories (open codification), organized to form new analysis grouping (axial codification) in order to allow the unveiling of central category phenomena (selective codification).

After receiveing the approval of the Comitê de Ética em Pesquisa em Seres Humanos of UFSC, under the number 0291/06, a sampling was formed, with a total of 15 health professionals in three sample groups. The chosen technique for collecting data was the semi-structured interview with main question: What do understand as being the NPCS? The conducting of the other questions was, then, directed by the researchers, leading the participants to reflect upon their practices and development of their "doing" in both studied institutions. In the first sample group two technical nurses, two nutrionists, a phisiotherapist, a phonoaudiologist, a doctor and a Medicine undergraduate in the last stage of the course participated. In the second sample group two nursing directors were interviewed and, in the third sample group, two nurses from the Regional Board of Nurses. The phenomena validation and main category was realized after an interview with a professional male nurse, director of nursing service of a hospital institution from Southeastern part of the country who is developing studies on NPCS.

Consequently, this study resulted in a theoretical model called "Gleaming the Nurse Patient Care System as an Interactive and Complex Phenomenon", which is presented with more two phenomena: "Checking the possibility of an interactive, complementary and multi professional care" and "Noticing the dislocation among knowing, making and legislating".

THEORIZING ABOUT ONE OF THE PHENOMENA THAT UNVEILED THE MAIN THEME

In a previous work, with the same title of main theme "Gleaming NPCS as an Interactive and Complex Phenomenon", a detailed report was presented about the development of the study and theoretical analysis of the results. However, as the number of pages for the presentation was limited and, given the importance of the obtained results, there was a decision of going deep in theorizing the second phenomenon: noticing the dislocation among knowing, making and legislating.

The present theme points out the contradiction between Nursing knowing and making and presents a paradox between doxa and episteme, in other words, between knowledge and common sense, loaded with cultural components and scientific knowledge of theoretical nature. It also shows deviations frequently observed between theoretical speech, present in formal education institutions and the professional practice developed in health institutions which absorb schools demand. Between these two realities are the regulating and supervising profession organs whose actors are much more worried about following legislation other than getting close to professional learning and doing.

This phenomena, in other words, the perception that exists a separation between theory and practice, was brought up from the groupings and message interpretation expressed from the participants during interviews. Thus, two categories stood out and were illustrated with some excerpts from the participants' speeches, designated with letter P:

- Noticing information disagreement and little knowledge regarding NPCS: "They (nursing) have a food routine, about acceptance, that I usually notice that is different from what we observe" (P5). "Regarding what Nursing develops we have little knowledge. There is, like, no information exchange" (P4). "The pieces of information are not precise, and in some wards, I don't know whether the staff changes or what determines it, but in some wards or some units it doesn't work well" (P3).

- Noticing NPCS as a mechanical process: "I think that some do make it mechanically and don't develop patient care system as a scientific method which organizes nursing work [ ] Some people see the system as doing the prescription, evolution and record and not as way of organizing patient care. Another point is that they do it without proper appreciation, do it because they have to and not because they understand that it is a way of organizing work and valuing the nurse work" (P12).

- Noticing multiple looks over the same object: "[ ] we can't understand well the role of other professionals. We know the importance, but we don't know the day to day, what the function is. So, when you talk about the steps, we don't see it clearly, you know" (P3). "I also think it is a very interdisciplinary work" (P7).

- Noticing the lack of dialog oportunities: "[ ] if we don't stimulate these periodical discussions, this ends being just a standard" (P12). "I'd like to point out that we only realize the importance of this multi-disciplinarity to offer good patient care, to offer what the patient needs and we need too [ ] a very clear communication, concise, that works" (P3)

- Associating NPCS to the organogram, regimen and fiscalization: "There is no system. Let's put it like this, there is no organogram in the institutions. Only the big ones have it [ ] And it identifies mainly the presence of a technician in charge in assistance units and, where there is a technician and an auxiliary, there is the obligatoriness by law of the presence of a nurse. This is a major thing in supervising, besides filiation questions [ ], of not being illegal in the profession, inside the three levels, if is in default or not [ ]" (P13 and P14).

- Promoting approaching/dialog among knowing, doing and legislating: "Even trying harder and harder we have to break this dichotomy of the one who does and the one who thinks [ ] So there is a disarrangement between what is produced in the academy and what services are incorporating from this knowledge production" (P12).

DISCUSSION

The separation between knowing and doing is clearer in hospitals and is an outcome, especially, from "[ ] the verticalization of academic processes and services, in other words, knowing overlaps and underestimates knowing as practice, while practice discredits knowing as reference for critical reflexion upon doing"^(8:433).

This phenomenon of dislocation among knowing, doing and legislating may be seen as a result of what is called post modernity, in other words, the uncertainty, the heterogeneity permanence, the conflict perception, disorder and possibilities of a new arrangement in a constant search for balance, complexity features, often little observed by the social authors who form the Nursing and Health System.

Multiple looks are needed in order to understand this great category, based on the multi dimensions of aspects it produced, as well as it is important to understand the history of the system process of nursing patient care and the moment experienced, today, by the profession.

The expression "nursing process" has been used, since the 60s, as a suggestion to systematize the nursing patient care, prioritizing interpersonal relationship between nurse and patient. In Brazil, Horta Model, based on attending basic human needs, is the most used, in its original model announced by the author and adapted according to patients' specificities and service features⁽¹⁾.

Since then, nursing courses have been presenting NPCS to students as an ideal model of nursing patient care to be adapted to hospitals, clinics and basic health units. To reinforce the importance of this methodology, such practice was established by the Conselho Federal de Enfermagen (COFEN) – (Federal Nursing Council) with resolution COFEN-272/2002, designating, among other things, NPCS as a private nurse function, to be used in all patient care areas⁽⁹⁾. After many years since the NPCS presentation as a patient care model and, in spite of the great number of developed theories and other academic researches on NPCS, its use is not total, not even in hospitals and institutions linked to Universities. Therefore, a series of questions such as: Formal education values teaching process and learning the many patient care system models? Why the disarrangement between knowledge production and its practical use persists? What is the meaning of NPCS to nurses inside the working market? How much employers/ service managers know, value and think its implementation is needed? The existence of a standardized model of patient care system for every institution is a guarantee of a better care?

These questions emphasize the dislocation among knowing, doing and legislating in nursing, in other words, a separation between theory and practice that was seen and verbalized by the participants of the study.

When questioned about their doing, participants noticed the multiple looks that exist on the same object, the need of dialog opportunities and the approach among knowing, doing and legislating as improving ways of health patient care as a whole.

"Knowing will be complete when it leads to the effectiveness in doing. In this sense there is a fragmentation: theoretical knowledge practice is not completely shared by nurses from practice. The distance between theorizing and doing nursing has its origin in academic preparation, bureaucratic situations, politic and economic matter already known and which challenge area professionals to search solutions"^(10:265)

The contrasted categories show us, once again, the complex thinking. Perhaps this is the way, a way of thinking that has principles: the need for promoting the apprehension of global problems to insert partial and local knowledge; the fragmented knowledge replacement by a knowledge capable of apprehend objects in their contexts, in their complexity and in their wholeness; the urge of teaching methods that allow the establishment of multiple relationships and the mutual influences among the parts and the wholeness in a complex world⁽¹¹⁾.

Observing Nursing in hospital institutions as an Organizational Care System, "[ ] one may see that the organizational phenomena network survive, modify and keep themselves by the multiple and complex relationship channels that are not always open in constant movement/waves, against their multiple and unpredictable influences" ^(12:39).

Embedded in the ecological view of phenomena network another possibility is important, the relation among disciplines as a different way of professional acting. From it, the professions/disciplines/sciences, with interdependent and interconnected knowledge, will enable the use of knowledge and knowing from a clear and proper language, making communication easier and allowing partnership and cooperation in solving health problems in an effective, efficient and wider way.

An interdisciplinary health practice establishes another kind of relationship at work and between professionals of different categories, because their disciplinary field knowledge can be democratically shared, as a way of a disciplinary strengthening and for the "valuing of life/health of the ones who are under their special care during their passage through the hospital environment"^(13:87).

CONCLUSION

The nursing patient care systematization, as an organizational process is capable of offering benefits for the development of interdisciplinary and human care methods/methodologies. The increasing opening to new methods/methodologies to produce knowledge through a human care process allows, differently, not only a reducing view and secure of the institutionalized knowing but also a different view to the surroundings of the health/disease process.

It is important that nurses have the sensibility to capture the emerging needs, other than technical competence, ability to understand and stimulate innovative actions and, especially, knowledge and strategic capability to involve and creatively compromise other professionals of health staff.

Besides, it is important to take into consideration that human being will be committed and engaged with the methodological processes, in this case with care methodologies, when he/she is active, creative, dialogical and committed, from an own programmatic content and from using participative and moving techniques, capable of revealing the subjective and transforming potential of the individuals involved. From this perspective, NPCS will be able to guide the nursing and health staff, slowly but continuously, to an everyday reflection, opening opportunities of sharing experiences and expectations, leading them to a feeling of value and responsibility for the continuous patient care practices improvement.

Differently, it is important to emphasize that care methodologies, whatever they are called, represent nowadays, one of the most important achievements in nursing patient care field. The professional embedded in this process needs, however, to widen and deepen, continuously, specific knowledge of his/her working area, and not forget interdisciplinary and/or multidimensional approach.

In the present study, the disarticulation phenomenon appearance among knowing, doing and legislating in Nursing, is followed by this category: Promoting the dialog/approach among knowing, doing and legislating, shown as a strategy or path to change reality, signaling to NPCS how organizing care based on Nursing discourse, but that needs to be updated, suitable to the institution philosophy, thought from the inclusion of other professions/discipline/systems and aware of the complexity of its inter-relationships.

[...] Only a simbiosis between tacit knowledge resulted from practice with knowledge scientifically constituted aggregates creativity, flexibility, dynamism and improvisation to bear with the diversities and misfortunes of everyday life from health services and education institutions.

Despite the dislocation seen among knowing and doing and the disarticulation with professional legislation, NPCS is still a recommended tool for nursing and health patient care improvement. However, it is important that the actors involved with its utilization commit themselves in articulating their practices with the institutional philosophy, rethinking the health working process in order to involve the other health field professionals, with the users too, last aim of NPCS. So, it is extremely important to think and understand the health system complexity, in which we are in, as well as its multiple relationships, associations and interactions.

We are, thus, standing in front of a great challenge!

Eventually, "one cannot reform the institution without a previous reform of the minds, but minds cannot be reformed without a previous reform of the institutions". This is a deadlock that has to be overcome so that the relevant changes in practice and academy can take place inside minds and institutions.

REFERÊNCES

Received article 02/07/2007 and accepted 17/08/2007

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*

Study performed with health professionals from two hospitals, one public and one private, and with nurses of the Santa Catarina Regional Nursing Counsel [COREN-SC], in Florianópolis (SC), Brazil.

Publication Dates

• Publication in this collection
  18 Jan 2008
• Date of issue
  Dec 2007

History

• Accepted
  17 Aug 2007
• Received
  02 July 2007