THE NURSI NG PROCESS PRESENTED AS ROUTI NE CARE ACTI ONS: BUI LDI NG I TS
MEANI NG I N CLI NI CAL NURSES’ PERSPECTI VE
1Ma. Elena Ledesm a- Delgado2 Mar ia Manuela Rino Mendes3
Ledesm a- Delgado ME, Mendes MMR. t he nursing process present ed as rout ine care act ions: building it s m eaning in clinical nur ses’ per spect iv e. Rev Lat ino- am Enfer m agem 2009 m aio- j unho; 17( 3) : 328- 34.
This qualit at ive st udy aim ed t o underst and t he m eanings at t ribut ed t o t he nursing process by clinical nurses at a Mexican hospit al. Dat a were collect ed t hrough sem i- st ruct ured int erviews, part icipant observat ion and docum ent r esear ch. Sy m bolic I nt er act ionism and Gr ounded Theor y w er e t he t heor et ical and m et hodological fr am ew or k s for dat a analysis, w hich per m it t ed under st anding t he exper ience and m eaning nur ses at t r ibut ed t o t he nur sing pr ocess in t h eir daily car e pr act ice, w h ich w as u n v eiled as r ou t in e car e act ion s, per for m ed differ en t ly fr om w hat t hey had lear ned in school.
DESCRI PTORS: nur sing; nur sing pr ocess; nur sing car e
EL PROCESO DE ENFERMERÍ A COMO ACCI ONES DE CUI DADO RUTI NARI AS:
CONSTRUYENDO SU SI GNI FI CADO EN LA PERSPECTI VA DE LAS
ENFERMERAS ASI STENCI ALES
Est e est udio de nat ur aleza cualit at iva t uvo com o obj et ivo com pr ender los significados at r ibuidos al pr oceso de enferm ería por enferm eras de una unidad clínica de un hospit al de México. La recolección de dat os fue realizada por m edio de en t r ev ist as sem iest r u ct u r adas, com plem en t ada con la obser v ación par t icipan t e y la con su lt a docum ent al. Los dat os fuer on analizados baj o el m ar co t eór ico y m et odológico del I nt er accionism o Sim bólico y la Teoría Fundam ent ada en los Dat os, que posibilit aron la com prensión de la experiencia y significado at ribuido por las enferm eras, al proceso de enferm ería en su práct ica cot idiana asist encial, que se desvela com o acciones de cuidado r ut inar io, aplicados de for m a difer ent e a lo enseñado y apr endido en la escuela.
DESCRI PTORES: en fer m er ía; pr ocesos de en fer m er ía; at en ción de en fer m er ía
O PROCESSO DE ENFERMAGEM COMO AÇÕES DE CUI DADO ROTI NEI RO: CONSTRUI NDO
SEU SI GNI FI CADO NA PERSPECTI VA DAS ENFERMEI RAS ASSI STENCI AS
Est e est udo, de nat ur eza qualit at iv a, t ev e com o obj et iv o com pr eender os significados at r ibuídos ao pr ocesso de enferm agem por enferm eiras da unidade clínica em um hospit al do México. A colet a dos dados foi realizada por m eio de ent r evist as sem iest r ut ur adas, com plem ent ada por obser vação par t icipant e e consult a docum ent al. Os dados for am analisados t endo com o r efer enciais t eór icos e m et odológicos o I nt er acionism o Sim bólico e a Teor ia Fu n dam en t ada n os Dados, possibilit an do a com pr een são da v iv ên cia e o sign if icado at r ibu ído pelas en f er m eir as ao pr ocesso de en f er m agem , n a pr át ica cot idian a assist en cial, qu e se desv ela com o ações de cuidado r ot ineir o, aplicados de for m a difer ent e daquilo que é ensinado e apr endido na escola.
DESCRI TORES: en f er m agem ; pr ocessos de en f er m agem ; cu idados de en f er m agem
1
Paper ext ract ed from Doct oral Dissert at ion; 2Doct oral St udent , Escola de Enferm agem de Ribeirão Pret o, da Universidade de São Paulo, WHO Collaborat ing Cen t r e f or Nu r sin g Resear ch Dev elopm en t , Br azil, Facu lt y, Escola de En f er m agem de I rapu at o da Un iv er sidade de Gu an aj u at o, Mex ico, e- m ail: m eld_82@hot m ail.com ; 3Ph.D., Facult y, Escola de Enferm agem de Ribeirão Pret o, da Universidade de São Paulo, WHO Collaborat ing Cent re for Nursing Research Developm ent , Brazil, e- m ail: m endes@eerp.usp.br.
I NTRODUCTI ON
T
h e ex p er ien ce acq u ir ed as n u r se t each er o n t h e n u r s i n g p r o c e s s h a s g e n e r a t e d f r e q u e n t r elat ion s w it h car e pr act ice in t h e h ospit al con t ex t . Thus, it could be v er ified t hat t he nur sing act iv it ies p e r f o r m e d i n p a t i e n t s w e r e f o c u s e d o n a l r e a d y e s t a b l i s h e d p r o c e d u r e s a n d r o u t i n e s , w i t h n o reference t o t heoret ical principles and how t o put t he nur sing pr ocess int o pr act ice.Feeling uneasy w it h reasons t hat cont ribut ed t o t his sit uat ion direct ed t he aut hor’s at t ent ion t o how pr of ession als w er e ex per ien cin g an d per ceiv in g t h e use of t he nursing process in t he hospit al cont ext .
Th e n u r s i n g p r o c e s s i s c o n s i d e r e d t h e appr opr iat e m et hod t o ex plain t he nur sing essence, i t s s c i e n t i f i c b a s e s , t e c h n o l o g i e s a n d h u m a n i s t a ssu m p t i o n s t h a t en co u r a g e cr i t i ca l t h i n k i n g a n d creat ivit y, and perm it s solving problem s in professional pr act ice( 1 - 2 ). Th is m et h od r epr esen t s an at t em pt t o ev id en ce an d u n d er st an d n u r sin g w or k f ocu sed on car e as a r eflect iv e pr act ice.
Th e dev elopm en t of t h e n u r sin g pr ocess in Mex i co w as b ased o n t h e w o r k d ev el o p ed b y t h e Nat ional Nur sing Associat ion in t he 1970s. This w or k focused on gat hering nurses in t he count ry t o reflect u p on an d ex p ose st r at eg ies on n ew scen ar ios an d ch a n g es i n t h e p r o f essi o n . On e o f t h e st r a t eg i es highlight ed was t raining on t eaching and nursing care based on t his m et hod( 3).
St ar t i n g f r o m t h i s i n i t i at i v e, t each i n g an d pr act ice st r at egies w er e dev eloped t o pr ov ide t ools t o u s e t h e n u r s i n g p r o c e s s i n t h e c u r r i c u l a o f u n der gr adu at e pr ogr am s an d in h ealt h in st it u t ion s. These st rat egies aim ed t o incorporat e it as a nursing care m et hod, focused on care and also t o facilit at e it s in t egr at ion in t h e con st r u ct ion m ov em en t of h ealt h car e as a social and collect iv e good.
So m e sch o l a r s h a v e r e ce n t l y sh o w n t h e invest m ent s m ade t o use t he nursing process in care pract ice, providing inform at ion on w hat nurses know , believe and adopt in various sit uat ions and difficult ies en cou n t er ed in h ospit als( 4 - 8 ). Th ese st u dies in dicat e t h e p o t e n t i a l o f i n v e s t m e n t s i n i t s p r a c t i c e , b y a p p r o a c h i n g n u r s i n g p r a c t i c e a n d h e a l t h c a r e , edu cat ion an d r esear ch .
B a s e d o n t h e a b o v e , w e r e a f f i r m t h e researchers’ view t hat t he nursing process is an act ion full of m eaning t hat can be used by nurses in pract ice, a s a m e t h o d f o r ca r e d e l i v e r y, w h i ch r e p r e se n t s challenges in educat ion and in pr act ice. The nur sing
process needs t o be deepened in t he hospit al cont ext , b ased on t h e p er cep t ion of n u r ses w or k in g t h er e, highlight ing t heir doubt s, uncer t aint ies and quest ions about how t o put it int o operat ion.
I n t h e at t em pt t o addr ess t h ese qu est ion s, t his st udy aim ed t o: underst and t he m eaning at t ribut ed t o t h e n u r s i n g p r o c e s s b y n u r s e s f r o m a hospit alizat ion unit in Mexico and describe act ions t hey per for m at t h is u n it accor din g t o t h e m ean in g t h ey at t r ibut e t o t he nur sing pr ocess.
TH EORETI CAL AN D M ETH OD OLOGI CAL
FRAMEW ORKS
This qu alit at iv e st u dy is based on Sy m bolic I n t er act ion ism becau se it em ph asizes t h e n at u r e of social in t er act ion , t h e d y n am ics an d social act iv it y involving act ors, in t he perspect ive t hat considers an act i v e h u m an b ei n g i n h i s( er ) en v i r o n m en t as an organism t hat int eract s wit h ot hers and wit h t he self. I n t er act ion m ean s t h at t h e act ion s of each h u m an b e i n g a r e co n t i n u a l l y co n st r u ct e d , w h i ch i n p a r t depen ds on w h at ot h er s do, in flu en cin g each ot h er. I n a ct i n g a n d i n t e r a ct i n g , l a n g u a g e i s u se d t h a t or igin at es f r om in t er su bj ect iv it y, basically oper at in g in sy m bolic r ealit ies sust ained in t his int er subj ect iv e space( 9 ). Sy m bolic in t er act ion ism is a social scien ce p e r s p e c t i v e d e s i g n e d t o p r o d u c e k n o w l e d g e o n collect ive hum an life and it s conduct ; focusing on t he m eaning event s have for hum an beings and sym bols u sed t o at t r ibu t e m ean in g t o t h em . Th ese sy m bols ar e so ci al l y d ev el o p ed d u r i n g i n t er act i o n an d ar e agr eed upon inside gr oups.
Sy m b o l i c i n t e r a ct i o n i sm i s b a se d o n t h e follow ing pr inciples: hum an beings act in r elat ion t o obj ect s based on m eanings t hese hav e t o t hem ; t he m eaning at t r ibut ed t o obj ect s/ t hings or iginat es fr om social int er act ions bet w een hum an beings; m eanings a r e m a n i p u l a t e d a n d c h a n g e d t h r o u g h a n in t er pr et at iv e pr ocess, dev eloped by h u m an bein gs w hen t hey are faced w it h obj ect s and t hem selves( 10). Hum an int eract ion is m ediat ed by t he use of sym bols, in t er p r et at ion an d in v est ig at ion of t h e m ean in g of ot her s’ act ions.
GT is a m et hod t hat m aint ains a close relat ion b et w een sy st em a t i c d a t a co l l ect i o n , a n a l y si s a n d
t heor y t hat em er ge dur ing inv est igat ion. The t heor y em erges from realit y and is not a m ere connect ion of concept s based on experience or assum pt ions on how
t hings should be or work( 11).
This m et hodological design dem ands ongoing d a t a c o m p a r i s o n , t h e r e s e a r c h e r ’ s t h e o r e t i c a l
sen sit iv it y, t h eor et ical sam plin g of em pir ical r ealit y, not es t hat corroborat e t he process of open, axial and select iv e codificat ion so as t o assur e t he concept ual
developm ent and densit y. The result of t his codificat ion and int egrat ion of dat a cont ribut es t o t he const ruct ion of t heor y.
Dat a collect ion, codificat ion and analysis occur sim ult aneously in GT, w hich allow s t he r esear cher t o u n d e r s t a n d t h e m e a n i n g s i n t h e p a r t i c i p a n t s ’
p er sp ect iv e.
METHOD
Th is st u d y w as car r ied ou t in t h e I n t er n al
Medicin e Un it at t h e Gen er al Hospit al No. 2 Fam ily Medicine Unit of t he Mexican Social Securit y I nst it ut e in I r apu at o, Gu an aj u at o Mex ico. Th is is a m ediu m -size inst it ut ion, linked t o t he healt h syst em and form al w or k er s’ social secu r it y. I t h as 1 1 0 operat ion al an d 52 ext ra beds wit h a st aff of 327 nurses.
Th e I n t er n al Med i ci n e Un i t h as t w o w i n g s ( Sou t h an d Nor t h ) w it h a capacit y for 2 5 beds an d t hree designat ed t o surgery. The nursing t eam consist s of 3 6 nur ses and nur sing aux iliar ies, and four head nur ses. The av er age per m anence in hospit al r anges fr om four t o nine days.
Th e r esear ch p r oj ect w as ap p r ov ed b y t h e Bioet hics Com m it t ee at t he Universit y of Guanaj uat o, Sch ool of Nu r sin g an d Midw if er y at Celay a, an d by t he Resear ch Com m it t ee at t he Gener al Hospit al No. 2 Fam ily Medicine Unit , of t he Mexican Social Securit y I nst it ut e in I rapuat o, Guanaj uat o. A free and inform ed con sen t t er m ex p l ai n i n g t h e st u d y ob j ect i v es an d m et hodological pr ocedur es w as pr esent ed and signed by all pr ofessionals w ho agr eed t o par t icipat e in t he st u d y, f ollow in g et h ical p r in cip les in r esear ch an d assu r in g an ony m it y.
Because t his is a qualit at iv e st udy based on GT, t he num ber of part icipant s was not predet erm ined. I t w as r at h er t h e r esu lt of a sam plin g pr ocess an d t heor et ical sat ur at ion, w hich m eans t hat t he num ber
of par t icipat ing nur ses w as det er m ined accor ding t o t h e r ep r esen t a t i v en ess o f co n cep t s t h a t em er g ed
dur ing dat a analy sis.
Dat a collect ion st r at egies u sed w er e: sem i-st r u ct u r ed i n t er v i ew , p a r t i ci p a n t o b ser v a t i o n a n d
d ocu m en t r esear ch b et w een Mar ch an d Sep t em b er 2 0 0 7 . Th e s e m i - s t r u c t u r e d i n t e r v i e w w i t h o p e n quest ions focusing on t he obj ect of int erest was t
ape-r e co ape-r d e d a f t e ape-r n u ape-r se s’ a u t h o ape-r i za t i o n . Th e t a p e s’ cont ent w as accur at ely t r anscr ibed and subm it t ed t o t he int er v iew ees for cont ent v alidat ion.
Part icipant observat ion was perform ed by t he r esear cher at t he I nt er nal Medicine Unit in t he t hr ee shift s according t o t he part icipant s’ work schedule, in
t h eir d aily r ou t in e, f ocu sin g on t h e w or k m et h od , i d e n t i f y i n g a ct i o n s, i n t e r a ct i o n s, p r o ce d u r e s a n d not at ions bet w een August and Sept em ber 2007. The
r e s e a r c h e r s p e n t a b o u t e i g h t h o u r s w i t h e a c h par t icipan t in t w o dif f er en t m om en t s. Obser v at ion s w er e r ecor ded in t he field diar y aft er w ar ds.
Do cu m en t r esear ch w as car r i ed o u t u si n g of f i ci al sou r ces at t h e Nu r si n g Dep ar t m en t o f t h e st udied healt h inst it ut ion, as well as records of nursing
act ions in form s defined by t he I nt ernal Medicine Unit w h er e t h e in t er v iew ed an d ob ser v ed p r of ession als w or k , aft er t he aut hor it ies’ consent .
D a t a a n a l y s i s w a s c a r r i e d o u t d u r i n g c o l l e c t i o n , c o m p a r i n g i n f o r m a t i o n o b t a i n e d i n i n t e r v i e w s, o b se r v a t i o n s a n d d o cu m e n t r e se a r ch based on cent r al quest ions on t he obj ect of int er est , co n si d er i n g o n g o i n g co m p ar i so n , w h i ch i s a b asi c p r i n c i p l e o f t h e c h o s e n m e t h o d . A f t e r d a t a t r an scr i p t i o n , a car ef u l r ead i n g o f i n t er v i ew s an d obser v at ions w as m ade so as t o per for m codificat ion ( o p e n , a x i a l a n d s e l e c t i v e ) a n d a l s o t h e o r y delim it at ion( 12).
Open codif icat ion w as in it iat ed as f r om t h e r eadin g of in t er v iew s, car ef u lly ex am in in g t h e t ex t , decom posing it in fr agm ent s called incident s, w hich w e r e e x a m i n e d a n d co m p a r e d i n t h e se a r ch f o r sim ilar it ies an d d if f er en ces, g en er at in g cod es. Th is p r o c e d u r e w a s r e p e a t e d w i t h t h e r e m a i n i n g i n t er v i ew s, o n e b y o n e, i n t h e a t t em p t t o d ef i n e cat egor ies, deepen ident ified codes and gr oup t hem so as t o ex p lain t h e m ean in g s t h at em er g ed f r om d a t a , r e d u ci n g t h e n u m b e r o f co d e s, a i m i n g f o r cat eg or izat ion .
in int erviews and observat ions. This process perm it t ed t o i d en t i f y an d l i st cat eg or i es, sp eci f y i n g t h em i n
par t icu lar ch ar act er ist ics.
Ax i al co d i f i cat i o n i m p l i es d eep an d d en se an aly sis of cat egor ies t h at em er ged f r om t h e open
codificat ion process, includes t he relat ion of cat egories a n d s u b c a t e g o r i e s f o l l o w i n g t h e l i n e s o f t h e i r p r o p r i e t i e s a n d d i m e n s i o n s . Ca t e g o r i e s a n d
su b ca t e g o r i e s w e r e r e l a t e d a n d g r o u p e d i n t h i s co d i f i ca t i o n b a se d o n t h e co d i f i ca t i o n p a r a d i g m , according t o t heir com ponent s t hat include condit ions,
act ions/ int er act ions and consequences, or ient ing and h e l p i n g t h e r e s e a r c h e r t o f o r m u l a t e q u e s t i o n s , gener at e hy pot heses and ongoing com par ison, w hich
is useful in t heory const ruct ion( 11).
I n t he select iv e codificat ion, cat egor ies w er e in t egr at ed an d r ef in ed so as t o iden t if y t h e cen t r al
cat egory and subcat egories, in an int eract ive process bet w een t he r esear cher and dat a.
RESULTS
S i x t e e n n u r s e s f r o m t h r e e w o r k s h i f t s par t icipat ed in t h e st u dy, 1 4 w om en an d t w o m en , b et w een 3 0 an d 4 8 y ear s o f ag e. Th er e w er e si x nurses wit h a t eaching diplom a and t en wit h t echnical edu cat ion on ly. Th e t im e of ex per ien ce var ied f r om 10 t o 20 years at t he inst it ut ion and in nursing.
Th e a n a l y s i s p r o c e s s p e r m i t t e d t h e co n st r u ct i o n o f t h e ce n t r a l ca t e g o r y t h e n u r si n g p r o cess as r o u t i n e car e act i o n s, r ep r esen t i n g t h e m ean in g at t r ib u t ed t o t h e p h en om en on st u d ied b y nur ses in daily pr act ice in t he hospit al cont ex t . This cat egor y is com posed of t he subcat egor ies: differ ent fr om w hat hav e been lear ned w it h loss of cont inuit y o f a ct i o n s; i n v e st i g a t i o n o f p a t i e n t s’ n e e d s a n d c o n d i t i o n s b a s e d o n m e d i c a l t r e a t m e n t a n d p e r c e p t i o n s o f d i s c o m f o r t ; p e r f o r m a n c e o f c a r e act ion s/ in t er act ion s b ased on t h e p at ien t s’ n eed s, m ed ical p r escr ip t ion an d est ab lish ed r ou t in es, an d r e co r d s o f ca r e a ct i o n s/ i n t e r a ct i o n s a n d m e d i ca l p r escr i p t i on s, w h i ch p er m it t o u n d er st an d n u r ses’ ex per ience in t he use of t he nur sing pr ocess.
Th e n u r ses a t t h i s i n t er n a l m ed i ci n e u n i t r epor t ed t hat t he w or k t hey per for m in daily r out ine is different from w hat t hey have learned w it h loss of cont inuit y of act ions, and com pare it t o undergraduat e ex p er ien ces, w h en t h ey lear n ed t o h av e in d iv id u al f ocu s, on a f ew p at ien t s, t o p er f or m st ep - b y - st ep
procedures in chosen sit uat ions, which is different from what t hey current ly experience. What has been t aught
at school is report ed as knowledge t hat cannot be put i n p r a ct i ce i n t h ei r p r o f essi o n a l r ea l i t y, a n d t h ey idealize t h e t r an sm it t ed t h eor et ical k n ow ledge t h at
su ppor t ed pr act ice…
I t ’s very different w hen you don’t pract ice it , when we
learn it at school, it has been m ore t han 20 years since I graduat ed,
as t im e goes by, you lose t his cont inuit y, we set aside t hings
t hat are im port ant , and don’t m anage it like when we’re at school,
wit h m ore det ail because we’re not wit h one pat ient or t wo, here
we at t end 13. ( E10) .
The m eaning nur ses at t r ibut e t o t he nur sing pr ocess is pr esent w hen t hey ex pr ess elem ent s t hat
int egr at e it dur ing car e in t he daily r out ine, as if it w er e a r o u t i n e an d m ech an i zed act i v i t y, k n o w i n g befor ehand w hat t hey ar e going t o do, as follow s.
…We use t he nursing process but we don’t even not ice
it , we have a work rout ine and don’t realize it , we don’t t hink we
are put t ing it in pract ice, but it is done because we plan act ivit ies
and perform act ions, but it is like rout ine act ivit ies ( E10) .
I nv est igat ing pat ient s’ needs and condit ions, b a se d o n m e d i ca l t r e a t m e n t a n d p e r ce p t i o n s o f discom fort, is perform ed as daily care act ions. Nurses r e p o r t t h a t t h e y e v a l u a t e p a t i e n t s ’ n e e d s a n d condit ions t hrough a process of inform at ion collect ion, at different m om ent s during t heir shift s, and it is not syst em at ic, wit h m ore or less det ails, does not follow a n e st a b l i sh e d st a n d a r d a n d d a t a f r o m m e d i ca l t r eat m en t ar e t h e p r ior it y an d d ir ect w h at asp ect s need t o be ev aluat ed and obser v ed.
…when you get t he shift , t hey say t he pat ient ’s nam e,
diagnosis, check if t he venoclysis has all dat a, of no m ore t han
t hr ee day s, and t hat t he pat ient has his ser um and t hat it
corresponds t o what has been prescribed ( E13) .
This invest igat ion is also perform ed based on t h e per cept ion s an d r epor t s of pat ien t s’ discom for t , w h ich m an if est n u r ses’ p ot en t ial au t on om y in t h e search for inform at ion so as t o direct t heir professional r esponse t o car e dem ands.
…w hen I receive t he shift I focus on observing t he
pat ient , checking again if his solut ion has t o be repeat ed, if t he
venoclysis is ok, if t here’s som e kind of drin, if it ’s dry, ask if
t here was any incident in t he previous shift , if t here’s anyt hing
pending, t his is m y evaluat ion…( E8) .
alt er in g t h e seq u en ce of t h eir d aily act iv it ies t h at dem and int er pr et at ion of collect ed infor m at ion based
on t h eir k n ow led g e, clin ical ex p er ien ce an d v alu es est ablished by t he hospit al.
…As soon as I arrive in t he m orning I go t o get t o know
t he pat ient s, see t heir m edical diagnoses, w hat m ay be t he
charact erist ics in t erm s of sym pt om s or som et hing bot hering
t hem ….and based on t his, I choose m y priorit ies, in case t here’s
som e pat ient who needs m ore urgent care, so I pay m ore at t ent ion
t o t his pat ient ( E3).
N u r s e s g i v e p r i o r i t y t o m e d i c a t i o n
adm inist rat ion during t im e available, according t o t he num ber of pat ient s and m edicat ion prescript ions. This act ivit y r elat ed t o m edical pr escr ipt ion is r evealed as
a cen t r al elem en t in n u r ses’ r ou t in e in t h e h ospit al con t ex t .
First I check how m any pat ient s I have and according
t o t his I get m y t rolley, prepare m y syringes wit h serum and
t hen I go pat ient by pat ient because, if you don’t do it t his way,
you lose t im e for adm inist ering m edicat ion ( E1) .
A l s o , t h e p e r f o r m a n c e o f c a r e a c t i o n s / i n t e r a ct i o n s, b a se d o n p a t i e n t s’ n e e d s, m e d i ca l prescript ion and est ablished rout ines som et im es follow ca r e p r o t o co l s n u r se s h a v e i n t e r n a l i ze d i n t h e i r rout ine. Nursing aut onom y at t he inst it ut ion is reflect ed i n t h e s e a c t i o n s / i n t e r a c t i o n s t h a t r e s u l t f r o m p r o f e ssi o n a l j u d g m e n t , a i m i n g t o m e e t p a t i e n t s’ needs, v aluing t heir decision- m ak ing.
…we do not only perform care according t o m edical
prescript ions, generally t he physician visit s t he pat ient and we
are t he ones who are responsible t o check if t he pat ient has any
changes, problem s or needs, so we m ake decisions on what has
t o be done for t he pat ient ( E9) .
Ca r e a c t i o n s / i n t e r a c t i o n s a l s o f o l l o w st andardized rout ines and est ablished funct ions in t he hospit al st ruct ure, working as guiding elem ent s so as t o discipline w or k .
…I t ’s alw ay s t h e sam e, ch eck sign s, pass n u r sin g
r eco r d s, co n t i n u e w i t h ca r e p r escr i b ed b y t h e p h y si ci a n
responsible for each pat ient , following what is already est ablished
in t he service ( E7) .
Re co r d s o f ca r e a ct i o n s/ i n t e r a ct i o n s a n d m edical pr escr ipt ions ar e consider ed a v aluable t ool in t h e p r of ession ; it is a t ool f or car e an d a leg al requirem ent , however, nurses perceive it as som et hing lit t le im port ant and undervalued by ot her professionals in t he scope of t heir act ions, alleging lack of t im e t o per for m it . Thus, r ecor ds ar e vague w it h lit t le det ail, incom plet e, repet it ive and do not evidence t heir act ions.
We don’t t ake not es of everyt hing we do because t here’s
not m uch t im e, so t here’re places where I put t he sam e t hing
from t he ot her shift “ all t he sam e” , I believe t hat we don’t have
t im e t o do a det ailed record of our act ions ( E13).
Th ey est ab lish d if f er en ces, h ow ev er, w h en
records are relat ed t o m edical prescript ions on w hich t hey spend a great part of t heir t im e, confront ing and u p d at in g t h em at d if f er en t m om en t s d u r in g sh if t s,
especially t h ose r egar din g m edicat ion ch an ges.
…we t ake care so t hat m edical prescript ions coincide
wit h nursing records, as I adm inist er m edicat ions and check t he
prescript ions again t o see if t here’s any change in t he t reat m ent
or if prescript ions are t he sam e ( E2) .
DI SCUSSI ON
The nur sing pr ocess as r out ine car e act ions
r ep r esen t s t h e n u r ses’ ex p er ien ce in car e d eliv er y b a se d o n t h e e v a l u a t i o n o f p a t i e n t s’ n e e d s a n d
con dit ion s, plan n in g of n u r sin g act ion s/ in t er act ion s, per f or m in g car e act ion s/ in t er act ion s w it h m or e an d less aut onom y, par t ially r ecor ding t hem . Most of t he
t im es, t hese prescript ive act ions/ int eract ions have an im m ed iat e r esolu t ion an d com e f ir st in r elat ion t o pending condit ions, needs and condit ions of risk, wit h lit t le t im e for at t ent iv e list ening or for dev eloping a close r elat ion w it h pat ient s.
Th u s, n u r ses’ r o u t i n e a ct i o n s/ i n t er a ct i o n s pr edom inat e in t he hospit al’s com plex daily r out ine, w h e r e t h e y t r y t o r e s p o n d f o r t h e i r r i t u a l i s t i c p e r f o r m a n ce , i n co r p o r a t e d i n t o t h e i n st i t u t i o n a l cult ure, as a norm al, learned and adapt ed pract ice( 12). Th e n u r ses, in v iew of t h e or gan izat ion al st r u ct u r e, becom e act iv e or gan ism s capable of m odelin g t h eir line of act ion, based on what t hey consider im port ant an d sign ifican t( 1 0 ), an d per for m t h e n u r sin g pr ocess a s r o u t i n e ca r e a ct i o n s, ex ecu t i n g h a b i t u a l t a sk s est ablished by t he or ganizat ion( 7).
This sit uat ion is a challenge for t he profession a n d g e n e r a t e s q u e st i o n i n g s r e g a r d i n g t h e m o st
adequat e way t o t each t he nursing process, st rat egies t o p u t i t i n t o o p er at i o n i n t h e t each i n g ar ea an d int egr at e it t o academ ic pr ogr am s, in addit ion t o t he
ideology and value syst em s of facult y m em bers. This way, t he need for great er int eract ion bet ween schools an d ser v ices is ev id en t , so as t o lin k p r of ession al
educat ion t o professional healt h pract ices( 7- 8). The gap bet w een nur sing pr act ice in t he hospit al r out ine and t he proposal of nursing process t eaching needs t o be
faced, so as t o find v iable st r at egies for it s effect iv e u se in h ealt h ser v ices an d t o su p p or t n u r ses’ car e act ion s. Nu r ses’ cr it ical ed u cat ion sh ou ld elect t h e
dim ension of applied science, know ledge and nur sing pr act ice as essent ial elem ent s( 14).
Nu r sin g h as cu r r en t ly f aced an ov er load of
t asks and lack of t im e. I t is oppor t une t o w or k on a m o r e p r a ct i ca l a n d r ed u ced n u r si n g p r o cess t h a t focuses on pat ient s’ current needs, w hich is an issue
nurses, facult y m em bers and st udent s need t o reflect on in order t o find viable pat hs for it s pract ice( 15).
I n t his per spect ive, nur ses acknow ledge t hat
t heir car e act ions and use of t he nur sing pr ocess in t h e h ospit al con t ex t ar e bein g com pr om ised, w h ich results in evaluations focused on patients’ signs, sym ptom s and needs, on their physical aspects and critical situations, m ediated by acquired knowledge, interiorized values and m eanings attributed to the care act.
The planning of care act ions and int eract ions, w hich occupies an im por t ant par t of nur ses’ t im e in t heir rout ine, is only perceived, orient ed by prot ocols an d r ou t in es est ablish ed in t h e ser v ice, w h ich h av e b een in t er ior ized an d f ollow ed as a lin e of act ion , t hr ough an int er pr et at ion pr ocess.
Nu r ses, as social act or s, in t er act w it h t h eir peers, ot her healt h professionals, pat ient s and fam ily m e m b e r s i n t h e h o sp i t a l co n t e x t , a n d f o r m u l a t e indicat ions of conduct based on inst it ut ional st andards, w hich or ient t heir int er act ion w it h ot her s, alienat ing t hem selves when t he perform ance of t asks is defined by t he healt h inst it ut ion, a fact or t hat det erm ines t heir car e act ion s/ in t er act ion s, m ain ly b ased on m ed ical p r escr ip t ion s.
I n a d d i t i o n , n u r ses ex ecu t e ca r e a ct i o n s/ i n t e r a ct i o n s f o cu se d o n p a t i e n t s’ n e e d s, sh o w i n g au t on om ou s ex er cise, b ased on k n ow led g e, cr it ical r at i o n al e an d d eci si o n - m ak i n g t h at o v er co m e t h e est ab l i sh ed n o r m at i v e m o d el , st r en g t h en i n g t h ei r n at u r e as agen t s( 1 0 ). Th is w ay, t h e n u r sin g pr ocess
perm it s aut onom ous act ion in t he face of ot her healt h pr of ession als( 7 ).
N u r s e s e x p e r i e n c e a u t o n o m y w h e n t h e y com p ly w it h p at ien t s’ car e g oals, u sin g k n ow led g e an d ab i l i t i es i n t h e co n t ex t o f u n d er st an d i n g an d con t r ibu t in g t o t h e car e plan , ev alu at in g t h eir n eeds an d con d it ion s, ex p r essin g con cer n s an d p r ior it ies, c o o r d i n a t i n g t h e m u l t i d i s c i p l i n a r y t e a m ’ s r eso u r ces( 1 6 ).
Th e n u r s i n g p r o c e s s i s c h a r a c t e r i z e d a s
rout ine in a cont ext of lim it ed int eract ions t o com plet e t asks, which is revealed as a m echanic act ivit y, where t h e n u r sin g p r escr ip t ion d oes n ot r ef lect p at ien t s’ i n d i v i d u a l e v a l u a t i o n( 4 ). Th i s co n t e x t r e f l e ct s t h e perspect ive of crit ical discussion of t he work process, in t he sear ch for benefit s t he nur sing pr ocess could i n t r o d u ce i n t h e st r u ct u r e o f t ea m ca r e p r a ct i ce, st r engt hening social int er act ion at w or k .
D u r i n g o b s e r v a t i o n s a n d i n t e r v i e w s , w e v er if ied t h at n u r ses’ act ion s/ in t er act ion s ar e m ain ly focused on pat ient s’ physical care, rout ine procedures and care prot ocols est ablished at t he unit , on following m e d i ca l p r e scr i p t i o n , a n d a l so o n r e ce i v i n g a n d p a s s i n g t h e s h i f t , m e d i c a t i o n a d m i n i s t r a t i o n , m easu r em en t of v it al sign s, n u r sin g clin ical r ecor ds and r efer r als( 17).
FI NAL CONSI DERATI ONS
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