THE HEALTH- I LLN ESS CARE PROCESS AN D THE LOGI C OF THE
NURSE’S W ORK I N THE I CU
1Leandr o Bar bosa de Pinho2
Silv ia Mar ia Azev edo dos Sant os3
Pinho LB, Sant os SMA. The healt h- illness car e pr ocess and t he logic of t he nurse’s w or k in t he I CU. Rev Lat
ino-am En fer m agem 2 0 0 7 m ar ço- abr il; 1 5 ( 2 ) : 1 9 9 - 2 0 6 .
The pr esent st udy aim s t o lear n t he healt h pr oduct ion logic in t he I CU based on t he discour se defended
by nur ses and on t he pr ofessional pr act ice t hat is r ecognized by t he r elat iv es accom pany ing t he hospit alized
pat ient s. This is a qualit at iv e and dialect ic inv est igat ion per for m ed w it h sev en nur ses and fiv e r elat iv es in an
I CU for adult s of a t eaching hospit al in Sant a Cat ar ina. The t heor et ical- philosophical r efer ent ial w as based on
Mar xist and Gr am scians r eadings. The r esult s show t hat t he logic of t he healt h pr oduct ion in t he I CU is inser t ed
in a dialect ic r h y t h m of au t on om y , depen den ce an d co- r espon sibilit y f or t h e car e. We u n der st an d t h at t h is
r ea l i t y ca n d em o n st r a t e t h e n eed t o r et h i n k t h e k n o w l ed g e a n d p r a ct i ces t o p r o m o t e t h e co n st a n t r
e-for m ular izat ion and t r anse-for m at ion of t he assist ant cont ex t of int ensiv e car e.
DESCRI PTORS: n u r sin g; em pat h y ; h ealt h - disease pr ocess; w or k
EL PROCESO DE SALUD- EN FERMEDAD- CUI DADO Y LA LÓGI CA EN EL
TRABAJO DEL ENFERMERO EN UCI
Est e est udio pr et ende conocer la lógica de pr oducción en salud en la UCI basado en lo que es expr esado
- defen dido por el en fer m er o den t r o de su pr áct ica pr ofesion al, la cu al es r econ ocida por los fam iliar es qu e
acom pañ an a los pacien t es in t er n ados. Se t r at a de u n a in v est igación cu alit at iv a con or ien t ación dialéct ica,
r ealizada con 7 enfer m er os y 5 fam iliar es de una UCI de adult os dent r o de un hospit al univ er sit ar io de Sant a
Cat ar ina. El r efer encial t eór ico- filosófico escogido se basó en lect ur as m ar x ist as y gr am scianas. Los r esult ados
dem uest r an que la lógica de pr oducción en salud en UCI se encuent r a incluida dent r o de una r ed com plej a, la
cual se da dent r o de un r it m o dialéct ico basado en aut onom ía, dependencia y co- r esponsabilidad par a con el
cu i d ad o. Com p r en d em os q u e l a r eal i d ad r ef l ej a l a n ecesi d ad d e r ep en sar sob r e el sab er y l as p r áct i cas
pr ofesionales pr om ov iendo la const ant e r efor m ulación y t r ansfor m ación de los cuidados int ensiv os dent r o del
con t ex t o asist en cial.
DESCRI PTORES: en f er m er ía; em pat ía; pr oceso salu d- en f er m edad; t r abaj o
O PROCESSO SAÚDE- DOEN ÇA- CUI DADO E A LÓGI CA DO
TRABALHO DO ENFERMEI RO NA UTI
O pr esen t e est u do pr et en de con h ecer a lógica da pr odu ção de saú de n a UTI com base n o discu r so
d e f e n d i d o p e l o e n f e r m e i r o e n a p r á t i ca p r o f i ssi o n a l q u e e f e t i v a m e n t e é r e co n h e ci d a p e l o s f a m i l i a r e s
acom panhant es dos pacient es int er nados. Tr at a- se de um a pesquisa qualit at iva, de or ient ação dialét ica, r ealizada
com 7 enfer m eir os e 5 fam iliar es em um a UTI de adult os de um hospit al univ er sit ár io de Sant a Cat ar ina. O
r ef er en cial t eór ico- f ilosóf ico baseou - se em leit u r as m ar x ist as e gr am scian as. Os r esu lt ados m ost r am qu e a
lógica da pr odução de saúde na UTI est á inser ida em um a com plex a t eia que se m ov e em um r it m o dialét ico
d e au t on om ia, d ep en d ên cia e co- r esp on sab ilização p ar a o cu id ad o. En t en d em os q u e essa r ealid ad e p ossa
dem onst r ar a necessidade de r epensar saber es e pr át icas pr ofissionais par a pr om over a const ant e r efor m ulação
e t r ansfor m ação do cont ex t o assist encial de cuidados int ensiv os.
DESCRI TORES: en f er m agem ; em pat ia; pr ocesso saú de- doen ça; t r abalh o
1
Ext ract ed from Mast er t hesis; 2 RN, Doct oral st udent in Psychiat ric Nursing at Universit y of São Paulo at Ribeirão Pret o College of Nursing, WHO Collaborat ing Cent r e for Nur sing Resear ch Developm ent , e- m ail: lbpinho@uol.com .br ; 3 RN, PhD, Pr ofessor at t he Feder al Univer sit y of Sant a Cat ar ina Depar t m ent of
Nur sing Healt h Sciences Cent er, e- m ail: silvia@nfr.ufsc.br
I NTRODUCTI ON
T
hroughout hist ory, t he healt h- disease process has offered a series of int riguing inquiries t hat m ake usr e t h i n k o u r d i sco u r se a n d p r o f e ssi o n a l p r a ct i ce .
Whenever we look at healt h prom ot ion, we also t hink
of disease. These ar e int er dependent concept s w hich
t end t o generat e approxim at ions and dist ances in healt h
professionals’ work at a dialect ic rhyt hm .
Th e h e a l t h / d i se a se si t u a t i o n s h a v e b e e n
gr adually const r uct ed and r econst r uct ed accor ding t o
so ci et y ’ s i n t er est s i n each ag e. Po l i t i cal - eco n o m i c
changes, t he reorient at ion of w ork goals, t he division
o f so ci a l cl a sses a n d t h e g r o w i n g p r o l i f er a t i o n o f
epidem ic diseases w er e fact or s t hat r efor m ulat ed t he
concept s about healt h and disease condit ions and also
r eor ient ed int er v ent ion for m s( 1 - 2 ).
N u r si n g h a s a cco m p a n i e d t h e h i st o r i ca l
-st r u ct u r al ev olu t ion of h ealt h - d isease in t h e w or ld ,
in clu d in g b ef or e it s p r of ession alizat ion in t h e 1 9 t h
c e n t u r y, a n d t o o k a m o r e h u m a n i s t i c v a n g u a r d
posit ion . I t r eceiv ed con sider able con t r ibu t ion s fr om
r el at ed h u m an sci en ce ar eas, su ch as p h i l o so p h y,
a n t h r o p o l o g y, p sy ch o l o g y a n d so ci o l o g y. Nu r si n g
follow ed t his for m at ion line, also as a w ay of t ur ning
it s car e act ion s in depen den t f r om t ech n ical m edical
k n ow ledge( 3 ).
I n t his sense, t hink ing about healt h-
disease-car e con cep t s n ow ad ay s m ean s u n d er st an d in g t h at
s t r a t e g i e s t o g u a r a n t e e h e a l t h c o n d i t i o n s a r e a
com plex process t hat m ixes t he realit ies of t he social
cont ex t , t he t eam ’s and t he pat ient ’s needs, am ong
ot hers. Thus, t hey are, above all, a set of discourses,
pr act ices, philosophies, w or k or ganizat ion and people
w it h needs and par t icular it ies.
This study aim s to get to know the logic of health
production at the I CU, based on the discourse the nurse
defends and on the professional practice that is actually
acknowledged by accom panying fam ily m em bers. I t is
based on t h e t h esis t h at n u r sin g car e can r ev eal a
contradictory nature, which is reflected in certain m om ents
of the care context, as well as in nurses’ discourse and
professional practice. We think that the reality we present
can allow for reflection on and constant transform ation of
the intensive care setting.
METHODOLOGI CAL TRAJECTORY
Th is q u alit at iv e an d d ialect ic r esear ch w as
car r ied ou t at t h e in t en siv e car e u n it – I CU of t h e
U n i v e r s i t y H o s p i t a l a t S a n t a Ca t a r i n a Fe d e r a l
Univer sit y. Toget her w it h t he pr oj ect , a docum ent was
sent t o t he inst it ut ional Resear ch Et hics Com m it t ee,
w hich gav e a fav or able opinion.
D a t a w e r e c o l l e c t e d t h r o u g h p a r t i c i p a n t
obser v at ion an d sem ist r u ct u r ed in t er v iew s. For t h is
p a p er, w e ch o se f r a g m en t s o f t h e sem i st r u ct u r ed
int er view s held w it h nur ses and accom panying fam ily
m em ber s w e select ed.
I n t ot al, 08 ( eight ) nur ses w or k at t he I CU,
0 7 ( s e v e n ) o f w h o m p a r t i c i p a t e d i n t h i s s t u d y,
accor ding t o pr ev iously defined cr it er ia, such as t he
t ype of em ploym ent cont r act w it h t he hospit al, ser vice
t im e at t he unit and w illingness t o par t icipat e in t he
st u d y.
Accom pany ing r elat iv es w er e select ed dur ing
f ield ob ser v at ion s in t h e d at a collect ion p h ase. On
t h e w h o l e , w e i n t e r v i e w e d 0 5 ( f i v e ) r e l a t i v e s, i n
a cco r d a n ce w i t h cr i t e r i a o f p h y si ca l o r a f f e ct i v e
pr ox im it y w it h t he pat ient , w illingness t o par t icipat e
i n t h e r e s e a r c h , c o m m u n i c a t i v e c o n d i t i o n s a n d
under st anding t o collabor at e in t he st udy.
For dat a analy sis, w e const r uct ed a specific
scr i p t f o r n u r se s a n d a n o t h e r f o r a cco m p a n y i n g
r elat iv es. To analy ze t hese dat a, w e r ead and r er ead
t he int erview t ext s, unt il reaching t he cat egories t hat
best in dicat ed w h at t h e in f or m an t s w er e say in g. I n
t h e n ex t p h ase, w h en w e w er e alr ead y st ar t in g t o
m ak e infer ences and int er pr et at ions, w e const r uct ed
t w o d iscu ssion ax es. I n t h is p ap er, w e ad d r ess t h e
issue about t he logic of healt h and car e product ion at
t h e I CU.
Th e r esear ch su b j ect s r eceiv ed g u ar an t ees
of an on y m it y an d r espect for an y decision t o cease
p a r t i c i p a t i o n , i n a c c o r d a n c e w i t h t h e Fr e e a n d
I n f or m ed Con sen t Ter m , Resolu t ion 1 9 6 / 9 6 b y t h e
Brazilian Healt h Minist ry and t he Et hics Code of Nursing
Pr of ession als. Nu r ses w er e iden t if ied w it h t h e let t er
“ E” f ollow ed b y t h eir or d er in t h e in t er v iew ( E2 f or
ex am ple) . Fam ily m em ber s w er e iden t if ied w it h t h e
let t er “ F”.
Th eor et ical- Ph ilosop h ical Fr am ew or k
We believe t h at t h e con st r u ct ion of n u r sin g
as a social pract ice goes beyond t he r elat ions bet w een
su b j ect s, t o t h e p r o m o t i o n o f i n t eg r al , r el at i o n al ,
int er subj ect ive car e. We obser ve t his const r uct ion as
a s e t o f c o m p l e x c h a r a c t e r i s t i c s , i n c l u d i n g
sense, w e use som e cont r ibut ions by Kar l Mar x and
An t on io Gr am sci, ab ou t t h e m at er ial con d it ion s of
exist ence and about w or k, t o suppor t discussions about
healt h- disease- car e k now ledge and pr act ices and t he
healt h pr oduct ion logic t r ansm it t ed at t he I CU.
Hist or y cov er s a ser ies of gener at ions, each
of w h ich ex p lor es t h e m at er ial g ood s, cap it als an d
pr oduct ive for ces fr om t he pr eceding gener at ions and
t he nat ure all of t his is sit uat ed in. This succession of
discour ses and pr act ices is t r ansm it t ed at a dialect ic
r h y t h m : t o t h e e x t e n t t h a t t h e y a r e r a d i c a l l y
t r an sf o r m ed , i n t h ei r su ccessi o n , t h ey m o d i f y t h e
f o r m e r c i r c u m s t a n c e s a n d m a k e t h e m r a d i c a l l y
differ en t( 4 ).
I f w e look ed at m an as a hist or ical pr oduct ,
w e could say t hat hist or y is also a pr oduct ion of m an,
bot h in a dialect ic pr ocess of ack now ledgem ent and
t r a n sf o r m a t i o n . Ma n i s a b e i n g i n p r o ce ss, m o r e
exact ly t he pr ocess of his ow n desir es and at t it udes( 5).
I n t h is sen se, w e con sider t h at m an , in dom in at in g
nat ur e, const r uct ing his social life, pr oduces him self,
r ev isit s h is ex ist en ce, h is con scien ce an d b ecom es
m o r e h u m a n . Th e r el a t i o n s m a n est a b l i sh es w i t h
p r o d u c t i o n m e a n s c o n s t r u c t m a t t e r a n d h u m a n
r elat ion s, w h ich ar e t h e b ase f or t h e m ov em en t of
l i f e an d t h e co l l ect i v e. Wo r k co n st i t u t es t h e b asi c
pr inciple t hr ough w hich m an pr oduces/ and r epr oduces
his hist ory, t urning him self a co- part icipant in t he w orld
an d t h e r elat ion s t h at p er m eat e it : “ I n su m , m an
should be conceived as a series of act ive relat ions ( a
p r ocess) , in w h ich , if in d iv id u alit y is of p ar am ou n t
im por t ance, it is how ever not t he only elem ent t o be
t ak en in t o accou n t . . . Mor eov er, t h ese r elat ion s ar e
not m echanical. They ar e act iv e and conscious, t hat
is, t hey cor r espond t o t he gr eat er or lesser ext ent t o
w h ich in d iv id u al m en u n d er st an d t h em . Hen ce, w e
m ay say t hat each m an t r ansfor m s and m odifies an
ent ire set of relat ions in w hich he is t he cent ral point ”( 5).
We o b se r v e t h a t t h e h e a l t h - d i se a se - ca r e
process, w hich perm it s t heor et ical- pract ical know ledge
about t he logic of healt h pr oduct ion at t he I CU, could
b ecom e a t ool f or t h e p r od u ct ion of lif e in sid e t h e
co n st i t u t e d so ci a l r e l a t i o n s. Wo r k , i n t h i s se n se ,
cor r espon ds t o t h e basic an d fu n dam en t al con dit ion
of all hum an life. I t is capable of m odifying bot h nat ure
and it self befor e nat ur e( 6). Hence, t he discour se and
pr ofessional pr act ice dev eloped in t he int ensiv e car e
set t ing ar e par t of a r ealit y filled w it h cont r adict ions,
i n f l u e n c i n g t h e m a n d b e i n g , i n t h e s a m e w a y,
influenced by t hem .
RESULTS AND DI SCUSSI ON
We consider t hat nur sing w or k cont em plat es
t he condit ions of people, t he w ork environm ent it self,
t heir dut ies and needs at a given m om ent in t im e. We
b e l i e v e t h a t , i n a s s u m i n g t h e s e c h a r a c t e r i s t i c s ,
pr ofessional w or k j oins t hem in t he spher e of social
ef f or t , r epr esen t ed by t h e pr odu ct ion of in div idu als’
subj ect ivit ies in t he condit ions offered by t he obj ect ive
con t ex t . Th e pr odu ct ion of m at er ial life r est s in t h e
pr oduct ion of t he m eans t hat m ake it possible t o at t end
t o t h e in d iv id u al’s n eed s r elat ed t o t h e con d it ion s
offer ed by nat ur e: “ The pr oduct ion of life... em er ges
as a dou ble r elat ion : on t h e on e h an d as a n at u r al
relat ion and, on t he ot her, as a social relat ion – social
in t he sense of a j oint act ion by different individuals,
no m at t er it s condit ions, w ay or goal( 4).
We o b se r v e t h a t , w i t h r e sp e ct t o h e a l t h
pr oduct ion at t he I CU, nur sing k now ledge and social
pr act ice per m eat e it s const it ut ion it self, based on it s
f or m at ion as a g r ou p of p eop le, w h o in t er r elat e in
or der t o im plem ent and m anage t he occupat ional car e
prom ot ion act ivit ies. Nurses believe, in t heir discourse,
t h a t t h i s c a r e p r o m o t i o n o c c u r s w i t h i n t h e
est ablishm ent of a m ult ipr ofessional t eam at t he I CU.
The r epor t s below dem onst r at e t his obser v at ion:
I t hink t hat t eam w or k, I t hink t hat is differ ent fr om
gr oup w or k, because it is m or e cohesive, a m or e com m on goal,
t he gr oup int er r elat es bet t er , I t hink it ’s a gr eat facilit y [ ...] I had
t he oppor t unit y t o get t o know all w or k shift s, know ing each
em ployee, difficult ies, all r ealit ies. I t hink t hat not all of t hem
have t he sam e char act er ist ic, r ight ? Som e of t hem w or k in gr oup
and ot her s in a t eam . I t hink t hat t eam w or k m eans one helping
t he ot her , you know ? So, as w e don’t w or k w it h int egr al car e, it ’s
ver y divided, ever yone has t o help. ( E3)
... t he m edical t eam t oo, it ’s easy t o w or k w it h m ost of
t hem , a good r elat ion, w e face difficult ies w it h only few , but w e
int er act w ell w it h a lar ge m aj or it y, I t hink t her e exist s quit e a lot
of confidence. The leader s, t he heads consult nur sing a lot [ ...]
t hey don’t feel like t hey ar e t he st ar t hat m uch. ( E4)
The t r ansfor m at ions in m oder n societ y hav e
in f lu en ced h ealt h b ecau se t h e lat t er is p ar t of t h e
f or m er, i n t er m s of i t s st u d y ob j ect – t h e h eal t h
-disease- car e pr ocess – and using t heor et ical- pr act ical
t ools t hat allow for t he or ganizat ion of w or k pr ocesses
and ser v ices. The healt h sect or needs t o cor r espond
t o m ult iple dem ands, w hich lack a differ ent iat ed look
in order t o provide a healt hier living condit ion. Wit hin
a n i n t e g r a l ca r e p e r sp e ct i v e , a n i n t e r d i sci p l i n a r y
r elat ion s am on g t h ese su b j ect s an d b et w een t h ese
subj ect s and t he env ir onm ent t hey liv e in( 7).
Th e I CU i s a cl o se d e n v i r o n m e n t w i t h a
r educed num ber of beds, w hich at t ends t o a par t of
t he populat ion t hat needs int ensiv e healt h car e. The
I CU r epr esent s a lim it ing phy sical space, sur r ounded
b y t h e g r av it y of t h e cases an d r eq u ir in g con st an t
and cont inuous care. Thus, t he m ult iprofessional t eam
is lim it ed t o daily r elat ions. This dem ands a policy of
good int erpersonal relat ions w it hin t he t eam , in order
t o pr om ot e a calm j oint life and t he pr om ot ion of bet t er
healt h car e( 8).
Accom pany ing fam ily m em ber s and pat ient s
r eceiv ing car e seem t o per ceiv e t hat t he m ov em ent
of people at t h e u n it is par t of t h e st r at egy n ot t o
par t icular ize car e in t er m s of specializat ion ar eas. A
lar ge m aj or it y r efer s t o t he div er sit y of pr ofessionals
w ho ar e par t of t he healt h t eam , w hich int er act s so
a s t o p r o m o t e t h e b est p o ssi b l e ca r e i n t h e ca r e
cont ext . The st at em ent below sum m ar izes t his r ealit y:
... it at t r act ed m y at t ent ion t hat t her e is a ver y gr eat
diversit y in t here: t here are t echnicians, t here are aids, t here are
nur ses, t her e ar e physicians, t her e ar e physiot her apist s, t her e
were people from psychology asking if we needed accom panim ent ,
som et hing, t hat t hey could help w it h. I t hink t hey t r y differ ent
kinds of appr oaches, not j ust t he per son’s physical par t ... ( F1)
We o b s e r v e i n F1‘ s s t a t e m e n t t h a t t h e
c o n s t i t u t i o n o f a h e a l t h t e a m a t t h e I CU i s a n
in t er v en t ion ist st r at egy t h at does n ot j u st f ocu s on
m edical k n ow ledge, bu t aim s t o deliv er car e t o t h e
ot her in or der t o pr om ot e t he com plem ent ar iness of
healt h act ions. According t o F1, t he m ult ifocal view of
I CU car e does not seem t o r epr oduce a r educt ionist
pr act ice t hat is fr equent at int ensiv e car e unit s and
d i sso ci a t e s b o d y, m i n d a n d so ci a l r e l a t i o n s. Th e
obj ect ive is t o consider t he being as a w hole, r anging
f r o m h i s / h e r b i o l o g i c a l c o n s t i t u t i o n t o h i s / h e r
su b j ect iv it ies, su f f er in g , ex p ect at ion s an d , m ain ly,
in t er per son al bon ds.
The m ult iprofessional aspect of care is part of
t he appropriat ion process of t he work obj ect , cent ered
in dist inct pract ices, alt hough wit h a com m on obj ect ive
i n t h e i n t e g r a l c a r e s p h e r e o f h e a l t h s e r v i c e s .
Mu l t i p r o f e s s i o n a l p r a c t i c e s a r e a p p o i n t e d a s a
privileged st rat egy t o im prove care and t he qualit y of
c a r e d e l i v e r y. H o w e v e r, p r a c t i c e s c e n t e r e d i n
m u l t i p r o f e s s i o n a l a c t i v i t y a l s o h a v e a l i m i t i n g
com ponent w hen t hey r efer t o t he r epr oduct ion it self
and t o t he organizat ion of healt h services, besides care
act ions focused on biom edical and fragm ent ary care( 9).
Wor k or gan izat ion in Br azil is con sider ed t o
be direct ly relat ed t o t he social t ransform at ions im plicit
an d ex plicit in t h e pr odu ct ion con t ex t . Th e For dist
-Taylorist * product ivit y inherit ance includes, unt il t oday,
a st r u ct u r a l co m p o n en t t h a t i s m a n i f est ed i n t h e
co n t r o l o f p r o d u ct i o n m o d es a n d t h e l a b o r f o r ce,
reflect ed in t he presence/ absence of rout ine act ivit ies
an d o f p r ecar i o u s w o r k co n d i t i o n s. I n t h i s sen se,
“ efficiency” and “ cont rol” concept s w ould be t he rules
t hat influence pr oduct ion, w hen it st ar t s t o focus on
t he r epet it ion of t ask s inst ead of t he int r oduct ion of
d iscu ssion s t h at w ou ld cr eat e act u al or g an izat ion al
changes in t he pr oduct ion cont ex t( 10).
Tay lor ism and For dism cr eat ed a pr oduct ion
p r o cess l o g i c cen t er ed i n p a r t i a l a ct i v i t y, t h a t i s,
fr agm ent ed in t er m s of t he exist ence of concent r at ed
and v er t icalized poles. For dism also cont r ibut ed t o a
separ at ion am on g m an agem en t , con cept ion , con t r ol
an d ex ecu t ion , con st r u ct in g a cu lt u r e an d a specific
w ay of life, w hich is adj ust ed t o t he r epr oduct ion of
w or k and t he r at ionalit y of pr oduct ion. Wit h r espect
t o healt h pr oduct ion, it is consider ed t hat t his r ealit y
st ill per m eat es pr ofessionals’ daily w or k , w ho should
under st and it as a com plexit y, in w hich t he for m at ion
and social/ t echnical division could not be ignored, nor
c o u l d a c t i v i t i e s b e r e s u m e d t o t h e i r p a r t s a n d
f r a g m e n t s( 1 1 ). N u r s e s b e l i e v e t h a t t h e r e l a t i o n s
est ablished am ong t eam s, t he inst it ut ions and t he I CU
env ir onm ent ar e im por t ant in t he cont inuous sear ch
for w or k “ efficiency” by guar ant eeing st aff t o per for m
f u n ct ion s sat isf act or ily. Th is also p r esu p p oses t h eir
com m it m ent t o realit y, and t hat realit y w ill allow t hem
t o m ak e decision s au t on om ou sly :
As t he head, I alw ays t r y t o m aint ain a sat isfact or y
quant it y of m at erial and st aff at t he unit , previewing t he coverage
of shift s, st at em ent s, good m at er ials, because t he UH w or ks
w it h good m at er ials [ ...] As a car e pr ofessionals, one pr om ot es
qualit y by calling upon t he st aff t o r eally w or k, m aint aining a
good r elat ion w it h t hem , because t he I CU is a closed unit and
conflict s have t o be solved [ ...] ot herw ise it t urns int o a snow ball.
( E3)
... No r est r ict ion w hat soever is put up against your
w or k, neit her m edical nor fr om t he nur sing head, fr om nobody. I
feel very free, t hat is very good, I have an enorm ous aut onom y...
you do not depend on anybody. The assessm ent is your s, you’r e
t he one who decides, if you have t o apply a dressing or not . You’re
going t o do t hings in accordance wit h t he pre- est ablished rout ine,
but you decide out side t hat . ( E7)
Nu r ses’ au t o n o m y t o d eci d e o n w h at car e
should be im plem ent ed exer t s an im por t ant influence
on t h e f low an d m an agem en t of I CU act iv it ies. Th e
r e l a t i o n s e st a b l i sh e d a m o n g p r o f e ssi o n a l s a t t h i s
sect or and t he great er flexibilit y of nursing prescript ion
act i v i t i es seem t o i m p r o v e p o t en t i al co n d i t i o n s t o
p r o m o t e/ r eco v er p eo p l e’ s h ea l t h . Nu r ses a r e a l so
responsible for m aint aining t he t eam ’s int erest focused
on cooperat ive act ivit y, in t he at t em pt t o m ake t hem
co- r espon sible f or car e ef f icacy.
How ever, t his is not always t rue, m ainly w hen
w hat is at st ak e ar e t he r elat ions am ong people and
inst it ut ional policy as a w hole, besides t he ( lack of )
int erest t hat m ay be im plicit or explicit in professionals’
at t it udes. I n som e cases, som e pr ofessionals int er act
w ell w it h t heir colleagues, helping t hem w it h pat ient
a ct i v i t i e s. I n o t h e r s, t h i s d o e s n o t o ccu r, a n d i s
per ceiv ed by som e accom pan y in g r elat iv es:
I t hink t hat t hey really aren’t very int egrat ed, t here are
kind of “ sm all gr oups” , you know , and som e people m ake m or e
effor t s. We see t hat som e people ar e alw ays m oving ar ound w it h
t he pat ient s, alw ays doing som et hing, and ot her s ar en’t , t hey
keep on calling t o get a coffee [ ...] I don’t know if t hat is so
because I only st ay for one hour , I don’t know if it ’s because of
t heir schedule, but I t hink t hat som e of t hem int er act m or e and
ar e m or e dedicat ed [ ...] We know t hat t his causes st r ess, t hat if
one w ant s t o leave a bit , go for a w alk, t hat t his is consider ed
negat iv ely . Why do t hat ex act ly dur ing v isit ing hour s? I t is
w hen t he r elat ive is in doubt , t hey w ant t o know if t he pat ient is
being t r eat ed w ell, it is seen negat ively. I t hink t hat t hey do not
neglect , but it is seen negat ively, it seem s like public ser vice
st uff. ( F5)
Hospit al w orkers are hired by launching a call
for candidat es t o fill in places. Exam calls t end t o be
r e l e a se d e v e r y t w o y e a r s, i n v o l v i n g t e st s a b o u t
sp ecif ic an d p r act ical k n ow led g e. Af t er p assin g t h e
t est s and being hir ed, t heir public ser v ice cont r act is
r u led by t h e Un ified Legal Regim e of Feder al Pu blic
Ser v ant s ( RJU – Law 8112/ 1990) . The RJU has been
const ant ly m odified t hrough t he issuing of Provisional
Execut ive Decr ees ( MP) . MP 1595- 14/ 1997 led t o one
o f t h e m o s t s i g n i f i c a n t c h a n g e s , r e l a t e d t o t h e
nom inat ion and const it ut ion of public exam s. Thr ough
t h i s sy st e m , t h e e m p l o y e e st a r t s t o a ccu m u l a t e
per sonal adv ant ages, as w ell as differ ent iat ed dut ies
in t he w or k env ir onm ent .
Th e RJU ad m i t s t h e em p l o y ee as a p u b l i c
ser vant , guar ant eeing em ploy m ent st abilit y, w hich is
rar e in t h e pr ivat e sect or, af t er t h is sam e ser van t ’s
ap p r ov al on a t r ain in g assessm en t ( n or m ally af t er
t w o y ear s) . Af t er t h at p h ase, ( s) h e r et u r n s t o t h e
or iginal funct ion ( s) he w as hir ed for, m aint aining t he
j ob an d salar y for life. Accor din g t o t h e RJU, pu blic
servant s w it h a st able cont ract can only lose t heir j ob
t h r o u g h a f i n a l l e g a l s e n t e n c e o r a d i s c i p l i n a r y
adm inist r at iv e pr ocess, dur ing w hich t heir r ight t o a
full defense is guar ant eed( 12).
This fact in part icular concent rat es one of t he
m ain n u r sin g com p lain t s, w it h d ir ect con seq u en ces
f or t h e log ic of h ealt h / car e p r od u ct ion at t h e I CU.
Th e RJU is clear ab ou t p en alt ies, b u t t h ey ar e n ot
alw ay s ap p lied an d , w h en t h ey ar e, t h ey ar e v er y
b u r e a u cr a t i c, a n d i t t a k e s y e a r s b e f o r e t h e y a r e
act u ally r ecog n ized :
I n t er m s of t he t eam , of cour se w e have absences,
st at em ent s, in gener al, and t hese absences ar e dir ect ly r elat ed
t o car e qualit y and t o t he qualit y of client s’ sat isfact ion. Because,
as soon as som eone’s absent , t he r est of t he t eam has t o get
or ganized differ ent ly and w or k m or e, m ainly w hen t his absence
is a j ust ificat ion t hat is not plausible in t he st aff’s opinion, so
t hen t he level of dissat isfact ion increases. And t hen t here’s gossip,
discussions, int r igues. ( E6)
... public ser vice difficult ies, for exam ple, w hen t he
em ployee is absent , t her e is no adequat e punishm ent for t hat ,
it ’s not effect ive. I face difficult ies t o adapt t o t he hospit al, you
know ? Dam n, t he guy doesn’t show up for w or k and invent s an
apology. That happens fr equent ly her e and I get quit e upset ,
because it im pair s car e. That ’s com plicat ed, Leandr o, t he w or ker
is absent , he’s absent , his absence is deduct ed, but follow - up
does not alw ays occur , t her e is a w ay dur ing t he t r aining per iod,
but once he’s st able t her e is no w ay of follow ing up. ( E4)
... t he difficult ies w e face her e ar e labor pr oblem s. The
gr eat est difficult y w e see is t he st aff’s dissat isfact ion, r elat ed
t o w ages, w e’ve passed a long t im e w it hout a r aise, you know ?
I t ’s bad w hen you m anage a dissat isfied per son. ( E7)
Th e p u b l i c se ct o r h a s a l o n g t r a d i t i o n o f
adm inist r at iv e r efor m s, w hich ar e gener ally init iat ed
at t he beginning of a new public m anagem ent m andat e
a s a p o ssi b i l i t y t o a d a p t t h e p u b l i c a p p a r a t u s t o
g ov er n m en t p lan s. Th ese r ef or m s seem t o m ar k a
p r ocess of su ccessiv e r em od elin g of t h e St at e an d
w er e im plem ent ed in t he Var gas age, in t he 1930’s.
They ev en cont inued under t he m ilit ar y dict at or ship,
in order t o realign adm inist rat ive st ruct ures t o exercise
pow er in a cen t r alized w ay t h at or gan izes societ y ’s
int er est s. Besides t he adm inist r at iv e appar at us, such
as t h e Depar t m en t of Pu blic Ser v ice Adm in ist r at ion
t o m ak e possible social policies in t he fields of social
insur ance, w or k , econom y, t axes, am ong ot her s( 1 3 ).
Fr om t he int er nat ional econom ic cr isis in t he
1 9 7 0 ’s onw ar ds, at t em pt s w er e m ade t o r est r uct ur e
t h e econ om y, m ak in g it g lob ally d issem in at ed an d
inser t ing it int o t he globalizat ion pr ocess. The lat t er,
in t ur n, pr oduced effect s dur ing t hat per iod in or der
t o s t i m u l a t e c o m p e t i t i o n a m o n g m a r k e t s , i n a n
increasing capit al accum ulat ion period. I n t hat phase,
bey on d facin g con j u n ct u r al difficu lt ies, Br azil h ad t o
d e a l w i t h t h e b o n d s o f u r b a n i z a t i o n a n d
indust r ializat ion, besides t r y ing t o undo t he gr ow ing
f r a g i l i t y o f i t s e c o n o m y t h r o u g h g l o b a l c r i s e s .
How ever, t he count r y, w it h it s gr ow ing deficit , ended
up being incapable of m aking t he invest m ent s needed
for it s grow t h, bot h in t erm s of t he definit ion of public
p o l i ci es an d t h e f u n ct i o n i n g o f t h e ad m i n i st r a t i v e
a p p a r a t u s , b e c o m i n g a r e f u g e e o f i n t e r n a t i o n a l
funding bodies for t his sak e( 14).
Dur ing t he 1990’s, t he r est r uct ur ing pr ocess
of t h e pu blic appar at u s w as ex pan ded t o in ser t t h e
cou n t r y in t o t h e ex t er n al m ar k et , as a n ew for m of
r edir ect ing t he public spher es and adapt t hem t o t he
in t er n at ion al t en den cies of a n ew polit ical econ om y.
This ent ire realit y was accom panied, in pract ice, by a
profound privat izat ion process, in com binat ion wit h t he
g r eat er f lex ib ilit y of w or k r elat ion s, w h ich w as n ot
a l w a y s p r a ct i ce d w i t h g o o d se n se . Th e f i n a n ci a l
-adm inist r at ive aut onom y m anagem ent achieved could
put an end t o t he st abilit y grant ed by t he RJU, m aking
p ossib le h ir in g an d r esig n at ion s f or t h e b en ef it of
g r e a t e r e f f i c i e n c y. B u t i t w a s d u r i n g t h e Co l l o r
governm ent t hat disbelief in public service reached it s
height , which neut ralized t he professionals t hem selves
i n t h e se a r ch f o r t h e i r r i g h t s a n d d e v a l u e d t h e i r
dem ands for bet t er w ages and labor condit ions( 13).
W i t h r e s p e c t t o t h e h o s p i t a l a n d h e a l t h
policies, t he hospit al is affiliat ed w it h t he Single Healt h
Sy st em - SUS and em ploy ees ex per ience pr ecar ious
w ork condit ions on a daily basis, besides labor issues,
w h i c h a r e v e r y b u r e a u c r a t i c a n d d o n o t a l w a y s
correspond t o t he agilit y t hat seem s t o pr evail in t he
p r i v at e car e sect o r. Al t h o u g h t h ey w o r k i n a car e
r ealit y in w h ich all p ossib le m easu r es ar e t ak en t o
avoid lack of supplies and not t o im pair t he qualit y of
int ensiv e car e, nur sing car e m anagem ent difficult ies
se e m t o b e cl o se l y l i n k e d w i t h p u b l i c p o l i ci e s t o
bureaucrat ize t he public service, as w ell as w it h social
p o l i ci e s t h a t d o n o t a l w a y s p a y a t t e n t i o n t o t h e
em p loy ees’ con cer n s.
Th e t h e o r e t i c a l f r a m e w o r k f o r t h e
rest ruct uring process of t he St at e and it s im plicat ions
for h ealt h w as t h e con st it u t ion of t h e Sin gle Healt h
Syst em . Dissem inat ed t hr ough t he 1988 Const it ut ion,
t he SUS has gone t hr ough const ant r efor m s in t er m s
of ser v ice funding and m anagem ent decent r alizat ion.
Th e ideology t h at at t em pt ed t o in t egr at e t h e St at e
and civil societ y in t he conquest of a cont rol exercised
t hrough t he m obilizat ion of all w ould not be a source
of fight against inequalit ies, as budget rest rict ions for
public int er vent ion and ser vice offer ing dest ined a par t
o f f u n d s t o p o l i ci es d i r ect ed at t h e p o o r est so ci al
se g m e n t s, su ch a s t h e Co m m u n i t y He a l t h Ag e n t
pr ogr am and t he Fam ily Healt h Pr ogr am( 15).
Pu b l i c ser v i ce a ct i v i t y i s essen t i a l f o r t h e
f u n ct ion in g of t h e St at e an d f or t h e r ed ef in it ion of
public policies, for any goal. Wit hin t he realit y of healt h
pr om ot ion in car e ser v ices, w e consider t hat nur sing
praxis is insert ed in a com plex social locus, m ediat ed
b y t h e s t a t e s t r u c t u r e , b y w o r k c o n d i t i o n s , b y
eco n o m i c p o l i cy an d ev en b y t h e p o w er r el at i o n s
e st a b l i sh e d a m o n g t h e p r o f e ssi o n a l s t h e m se l v e s.
H o w e v e r, t h e p o s s i b l e “ d i s c o u r a g e m e n t ” o f I CU
p r of ession als seem s t o b e closely r elat ed w it h t h e
or igins of t he feder al public ser v ice and it s const ant
discr edit in g by su bsequ en t gov er n m en t s.
Mo r eov e r, w e b el i ev e t h a t t h i s co n t ex t o f
“ d iscr ed it ” in p u b lic ser v an t s’ w or k is accom p an ied
par i passu by in cr easin g u n h ealt h y w or k con dit ion s,
r ev ealed in in su f f icien t ad m in ist r at iv e in v est m en t s,
as w ell as in w age r eadj u st m en t policies t h at of t en
g i v e l i t t l e at t en t i o n t o w o r k er s’ i n t er est s, b esi d es
i n st a b i l i t i e s i n t h e Br a zi l i a n e co n o m i c p o l i cy t h a t
in t er f er e in t h ese in t er est s. I n t h e w or k con t ex t of
t h e h o sp i t al I CU, o n e ex am p l e o f t h i s co n cer n i n g
r ealit y is t he fight t o adopt t he 30- hour w or k j our ney,
as show n below :
... I hav e r equir ed t he 30 hour s because, act ually ,
alt hough not officially, ot her ar eas do it inside t he I CU and w e
w ho fight for t he 30 hour s do not m anage t o. I r eally r equir e it ,
also because ot her ar eas w it h lesser dem ands, such as nur sing
in a hospit al inst it ut ion, w or k 30 hour s [ ...] I t hink m anagem ent
is ill- w illed and t he cur r ent m anagem ent is ext r em ely r igid in
t his sense. Because t her e alr eady exist s a decr ee, pr ovided t hat
w e m anage t o get or ganized. That ’s life, t hat ’s polit ics, w hile w e
see ot her em ployees w or king even less, w ho ar e som et im es not
so dir ect ly involved w it h t he pat ient [ ...] t hat inj ust ice bot her s
m e a lot . ( E3)
Th e St at e is be t h e appar at u s t h at con t r ols
legal-e t h i ca l - legal-e co n o m i c a p p a r a t u s t h a t i s m a n i f legal-e st legal-e d i n
m at erial life, in int erpersonal relat ions, in polit ics and
in t he econom y. I t w ould also inhibit m anifest at ions
t hr ough social coer cion m echanism s. How ev er, m an,
no m at t er how suffocat ed by t he r egulat or y condit ions
pr om ot ed by t he St at e, should never give up fight ing.
He sh ou l d al w ay s r el at i v i ze h i s w or l d , h i s h i st or y,
seeking his life philosophy in it , w it h a view t o finding
his indiv idualit y, his et hical- m or al conscience and his
concept ion of t he w or ld( 5).
We con sider t h at , n o m at t er h ow m u ch w e
t hink about a discr edit ed civ il ser v ice, w hich is also
d iscou r ag ed b y t h e f ed er al g ov er n m en t ’s con st an t
im p osit ion s on t h e in v est m en t p olicy, an d ab ou t a
career plan t hat has not considered t he professional’s
v aluat ion, t her e seem s t o ex ist , in E3’s discour se, a
m obilizin g f eelin g t h at is t r an slat ed in t h e con st an t
sear ch for his r ight s and adv ant ages. E3’s discour se
seem s t o be a t endency w hose ideology goes against
t h e con f or m ist policy w h ich n u r sin g, t h r ou gh ou t it s
h i st o r y, h as l ear n ed t o l i v e w i t h – an d t o accep t ,
definit ely fight ing lit t le for t he t ransform at ion of realit y.
Th i s f e e l i n g o f st r u g g l e b y E3 i s i m p o r t a n t a s a
m e c h a n i s m t o c o p e w i t h t h e i n e r t i a a n d a s a n
alt ernat ive t o recover a new hegem onic relat ion, w it hin
a polit ical pr act ice of inv olv em ent w it h t he dignit y of
t he value of w or k in t he public spher e.
I n t h i s sen se, t h e m u l t i p r of essi on al t eam ,
w h ich can be a w ay of em an cipat in g it s con st it u en t
su b j ect s an d an i n st r u m en t t o r ev i t al i ze t h e w or k
pr ocess, needs t o adopt a fr ont line t hat is capable of
r ecogn izin g t h e cou r se t o con st r u ct h ealt h an d car e
p r a c t i c e s . Ev e n i f t h e i n t e n t t o c o n s t i t u t e a n
env ir onm ent posit iv ely affect s t he spher e of t he car e
ob j ect iv e, it is n ot en ou g h j u st t o t h in k ab ou t I CU
act iv it ies as t ot alizing healt h act ions. I t is im por t ant
t o c o n t i n u o u s l y a n d c o l l e c t i v e l y m o b i l i z e a l l
professionals, considering t hat t he healt h- disease- care
pr ocess, as w e could per ceiv e, also inv olv es polit ics,
inst it ut ional organizat ion and relat ions am ong different
pr ofessions. The t r ansfor m at ion of car e goes t hr ough
an int r iguing dialect ics, w hich is oft en int er m ediat ed
by a t or t uous cour se, but t his t r ansfor m at ion should
be a sou r ce of per m an en t st r u ggle, h igh ligh t in g t h e
r ight t o a dignified life, t o adequat e w or k condit ions,
t o polit ical right s, as w ell as t o t he value of t he hum an
b ein g , as a car eg iv er an d as a b ein g t h at r eceiv es
car e, in t his com plex it y.
FI NAL CONSI DERATI ONS
I t could be per ceived t hat t he w or k and logic
of h ealt h p r od u ct ion at t h e I CU ar e m ix ed u p in a
com plex n et w or k t h at inv olv es hu m an, pr ofessional,
in st it u t ion al an d polit ical r elat ion s, w h ich dir ect ly or
indir ect ly influence t he car e t he healt h t eam deliv er s
t o pat ien t s an d accom pan y in g f am ily m em ber s w h o
ex per ience t he healt h- disease pr ocess at t he I CU.
We con sid er t h at t h e r elat ion s est ab lish ed
bet w een w or ker s and or ganizat ional inst it ut ions seem
t o influence, t o a great er or lesser ext ent , t he qualit y
o f c a r e d e l i v e r y, a s w e l l a s t h e p r o f e s s i o n a l s ’
k n ow ledge abou t h ealt h an d illn ess at t h e I CU. We
b eliev e t h at u n v eilin g t h is r ealit y is in t er est in g t o
pr om ot e const ant r eflect ion and t r ansfor m at ion of t he
i n t e n s i v e c a r e c o n t e x t b y t h e h e a l t h t e a m a n d
accom p an y in g f am ily m em b er s.
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