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MEANI NGS OF THE NURSI NG DI AGNOSI S I MPLEMENTATI ON
PROCESS FOR NURSES AT A UNI VERSI TY HOSPI TAL
1Ant ônio Fer nandes Cost a Lim a2 Paulina Kur cgant3
Lim a AFC, Kurcgant P. Meanings of t he nursing diagnosis im plem ent at ion process for nurses at a universit y hospit al. Rev Lat ino- am Enferm agem 2006 set em bro- out ubro; 14( 5) : 666- 73.
This qualit at ive st udy aim s t o underst and t he m eanings nurses at a universit y hospit al at t ribut e t o t he im plem ent at ion pr ocess of t he Nur sing Diagnosis Classificat ion Sy st em ( DEn) as a phase in t he Nur sing Car e Sy st em ( NCS) . Dat a w er e collect ed t hr ough int er v iew s w it h eight nur ses fr om t he Medical Clinical Unit , w ho part icipat ed in t he creat ion of an inst rum ent t o im plem ent t he DEn in t he NCS. I n t heir report s, t he respondent s ex pr essed a posit iv e ch an ge in t h eir feelin gs, fr om in it ial discom for t an d adv er se per cept ion of t h e ch an ge pr oposal. Th e st epw ise appr opr iat ion of t h e pr ocess st ages allow ed t h em , besides t h e sh ar in g of f eelin gs, d ecision s an d r esp on sib ilit ies f or t h e r esu lt s, t o d ev elop t h e b elief t h at t h ey w ou ld ab le t o ov er com e t h e dif ficu lt ies.
DESCRI PTORS: nur sing diagnosis; or ganizat ional innov at ion; r esour ces m anagem ent
SI GNI FI CADOS DEL PROCESO DE I MPLEMENTACI ÓN DEL DI AGNÓSTI CO
DE ENFERMERI A PARA ENFERMERAS DE UN HOSPI TAL UNI VERSI TARI O
Est e est udio cualit at iv o busca com pr ender los significados at r ibuidos por enfer m er as de un hospit al univ er sit ar io al pr oceso de im plem ent ación del diagnóst ico de enfer m er ía ( DEn) com o et apa del Sist em a de At ención de Enferm ería ( NCS) . La recolect a de dat os fue realizada por m edio de ent revist as con ocho enferm eras de la unidad de Clínica Médica, que par t icipar on de la const r ucción de un inst r um ent o par a la im plem ent ación del DEn en la NCS. Dur ant e las nar r aciones, las colabor ador as explicit ar on una t r ansfor m ación posit iva de sus sent im ient os, a par t ir del desconfor t o inicial y de la per cepción desfav or able con r elación a la pr opuest a de m u d an za. En v ir t u d d e la ap r op iación g r ad u al d e las et ap as d el p r oceso p or la cu al p asar on , p er m it ier on ad em ás d e com p ar t i r sen t i m i en t os, d eci si on es, r esp on sab i l i d ad es p or l os r esu l t ad os, f u n d am en t al m en t e alcanzar on el desar r ollo de la cr eencia de que ser ian capaces de super ar las dificult ades.
DESCRI PTORES: diagnóst ico de enfer m er ía; innov ación or ganizacional; gest ión de r ecur sos
SI GNI FI CADOS DO PROCESSO DE I MPLEMENTAÇÃO DO DI AGNÓSTI CO
DE ENFERMAGEM PARA ENFERMEI RAS DE UM HOSPI TAL UNI VERSI TÁRI O
Est e est udo qualit at iv o busca com pr eender os significados at r ibuídos por enfer m eir as, de um hospit al u n iv er sit ár io, ao p r ocesso d e im p lem en t ação d o sist em a d e classif icação d e d iag n óst icos d e en f er m ag em ( DEn) com o et apa do Sist em a de Assist ência de Enfer m agem ( NCS) . A colet a de dados foi r ealizada por m eio de en t r ev ist as com oit o en f er m eir as da u n idade de Clín ica Médica, qu e par t icipar am da con st r u ção de u m in st r u m en t o p ar a a im p lem en t ação d o DEn n o NCS. Nos seu s r elat os, as colab or ad or as ex p licit ar am u m a t r ansfor m ação posit iv a em seus sent im ent os, a par t ir do desconfor t o inicial e da per cepção desfav or áv el em relação à propost a de m udança, em virt ude da apropriação gradat iva das et apas do processo que lhes perm it iu, a l ém d o co m p a r t i l h a m en t o d o s sen t i m en t o s, d a s d eci sõ es e d a s r esp o n sa b i l i d a d es p el o s r esu l t a d o s, o desenv olv im ent o da cr ença de que ser iam capazes de super ar as dificuldades.
DESCRI TORES: diagnóst ico de enfer m agem ; inov ação or ganizacional; gest ão de r ecur sos
1 Extracted from the Dissertation; 2 RN, PhD, University Hospital, e- m ail: [email protected]; 3 RN, Full Professor, College of Nursing, e- m ail: [email protected].
University of São Paulo
Rev Latino- am Enferm agem 2006 setem bro- outubro; 14( 5) : 666- 73 www.eerp.usp.br/ rlae
Art igo Original
I NTRODUCTI ON
S
ince 1981, the Nursing Departm ent ( ND) at the University Hospital of the University of São Paulo ( HU- USP) has been im plem enting the Nursing Process, l a t e r ca l l e d Nu r si n g Ca r e Sy st e m ( NCS) , w h i ch con sist s of t h r ee p h ases: Hist or y, Ev olu t ion an d Nur sing Pr escr ipt ion. Since t hat t im e, nur ses hav e b e e n d e v e l o p i n g t h e sy st e m a s a n i m p o r t a n t inst rum ent t o guide care, t eaching and research.Nurses from the ND believe that the NCS not o n l y f a v o r s h ea l t h p r o m o t i o n , m a i n t en a n ce a n d recovery, but also st im ulat es self- care and allows for the integration of teaching- care actions, as a learning strategy for undergraduate and graduate students and t he nursing t eam( 1).
Acr oss t he y ear s, t he nur ses fr om t he HU-USP h av e pr ov ed t h e su ccess an d ef f icacy of t h e N CS( 2 ). Ho w e v e r, t h e y h a v e a l so i n d i ca t e d t h e
difficult ies t hey ar e confr ont ed w it h t o dev elop t he sy st em , as w ell as t h e n eed f or ch an ges t ow ar ds great er agilit y, increasingly im proving t he qualit y of car e and educat ional act ions. Hence, in Decem ber 2001, ND m anagem ent started the Nursing Diagnosis im plem ent at ion process, as t he second phase of t he NCS, also aim ing for it s com put erizat ion.
I m plem ent ing a new m et hodology t o guide n u r si n g ca r e d el i v er y i m p l i es f a ci n g a ser i es o f ch a l l e n g e s, w h i ch r e q u i r e s t h e a p r i o r i acknowledgem ent of t he inst it ut ion’s and t he nursing team ’s possibilities and lim its( 3). Thus, in March 2002,
t h e Fa ci l i t a t o r Gr o u p f o r Nu r si n g D i a g n o si s I m plem ent at ion ( GFI DE) was const it ut ed, t o support t he guidance of t he planned change pr ocess, using t he nursing diagnosis classificat ion syst em proposed by t he Nort h Am erican Nursing Diagnosis Associat ion - NANDA( 4) as a t heoret ical reference fram ework.
Be t w e e n Ju n e a n d D e ce m b e r 2 0 0 2 , t w o courses were held about nursing diagnosis, wit h t he part icipat ion of 157 ( 97% ) nurses act ive in t he HU-USP, including practical exercises to apply the nursing diagn osis classificat ion in t h e differ en t u n it s’ car e r ealit y, as w ell as scient ific m eet ings w it h nur sing technicians and auxiliaries, during which professionals shared t heir perspect ives and expect at ions about t he new work proposal. I t should be highlighted that, during t he cour ses, m ost nur ses did not possess pr ev ious knowledge about the addressed contents and indicated their concern about the changes needed to im plem ent t he nursing diagnosis as a phase of t he NCS; som e
nur ses dem onst r at ed t heir int er est and ex cit em ent about the new work proposal, while others m anifested their resistance to the new proposal, stating that this would ent ail a work overload for t he nurses.
A large part of resistance to change originates in individual percept ions relat ed t o im aginat ion about t he fut ur e, t o past ex per iences and t o t he bur den inherent t o t he change process it self( 5). Therefore,at
the sam e tim e as the developed activities, workshops were held, wit h t he presence of guest specialist s in t he nursing diagnost ic process, and som e ND nurses got the chance to participate in international scientific ev ent s about t he t hem e. Fur t her m or e, v isit s w er e o r g an i zed t o o t h er i n st i t u t i o n s t h at h ad al r ead y im plem ented the nursing diagnosis, to get to know its funct ioning and shar e ot her nur ses’ ex per iences in t his process.
I n January 2003, with a view to the creation of an in st r u m en t t o p u t t h e n u r sin g d iag n osis in pract ice in t he NCS, which would be appropriat e for the ND‘s philosophy and for nursing reality at the HU-USP, a 30- day survey was carried out of t he nursing diagnoses observed in pat ient s at t he different unit s. At t he end of t he est ablished per iod, t he ident ified diagnoses w er e inser t ed in a dat abase t o calculat e t he fr equencies of diagnost ic cat egor ies. The need for t he inst r um ent t o consider t he par t icular it ies of each unit r ev ealed t he im por t ance of a pr elim inar y study at a unit where the nursing diagnoses, elaborated by t he nur ses, had alr eady been inser t ed int o t he database. This research was carried out at the Medical Clinical unit ( MC) , w hich at t ended t o t his condit ion and, as it hospitalizes adult patients, its results could be replicated in other units of the institution.
THE EXPERI ENCE
I nit ially, t he nurses from t he MC received a list of all nursing diagnoses contained in the database, dist ribut ed according t o t he dom ains est ablished by NANDA’s( 4) Taxonom y I I , t oget her wit h a let t er t hat
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Th e ND m an ag em en t em p h asi zed t o t h e p er son s r esp on sib le f or h old in g t h e m eet in g an d conduct ing t he pr elim inar y st udy, t hat t hey should f a v o r r e f l e ct i o n s a b o u t t h e e v i d e n ce d t h e m e s, respect ing and welcom ing t he group’s choices. Thus, the m eeting took place in May 2003. I t presented the r esult of t he abov e descr ibed analy sis, aft er w hich t he MC nurses were inform ed about t he int ent ion t o in v olv e t h em in w or k sh ops, aim ed at cr eat in g an in st r u m en t t h ey w ou ld con sid er ad eq u at e t o t h e dem an ds of t h e pat ien t s t h ey at t en ded, an d w er e invit ed t o part icipat e in t he proposed proj ect . I t was explained that, to carry out this activity, som e m eetings would be required, and the im portance of spontaneous p a r t i ci p a t i o n w a s e m p h a si ze d . Pa r t i ci p a t i o n i s consider ed t o be a shar ed pr ocess in w hich people get em ot ionally involved, in group sit uat ions, which encourage them to contribute to the group’s obj ectives an d t o assu m e r esp on sib ilit y f or ach iev in g t h em . Hen ce, d ecision s sh ou ld b e m ad e t h r ou g h g r ou p co n se n su s, w i t h t h e p a r t i ci p a n t s’ m a x i m u m involvem ent and com m it m ent( 6).
Next , seven t wo- hour workshops were held, on days and tim es chosen by the participants, during w h ich t h ey t h or ou g h ly d iscu ssed t h e 1 4 select ed nur sing diagnoses, based on NANDA’s( 4) t heor et ical
reference fram ework. Then, t he m ain corresponding n u r sin g in t er v en t ion s w er e ch osen , b ased on t h e knowledge t hat guides nursing care pract ice and on p r o t o co l s t h a t e x i st e d a t t h e i n st i t u t i o n . Th e const ruct ed inst rum ent cont ained t he diagnoses and respect ive int ervent ions in print , as well as room t o record the nursing evolution, and was therefore called Nur sing Diagnosis- Ev olut ion- Pr escr ipt ion.
Lat er, t he nurses held m eet ings wit h nursing t echnicians and aux iliar ies at t he MC t o shar e t he changes in the NCS and to em phasize the im portance of their participation for the success and concretization of t his new w or k pr oposal. Dur ing t hese m eet ings, t he nursing t echnicians and auxiliaries assessed t he new instrum ent and suggested changes that were later incorporat ed. These professionals indicat ed t hey felt valued and respect ed because t hey could give t heir opinion and decide about t he cont ent s of t he new inst r um ent and m anifest ed t heir eager ness t o st ar t using it.
Despit e t h e dou bt s an d u n cer t ain t ies t h at em erged during the workshops, the nurses constantly dem on st r at ed t h eir m ot iv at ion t o p ar t icipat e in a pr elim inar y st udy t hat could be a landm ar k for t he
im plem ent at ion of t he nursing diagnosis as a phase of t he NCS. We decided t o car r y out t his st udy t o understand the m eanings the MC nurses attributed to t his pr ocess of im plem ent ing t he nur sing diagnosis classificat ion syst em at t he NCS of t he HU- USP.
THE METHODOLOGI CAL TRAJECTORY
We u sed t h e q u alit at iv e case st u d y as a m et hodological reference fram ework. The case st udy i s a q u a l i t a t i v e m e t h o d o l o g i ca l a p p r o a ch t h a t r e p r e se n t s a r e se a r ch m o m e n t , g u i d e d b y a n i n t er p r et a t i v e ep i st em o l o g y, w h er e t h e su b j ect , consider ed as t he st udy obj ect , is conceiv ed as an in d iv id u al an d con cr et e b ein g , u n iq u e in h is/ h er exist ence, develops his/ her act ivit ies creat ively, in a d et er m i n ed sp ace an d t i m e, w i t h i n a st r u ct u r ed sociocult ural syst em( 7).
I nit ially, t he research proj ect was subm it t ed t o t he Teaching and Resear ch Com m ission and t he Et hics Com m it t ee of t he HU- USP. Aft er t heir approval, d at a collect ion st ar t ed . Th en , w e in v it ed t h e MC nurses who had part icipat ed in t he nursing diagnosis cour se, car r ied out t he case st udies by for m ulat ing nursing diagnoses and part icipat ed in t he prelim inary st u d y f or t h e con st r u ct ion of t h e in st r u m en t , t o part icipat e in t his research by grant ing an int erview, which would be recorded. Am ong t he t en nurses who w or k ed at t he unit , eight at t ended t o t he adopt ed select ion cr it er ia an d w er e in v it ed. Non e of t h em r efused t o par t icipat e.
Three guiding quest ions were form ulat ed for the interviews: “ How do you perceive the NCS of the HU- USP before t he nursing diagnosis im plem ent at ion process?”, “ How do you perceive the nursing diagnosis im plem ent at ion process in t he NCS of t he HU- USP?” and “ How do you perceive t he concret izat ion of t he nur sing diagnosis im plem ent at ion pr ocess and y our insertion in this process from this m om ent onwards?”. Af t er each i n t er v i ew , t h e t r an scr i p t i on ( r i g or ou s t r ansfer ence of t he r ecor ded or al r epor t t o w r it t en language) , t ext ualizat ion ( reorganizat ion of t he t ext , where t he quest ions asked are elim inat ed and added t o t h e i n t er v i ew ee’s an sw er s) an d t r an scr eat i o n ( inversion of paragraph order, addit ion or rem oval of w or ds, based on agr eem ent s w it h t he int er v iew ee) phases were realized. I t should be highlight ed t hat , due to their significant roles in the entire process, the int erviewees are called collaborat ors( 8).
Meanings of t he nursing diagnosis...
Lim a AFC, Kurcgant P.
The t ranscreat ed t ext s were ret urned t o t he collabor at or s, so t hat t hey could aut hent icat e t hem and authorize their publication. To m aintain anonym ity, we decided, with the collaborators’ agreem ent, to use t he nam es of Egypt ian queens. I n t he Egypt of t he p h ar aoh s, a w om an cou ld occu p y d if f er en t social posit ions, w het her as a queen- phar aoh, high r oy al wife, housewife, worker, initiated in a religious cult or pr iest ess. Wom en w er e consider ed equal t o m en in t h e m at er ial as w ell as sp ir it u al d om ain , h av in g aut onom y t o organize her life and form of living( 9).
The collabor at or s‘ ages r anged fr om 25 t o 40 years, and t hey had graduat ed bet ween one and a h alf y ear s an d 1 6 y ear s. Tw o collabor at or s h ad worked at the MC for less than three years, four had w or k ed bet w een fiv e and t en y ear s and t w o m or e t h an t en y ear s. Fou r collab or at or s w er e t ak in g a specialization course in Gerontology Nursing; one was t aking a Mast er’s course in Adult Healt h; one was a specialist in Hospital Adm inistration and had a Master’s degree in Nursing Adm inistration, while two were not t aking any graduat e course.
I NTERPRETATI VE DATA ANALYSI S
The int erpret at ive analysis of t he narrat ives allowed us t o const ruct t hree cat egories: Percept ion o f t h e NCS b e f o r e t h e n u r si n g d i a g n o si s im plem en t at ion ; per cept ion abou t t h e NCS in t h e nursing diagnosis im plem ent at ion and percept ion of new roads for t he NCS.
Perception about the NCS before the nursing diagnosis im plem ent at ion
This first category presents the collaborators’ p e r ce p t i o n s a b o u t t h e NCS b e f o r e t h e n u r si n g diagnosis im plem ent at ion pr oposal, consider ing t he infor m at ion r eceiv ed accor ding t o t heir ex per iences in differ ent cont ex t s. Accor ding t o t he discour se of t he collaborat or present ed below, t he t heoret ical or t heoret ical- pract ical inform at ion received during her undergraduat e course, as well as her experiences at t he HU- USP it self and in ot her inst it ut ional realit ies, influenced her per cept ion about t he NCS: I st ar t ed
working at t he Medical Clinical unit 12 years ago. I did not have
any experience wit h t he NCS, t his t hem e had been t reat ed very
t heoret ically in college, wit hout any pract ice. I t was a very good
experience, I learned how t o use t he NCS t o guide m y act ions and
plan nursing care. I had t he opport unit y t o work at anot her hospit al
t hat did not use t he NCS and I observed how difficult it was t o
plan care... I was lost because I did not m anage t o direct t he
act ions I int ended t o deliver t o each pat ient ... ( Meresankh)
The other collaborators’ statem ents evidenced t h a t , i n g e n e r a l , t h e n u r si n g p r o ce ss h a d b e e n a d d r e sse d o n l y su p e r f i ci a l l y d u r i n g t h e i r u n d e r g r a d u a t e co u r se , m e r e l y f o cu si n g o n t h e t heoret ical dim ension. I t was only aft er t hey st art ed working at t he HU- USP and lived t he NCS, in t heory as w ell as in pract ice, t hat t hey could perceive t he im portance of this care m odel as an elem ent to guide nursing care.
Th e an aly sis of d iscou r se ab ou t t h is f ir st ca t e g o r y a l l o w e d u s t o co n st r u ct t h e f o l l o w i n g su bcat egor y :
- Aspects related to put t ing t he NCS in practice
The collabor at or s ex plained t hat t heir daily NCS experience allowed them not only to reflect about i t s p r a ct i ce , b u t a l so t o co m p a r e i t w i t h o t h e r inst it ut ional scenar ios, highlight ing facilit at or s and aspect s t hat t urn care delivery m ore difficult . I n t he following statem ent, the sim ultaneous presence of the posit iv e and negat iv e poles is r em ar k able: I believ e
t he NCS grant s t he nurse a global view of t he pat ient , allowing
her t o ident ify care needs and facilit at ing t he daily dist ribut ion
of nursing t eam act ivit ies. The NCS helps us a lot , we are a
reference for t he pat ient , we at t em pt t o clarify his doubt s during
our daily visit , w e give or ient at ions, in shor t , w e ar e alw ays
following him in one way or anot her. What used t o m ake som e of
our act ions m ore difficult was t hat we wrot e a lot ... regist ering
unnecessary inform at ion, not always t he m ost adequat e cont ent s.
This used t o t ake a large part of our t im e ( Cleopat ra)
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associat ed t h e NCS w it h n egat iv e aspect s, m ain ly r elat ed t o t h e r egist r at ion of NCS docu m en t at ion , which requires a lot of tim e and distances them from care and supervision. Som et im es, t he collaborat ors’ concept ion of NCS as a bur eaucr at ic act ivit y point s towards the need to reflect about how they have been conduct ing t he sy st em , w it h a v iew t o a conscious and crit ical pract ice, based on clinical reasoning, t o achieve results the nurses and the entire nursing team are responsible for.
Per cept ion about t he NCS in t he nur sing diagnosis im plem ent at ion
Two subcat egories were ext ract ed from t his second category, one of which addresses the technical dim ension in t he nur sing diagnosis im plem ent at ion pr ocess, and t he ot her t he feelings ex per ienced at different t im es during t his process.
- The t echnical dim ension in t he nur sing diagnosis im plem ent at ion pr ocess
ND m anagem ent believ ed t hat t he success of the planned changed process presupposed training for t he per sons inv olv ed and, t hus, w as const ant ly concerned about grant ing t he nurses t he necessary conditions for training: Through t he st udies, we obt ained a
clearer underst anding of t he diagnost ic process and also observed
t he singularit y of t he Medical Clinic in relat ion t o ot her unit s.
When we st art ed t o survey t he m ost frequent diagnoses, we
were already m ore accust om ed t o elaborat e t hem ... Of course we
had t o cont inue st udying a lot , consult ing books... We want ed t o
m ak e t he nur sing diagnosis happen, w e w ant ed it t o w or k .
( Nefert ari)
I n view of recom m endations for the execution of t h e n u r sin g d iag n osis im p lem en t at ion t o f ocu s init ially on know ledge, t hen on at t it udes, individual behavior and, finally, on organizat ional change, i.e. four change levels( 11), various individual and groups
st rat egies were used for t raining t he nurses, such as case st u dies, m eet in gs an d scien t if ic discu ssion s, w i t h i n a n d o u t si d e t h e HU- USP, w i t h f a v o r a b l e repercussions on t he collaborat ors’ concept ion.
- The feelings exper ienced in t he nur sing diagnosis im plem ent at ion pr ocess
Th e f e e l i n g s t h e co l l a b o r a t o r s d i scl o se d show ed how each of t hem r eact ed t o t he changes
deriving from t he new work proposal. The following discour se pict ur es one collabor at or ’s feelings in t he init ial st age of t he nursing diagnosis im plem ent at ion:
At first , I felt t he nursing diagnosis im plem ent at ion was being
im posed by t he Nursing Depart m ent ... The nurses I had cont act
wit h said t hey felt t he sam e t oo... I was one of t hose persons
who could not even hear t he words nursing diagnosis, I pret ended
t hat it did not exist as long as I could... I t hought it was yet
anot her t ask, am ong so m any ot hers I had t o deal wit h... And
t hen t hey were invent ing t his new hype... ( Neit h)
This ev idences t hat , for m any nur ses, t he con t act w it h t h e ND’s n ew w or k p r op osal cau sed feelings of discom fort, such as fear, insecurity, fragility, despair, difficult y t o accept t he new and perceive t he proposal as an im position by the heads. These j ointly p e r ce i v e d a n d e x p r e sse d f e e l i n g s g a v e r i se t o r eact ion s lik e f lig h t , d iscr ed it an d , con seq u en t ly, resistance to the proposal, which is considered a factor t hat m akes work m ore difficult .
I n o r d e r t o u n d e r st a n d b e h a v i o r s o f r esist an ce t o ch an g e, it is n ot on ly n ecessar y t o exam ine individual at t it udes t owards t he novelt y, but also t o an aly ze b eh av ior s, w h ich can r an g e f r om indifference and subtle form s of im pedim ent to radical opposit ion act ions. I n t his sense, t he change leaders need t o develop t oler ance, as people ar e differ ent ; com p r eh en sion , b ecau se ad m in ist r at iv e b eh av ior s h av e a cau se; cau t ion , b ecau se n ew p eop le an d k n ow ledge t h r eat en s w h at alr eady ex ist s an d t h e ack now ledgem ent of em ploy ees’ capacit y, because cr eat iv e an d in n ov at iv e r esou r ces ex ist w it h in t h e organizat ion it self( 5).
As m e n t i o n e d a b o v e , t h e m e t h o d o l o g y adopt ed t o im plem ent t he nursing diagnosis process in t h e NCS sou gh t t o pr iv ilege t h e n u r ses’ act u al par t icipat ion, w hich r equir ed t heir gr adual t r aining. Th e collabor at or s ex pr essed t h eir per cept ion s an d feelings when going t hrough t he different phases of this process, as follows: When we st art ed t o elaborat e t he
diagnoses, we faced m any difficult ies and we had no one t o t urn
t o, it was all new t o everybody. So it was difficult because we did
not have a m ore experienced person t o help us wit h our doubt s...
Even t he heads were part icipat ing in t he process and learning
t oget her wit h us. ( Nit ocris)
So m e co l l a b o r a t o r s ev i d en ced h o w t h ei r f eelin gs t r an sf or m ed f r om in it ial discom f or t , bot h individually and collect ively, t o ot her m ore favorable f eel i n g s an d , t h u s, h o w t h ei r co n cep t i o n o f t h i s experience changed. According to their discourse, the f ou n d at ion f or each of t h e p h ases in t h e n u r sin g
Meanings of t he nursing diagnosis...
Lim a AFC, Kurcgant P.
diagnosis im plem entation process and the fact that they could act ually part icipat e played a param ount role in this positive transform ation: We perceived t hat t he diagnosis
was not som et hing invincible, t hat , in a way, it would help us,
m ainly by decreasing t he t im e spent t o put t he NCS in pract ice...
We gradually recovered from t he init ial shock and act ually got int o
t he t hing, we incorporat ed t he process and, nowadays, we believe
it really cam e t o im prove a lot of t hings... ( I sis)
For t he MC nurses, t he j oint const ruct ion of an inst rum ent t o put t he nursing diagnosis int o t heir daily practice, as well as the possibility that their needs and proposals would be t aken int o account , creat ed feelings of appropriat ion and co- responsibilit y for t he concret izat ion of t his phase of t he nursing diagnosis im plem entation process in the NCS: The const ruct ion of
t his inst rum ent was very valuable because it was accom plished
by our group, which lives t he realit y of t he Medical Clinic, including
ou r div ision dir ect or an d a r epr esen t at iv e f r om per m an en t
educat ion. We all conquered t his, t oget her. Since I have st art ed
working here, I have never heard of an inst rum ent const ruct ed
by nurses. All inst rum ent s had been im plem ent ed m any years
ago and no change had been proposed in t he NCS... When we
part icipat e, we are m ore involved, we give m ore, our effort is
bigger because we want t o facilit at e our work. ( Nefert it e)
I t is im portant to listen to em ployees in order t o u n d e r st a n d t h e i r m o t i v e s t o b e sa t i sf i e d o r dissat isfied. Managem ent should t ransm it inform at ion about im por t ant fact s and decisions r elat ed t o t he com pany’s obj ect ives, t he problem s it is facing, t he responsibilit ies and at t ribut ions t o be com plied wit h, t he fut ur e and pr ogr am m ed ev ent s t hat w ill affect the staff( 12).
Th e n u r se s e x p l a i n e d t h a t , d u r i n g t h e m eetings to construct the instrum ent, when they could share t heir feelings and experiences, t hey perceived sim ilarit ies bet ween t he sit uat ions t hey experienced, no m at t er w hat shift t hey w or ked. The view of t he w h o l e m a d e t h e m cr e a t e a w a r e n e ss a b o u t t h e d im en sion of t h is m om en t , as w ell as solid ar it y, considering t hat t hey were facing com m on problem s, and that they should seek the answers together. I t is n o t i ce a b l e t h a t t h e y a ssu m e d r e sp o n si b i l i t y, i n d i v i d u a l l y a n d co l l e ct i v e l y, f o r t h e a ct i v i t i e s developed during t he workshops, when t hey st art ed t o consider t he proposal no longer as a perspect ive im posed by t he ND, but as som et hing shared by t he ent ir e gr oup. This st ar t ed t o expr ess t heir belief in t he process.
As so o n a s t h e co l l a b o r a t o r s st a r t e d t o i n co r p o r a t e t h e ch a n g e p r o ce ss, se e k i n g t h e
knowledge needed for t heir t raining and t urning int o act ive part icipant s, t hey st art ed t o reflect about t he new realit y and about t he event s t hey experienced, facing them differently: When I t hink about t hings t oday, I
don’t see how t his could have been im plem ent ed different ly,
because we needed t o live t he difficult y of t he process t o value it
and t o m anage t o underst and it ... To feel t hat t his process was
m ade possible based on our realit y, t hat it was not im posed, we
const ruct ed it by living it each day. Today, I feel quit e at ease in
t his process, because I like it a lot when I have t he opport unit y
t o learn new t hings. ( Nit ocris)
W h e n t h e i r p a r t i ci p a t i o n b e ca m e m o r e int ense, gradually st art ing t hrough t he case st udies a n d f o l l o w e d b y t h e w o r k sh o p s a t t h e MC, t h e collabor at or s’ discour se ex pr essed t hat t he change st art ed t o be seen as a posit ive event , which m oved int o t he fut ure. I n t his sense, t he nurses st art ed t o sh ar e t h e co m m i t m en t s an d r esp o n si b i l i t i es an d created awareness of their potential, as dem onstrated below: My m ot ivat ion t o part icipat e in t he m eet ings was t he
sear ch for know ledge, t he fact t hat w e t hor oughly st udy t he
int ervent ions, t o t urn t hem act ually viable in our pract ice... Our
conduct s gradually becam e m ore uniform , less individual and
m ore represent at ive of our work at t he Medical Clinic. We m et ,
t alked and chose t he int ervent ions t hat were m ost coherent wit h
our professional pract ice, respect ing our colleagues, seeking a
consensus... The im plem ent at ion of t he diagnosis is a new t hing
and, as we are a reference at t he NCS, our experience will also be
useful t o ot her inst it ut ions. ( Neit h)
As m e n t i o n e d b e f o r e , t h e g r a d u a l appropriat ion of t his phase in t he nursing diagnosis im plem entation allowed the collaborators to transform t he feelings of discom fort int o posit ive feelings, such a s p e r so n a l a n d p r o f essi o n a l r ea l i za t i o n . Th i s t r a n sf o r m a t i o n d i d n o t o n l y o ccu r t h r o u g h t h e construction of the instrum ent, but m ainly because they could j oint ly assum e t he responsibilit ies and visualize t h e p e r sp e ct i v e s r e l a t e d t o t h e co n d u ct i o n a n d assessm ent of t he process. Despit e t he uncert aint ies they revealed, the nurses showed the transform ations that occurred not only in their way of feeling, but also in their ways of thinking and reacting, referring to their p r ep ar at ion t o cop e w it h f u t u r e ch allen g es: I f eel
encouraged t o part icipat e in t his process, I know I need t o st udy
m ore, t o act bet t er... I int end t o do t he best I can, t o discuss t he
diagnosis wit h t he ent ire nursing t eam , t o st im ulat e t hem t o
part icipat e... Aft er all, t his is a great opport unit y for all of us t o
part icipat e in som et hing t hat is st ill being const ruct ed. Despit e
t he difficult ies and challenges we will face, I believe it is going t o
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The planned change process is still a challenge for the collaborators. However, the challenge is already faced w it h opt im ism , in spit e of doubt s, fear s and u n ce r t a i n t i e s a b o u t t h e co n cr e t i za t i o n o f t h e prelim inary study and its developm ents. The presence of these feelings no longer represents a threat, but a sign of alert and challenge t o m aint ain at t ent ion and co m m i t m e n t i n t h e co n d u ct i o n o f t h i s p r o ce ss, legit im at ed by t he collaborat ors.
Percept ion of new roads for t he NCS
Th i s t h i r d cat eg o r y r eco v er s t h e n u r ses’ perceptions about new roads for the NCS through the int egrat ion of t he nursing diagnosis phase, wit h t wo subcat egories. The first considers t he conduct ion of t he nur sing t eam , w hile t he second deals w it h t he proposal t o com put erize t he NCS.
- I n the conduction of the nursing team
By t a k i n g h o l d o f t h e n u r si n g d i a g n o si s im plem entation process, the collaborators showed that d i f f i cu l t i es can b e o v er co m e an d t h at i n d i v i d u al d i f f e r e n ce s ca n b e d e cr e a se d t h r o u g h t h e com plem ent ar iness of t heir act ions. They indicat ed possible roads t o cont inue and im prove t he change process: When t he nursing diagnosis is im plem ent ed, we will
be able t o spend m ore t im e wit h t he em ployees and plan care
t oget her, wit h t he new inst rum ent , t hey will be able t o underst and
bet t er why we are proposing a cert ain int ervent ion... And t hat is
very im port ant : t hat t he t eam st ays t oget her, and t hat it ’s not
j ust t he nur se sit t ing t her e and pr escr ibing, w hile t hey only
execut e t he prescript ion. ( Meresankh)
To nurses, t he Nursing Diagnosis- Evolut ion-Prescript ion inst rum ent represent s t he expect at ion of decreased t im e spent on docum ent at ion for t he NCS and, consequently, that they will be able to get closer to patients and the nursing team . Thus, they consider t hat t hey will be able t o part icipat e m ore frequent ly in car e d eliv er y, d iag n ose n eed s f or p r of ession al nursing t raining and developm ent and act , t oget her with the Educational Support Service ( ESS) , to conduct st rat egies t hat favor t hese professionals’ qualificat ion and, consequently, im prove nursing care and teaching. The collaborat ors evidenced t heir awareness about the need for continuous im provem ent, indicating st r at egies t hey consider r elev ant for t he adequat e m a i n t e n a n ce a n d co n cr e t i za t i o n o f t h e n u r si n g d iag n osis im p lem en t at ion p r ocess in t h e NCS: To
concret ize t he nursing diagnosis in t he NCS, we will have t o keep
on st udying a lot , our pat ient profile is very com plex... We will
have t o cont inue our involvem ent and m aint ain our availabilit y...
Accept ing t hat we can m ake m ist akes and being flexible t o change
what is needed. I am sure t hat we will have t o m ake changes in
t he inst rum ent , and also t hat it ’s going t o work. This will all be
very good t o keep t he group t oget her, aft er all, we perceived t he
im port ance of st icking t oget her always, discussing our realit y.
Of cour se disagr eem ent s w ill alw ay s ex ist , but t hat is w hat
m akes us grow. ( Nefert ari)
The nurses believed it is im portant to m aintain a participatory process that favors spaces, within and outside the HU- USP, to exchange knowledge, feelings, e x p e r i e n ce s a n d co m m i t m e n t s. Pa r t i ci p a t o r y adm inist r at ion can be consider ed as a lev er for an inst it ut ion t o progress, base don t he people direct ly i n v o l v e d i n i t s m a n a g e m e n t . Th i s f o r m o f ad m in ist r at ion is an ev olu t ion of t h e d em ocr at ic process, as what prevails is the result of negotiations am ong all sides, including t he m inorit y’s will( 8).
- I n t he NCS com put erizat ion proposal
One of the ND’s goals in proposing the use of t h e n u r sin g diagn osis as a st an dar dized lan gu age system is to favor conditions to com puterize the NCS. Th e Nu r si n g D i a g n o si s- Ev o l u t i o n - Pr e scr i p t i o n inst r um ent , const r uct ed by t he nur ses, concr et izes a n i n t e r m e d i a r y p h a se b e t w e e n t h e p r e v i o u sl y d e v e l o p e d NCS a n d t h e p r o p o se d g o a l o f a co m p u t e r i ze d NCS: I s t i l l c a n n o t i m a g i n e h o w t h e
com put erizat ion of t he NCS will be put in pract ice... From our
discussions, it seem s t hat it will be som et hing good, t hat it will
facilitate our work. However, the fact of m oving from one extrem ity
t o t he ot her, t hat we will not writ e anyt hing anym ore, it scares
m e, it seem s t hat som et hing will be m issing... That is why we
need t o develop and achieve m ore securit y in t he diagnost ic
p r o c e s s , b e l i e v i n g t h a t i t w i l l b e v e r y u s e f u l t o m a k e
com put erizat ion viable as well. Any change creat es doubt s and
discom fort in people... We will have t o be flexible t o experience
t h is n ew r ealit y an d assess it s r eper cu ssion s f or ou r w or k
process. ( Cleopat ra)
Th e n u r se s e x p r e sse d t h e y se e co m p u t e r i za t i o n a s a n e w ch a l l e n g e a n d , a s i t represent s yet anot her change, it produces feelings of alert and concern about the need to adapt hum an and m at er ial r esour ces. How ev er, t hese feelings do not cause paralysis and resistance, as the collaborators dem onstrated their willingness to assum e a pro- active attitude, as well as the belief that they will be capable
Meanings of t he nursing diagnosis...
Lim a AFC, Kurcgant P.
to overcom e difficulties when new events com e about. The process t hey have experienced m akes sense t o t he collabor at or s and is v alued, because t hey feel that they are a part of it, that they are partners in its conduction and are responsible to assess the process and achieve result s.
FI NAL CONSI DERATI ONS
Accor ding t o t he collabor at or s, t he nur sing d i a g n o si s i m p l e m e n t a t i o n w a s co n ce i v e d a s a n im posit ion, as t hey had not chosen t he ND’s change p r o p o sa l , p r o d u ci n g r e si st a n ce a n d f e e l i n g s o f discom for t .
Th r ou gh ou t t h e pr ocess, w it h t h e gr adu al i n cr e a se o f t h e o r e t i ca l - p r a ct i ca l t r a i n i n g a n d p ar t icip at ion , t h e collab or at or s b ecam e ag en t s of change, disclosing a posit ive t ransform at ion in t heir feelings, aft er t heir init ial discom fort and unfavorable percept ion about t he im plem ent at ion of t he nursing diagnosis in t he NCS.
During the realization of the prelim inary study at t he MC, t he feelings t he nurses shared st art ed t o
be t reat ed m ore easily, as t hey st art ed t o assum e a pro- act ive at t it ude t owards t hem , confident t hat t hey co u l d co p e w i t h t h e se f e e l i n g s a n d o v e r co m e d if f icu lt ies t og et h er. I n n ovat iv e t h in k in g - act in g in health care requires a perm anent attitude of reflection and ethical investm ents from professionals, about the construction of a new care quality, in accordance with inst it ut ional possibilit ies and pot ent ials( 13).
The experience showed that the result turned into individual growth and, consequently, into an actual collect iv e p r od u ct . Wh en t h e n u r ses ap p r op r iat ed them selves of the process, this not only enabled them t o share decisions, but also t o assum e responsibilit y for t he result s. A part icipat ory cult ure only em erges an d dev elops in or gan izat ion s w h en t h eir leader s consider that the hum an being is reliable and likes to assum e responsibilit ies( 6).
Finally, it should be em phasized that the work m e t h o d o l o g y w e d e scr i b e d i n t h i s st u d y w a s successfully r epr oduced at t he ot her ND unit s and h a s sh o w n t h a t t e ch n i ca l - sci e n t i f i c t r a i n i n g , i n com binat ion w it h t he cr eat ion of spaces t hat v alue participation, favor professionals’ em otional dim ension t ow ar ds changes.
REFERENCES
1. Melleiro MM, Fugulin FMT, Rogenski NMB, Gonçalves VLM, Tr on ch in DMR. A ev olu ção do Sist em a de Assist ên cia de Enfer m agem no Hospit al Univ er sit ár io da Univ er sidade de São Pau lo: u m a h ist ór ia de 2 0 an os. I n : Cian ciar u llo TI , Gu a l d a D MR, Me l l e i r o MM, An a b u k i , MH . Si st e m a d e Assist ên cia d e En f er m ag em : ev olu ção e t en d ên cias. São Paulo ( SP) : Í cone; 2001. p. 109- 30.
2. Cianciarullo TI , Gualda DMR, Melleiro MM, Anabuki, MH. Si st e m a d e Assi st ê n ci a d e En f e r m a g e m : e v o l u çã o e t endências. São Paulo ( SP) : Í cone; 2001.
3 . Ba r r o s ALB d e , Gu t i é r r e z MGR. Si st e m a t i za çã o d a Assist ência de Enferm agem sob o referencial do cuidar. I n: Pr o g r a m a f i n a l e a n a i s d o 7 º Si m p ó si o Na ci o n a l d e Diagnóst icos de Enfer m agem ; 2004; Belo Hor izont e ( MG) . Belo Horizont e: ABEn; 2004. p. 45- 52.
4. Nor t h Am er ican Nur sing Diagnosis Associat ion. Nur sing d i a g n o se s: d e f i n i t i o n s & cl a ssi f i ca t i o n 2 0 0 1 - 2 0 0 2 . Ph iladelph ia: NANDA; 2 0 0 2 .
5. Mot t a PR. Transform ação organizacional: a t eoria e a prát ica de inovar. Rio de Janeiro ( RJ) : Qualit ym ark; 1998.
6. Chiavenat o I . Gerenciando pessoas: com o t ransform ar os ger ent es em gest or es de pessoas. 4a ed. São Paulo ( SP) :
Prent ice Hall; 2002. p. 47- 73.
7 . Bl a sco JS. Est u d i o d e ca so s. I n : Ag u i r r e Ba zt á n A. Et n og r af ia: m et od olog ía cu alit at iv a em la in v est ig ación soiciocult ural. Barcelona ( ES) : Marcom bo; 1995. p. 203- 8. 8. Meihy JCSB. Cant o de m ort e Kaiwá: hist ória oral de vida. São Paulo ( SP) : Loyola; 1991.
9. Jacq C. As egípcias: ret rat os de m ulheres do Egit o faraônico. 5ª ed. Rio de Janeiro: Bert rand Brasil; 2002.
1 0 . Cr u z I CF d a . A Si st e m a t i za çã o d a Assi st ê n ci a d e Enferm agem ( SAE) e o Sist em a Único de Saúde ( SUS) : breves consider ações. I n: Pr ogr am a final e anais do 7º Sim pósio Na ci o n a l d e D i a g n ó st i co s d e En f e r m a g e m ; 2 0 0 4 ; Be l o Horizont e ( MG) . Belo Horizont e: ABEn; 2004. p. 24- 30. 11. Miller E. I m plem ent at ion issues: an overview. I n: Miller E, edit or. How t o m ake nursing diagnosis work: adm inist rat ion an d clin ical st r at egies. Nor w alk : Applen t on Lan ge; 1 9 8 9 . p . 7 3 - 1 1 7 .
12. Maxim iano ACA. Teoria geral da adm inist ração: da escola cient ífica à com pet it ividade na econom ia globalizada. 2a ed.
São Paulo ( SP) : At las; 2002. p. 457- 78.
13. Mandú ENT. I nt ersubj et ividade na qualificação do cuidado em saúde. Rev Lat ino- am Enfer m agem 2004 j ulho- agost o; 1 2 ( 4 ) : 6 6 5 - 7 5 .
