Participation of the nursing technician at the systematization of nursing assistance: integrative literature review

Pétala Tuani Candido de Oliveira Salvador^I; Viviane Euzébia Pereira Santos^II
INurse. Master in Nursing, Professor of the Graduation Course Technology in Hospital Management, Nursing School of Natal and of the Laboratory Research Group of Care, of the Federal University of Rio Grande do Norte. Brazil. E-mail: petalatuani@hotmail.com
^IINurse. PhD in Nursing. Adjunct Professor of the Graduate Program in Nursing and Vice-Leader of the Laboratory Research Group of Care, Federal University do Rio Grande do Norte. Brazil. E-mail: vivianeepsantos@gmail.com

ABSTRACT: The objective of this study was to identify, by an integrative review, the produced knowledge on the national scope about the involvement of nursing technician in the systematization of nursing assistance. The data collection was made from July to August of 2011, at databases BDENF, LILAC’s, SciELO, MEDLINE and PUBMED, by the controlled keywords - education, nursing, associate, nurses’ aides, patient care planning and nursing process - and the not controlled keywords - technician nurse and systematization of nursing assistance. 12 scientific productions were chosen and the results were clustered in two pillars: characterization of founded studies, for the year of publication, magazine, research type, besides others factors; and theoretical questions brought by studies, emphasizing the building process of the nursing technician, theirs perceptions and theirs insertions at the systematization of nursing assistance.

Keywords: Education, nursing, associate; nurses' aides; patient care planning; nursing process.

INTRODUCTION

The nursing technician (NT), according to Decree No. 94.406/87, which regulates Law No. 7,498, of June 25, 1986 - The Law of Professional Nursing Practice - is a professional component of the nursing team, having as prerequisites for the exercise of their profession to hold a diploma or certificate of Nursing technician, issued in accordance with the rules and be registered with the competent body¹.

This professional performs auxiliary activities, mid-level technical, assigned to the nursing staff, and pursuant to Article 10 of this Decree: to help the nurse in planning, scheduling, orientation and supervision of nursing care activities in providing direct nursing care to critically ill patients, the prevention and control of communicable diseases in general epidemiological surveillance programs, prevention and systematic control of hospital infection prevention and control and systematic physical damage that may be caused to patients during health care; performing nursing care activities, except those of the nurse; and be part of the health team¹.

Then we see that such professional is an odd component of the nursing team, assisting nurses in their care and planning activities. It is still added the fact that the NT represent, nationally, the class with the largest contingent of professionals in nursing. According to the Federal Board of Nursing (COFEN), in 2011 there were 750,205 NT in Brazil, value corresponding to 40.41% of all nursing professionals².

It is, therefore, a professional key in the care, in quantitative and qualitative terms, component that acts directly and continuously in nursing care process. However, despite the undoubted importance of this professional category in the construction of nursing care, it is referred to in the literature the fact that the professionals still have their participation in the Nursing Care System (NAS) as an obscure field, where questions and doubts prevail, the ending with establishing as an obstacle to the proper enforcement of NAS^3-4.

Researchers emphasize, however, that the current setting of the working process of the NT reflects the historical journey that culminated in professional legalization of that category, since the institutionalization of nursing as a profession, from the mid-nineteenth century, such an exercise is characterized by division of labor, through consolidation of various forms of aid work, fitting to the nurse's teaching, supervision and administration and auxiliary care activities most⁵.

So we grasp that nursing is built up in its genesis, based on a Cartesian dissociation of the care, which process, it is worth noting, has practical remains to the present: on one side the top-level professionals responsible for thinking; and in the other auxiliary professionals working.

In this perspective, it is envisaged that this fragmented vision of the nursing care process predominates the historical path of this profession even with the development of auxiliary categories: the nursing attendants, first class that did not exist any theoretical training; passing by nursing assistants, course that came up the need for professional training as a result of complex activities assigned to such subjects; to the NT, the current configuration that sees the need for specialized technical training to assist implementation of nursing actions.

Currently, NT performs auxiliary activities assigned to the nursing team, assisting nurses in their care and planning practices, as stated in the Law of Professional Nursing Practice, aspect already evidenced.

However, unanimously in the literature arises that such aspects are not yet vested in a realistic way, especially regarding the NAS, healthcare methodology that since 2002, through Resolution No. 272 COFEN is understood as a means of demonstrating the contribution of nursing care to the population, able to offer subsidies for the development of interdisciplinary care actions, establishing conceptual assumptions capable of recovering the intrinsic care nursing scientific aspects, aspect most recently reaffirmed by Resolution No. 358 of 2009 COFEN^6-7.

It is evident, therefore, that the effectiveness of the NAS requires the integration of professional NT, overcoming the dichotomy between thinking and performing since consolidating activities in the biomedical domain, in any degree, requires theoretical and practical prior preparation and, therefore, needs dualistic view of the run and think, considering that such aspects are interdependent actions.

Given the above, the object of study of this paper presents the participation of the NAS NT, given the unique importance of understanding the reality of such a process to become effective NAS with concrete result of an articulated and integrated work of all nursing staff.

Thus, the objective was to identify, through integrative review, the knowledge produced at the national level about the participation of the nursing technician in NAS.

METHODOLOGY

This is an integrative literature review of the involvement of the nursing technician in NAS. The literature review is a valuable method of synthesis of knowledge, enabling raise general conclusions about a particular subject, as well as highlighting important to be overcome to improve healthcare practice⁸.

Data collection was performed in the Database of Nursing (BDENF), Latin American System data and Caribbean Center on Health Sciences (LILAC's), Scientific Electronic Library Online (SciELO), Medical Literature Analysis and Retrieval System online (MEDLINE) and U.S. National Library of Medicine (PubMed).

For the location of the studies, controlled descriptors were used – technical education in nursing, nursing assistants, patient care planning and nursing process – and descriptors uncontrolled – nursing technician and systematization of nursing care –, which were integrated research in three combinations: Technical education in nursing / nursing care systematization; nursing aides / nursing process; and technical nursing / patient care planning.

The research was conducted during July and August 2011, being structured in three stages, namely: First, we identify the descriptors controlled by the Virtual Health Library (BIREME) through the Health Sciences Descriptors Headings (MeSH), selecting those considered relevant to achieving the research; in the second stage, we conducted research using these descriptors in the databases mentioned above; and finally we proceeded with the critical analysis of the studies, excluding those not consistent with the scope of the search, and duplicate productions.

IAs iclusion criteria for the studies were selected scientific productions of showing the proposed theme, available in full text mode, written in Portuguese, English or Spanish languages ​​and published in the last 10 years (2002-2011), temporal dimension defined from year that Resolution No. 272 COFEN was published – 2002 it is noteworthy choice for productions with Brazilian reports, which arises from the different configuration of nursing in other countries, something which therefore influence the analyzes of participation of NAS technical nursing.

RESULTS AND DISCUSSION

After a systematic analysis of 12 scientific works selected^3,5,9-18, the results were grouped into two pillars: first, we present the characterization of the studies found, as the year of publication, journal, type of research, among other factors; and subsequently put into relief theoretical questions raised by the studies, emphasizing the formative process of NT, NT perceptions about NAS and the insertion of NT in NAS.

Characterization of the selected studies

After initial studies in search of selected databases using the three aforementioned combinations, it was proceeded to the discussion of the relevance of the studies, excluding those not consistent with the object of literary review, as quantitative portrait shown in Table 1.

Thus, the literature review was constructed guided by the 12 selected studies. The characterization of these studies is found in Figure 1.

The selected scientific production was therefore composed of the following categories of studies: 10 research articles (83%), a theoretical study and a dissertation. The temporal dimension of publications ranged from 2002 to 2009, predominantly the years 2008 and 2009, with three publications each year, corresponding thus, 50% of literary sample.

As for the largest number of journal publications, we highlighted the Brazilian Journal of Nursing (REBEn), with the release of three selected studies (25%).

Most research has been fostered in the State of São Paulo (six studies, which equates to 50% of the total). It is important the significant predominance of studies conducted in South and Southeast regions of Brazil, with only one representative of the Northeast Region, the State of Paraíba. This result reflects a more complex national context, and in regions of prevalence of these studies, NAS is configured with a strongly consolidated healthcare methodology, especially in its theoretical aspects, in opposition to the Northeast and North region that is undergoing strengthening.

It is noteworthy that all the authors examined the scientific literature were nurses, which indicates the fragility of scientific development in other components nursing categories.

Finally, it was possible to identify three theoretical pillars of discussion in the selected studies, which is worth mentioning, do not constitute categories of fragmented and independent analysis, but rather interdependent and integrated aspects of a comprehensive reflective context: the participation of NT in NAS, object of the present study. The pillars will be analyzed didactically exposed below, contemplating: training process of NT, object studied in six selected scientific publications; Perceptions of NT on the NAS aspect reflected in two studies; The insertion of the NT and the NAS, which was discussed in four papers.

Theoretical discussions in selected studies

The consolidation of nursing as a science of caring profession solid based in the scientific field, has been associated with the scope to overcome the paradigm that overpowered as an auxiliary medical practices profession9. In Brazilian context, this historic route is added to the rise of various forms of work, featuring technical division of nursing work that prevails until today, the result of a dichotomous perspective of planning and implementation of care.

From this perspective, it is perceived the existence, since the building of nursing as a profession, of a

[...] Split between the moments of conception and execution of care - who performs nursing care not directly involved in their planning, while providing daily observations and information about activities carried [...]^5:397.

It is strong, however, that much progress has been made over the years through especially the unquestionable need for professionalization of components nursing categories, subjects, to deal with complex situations that cross the thin line between life and death, need to base their practice on sound scientific knowledge, consolidating nursing as a science guided by care.

Meanwhile, to assist Brazilian nursing category was marked by a historical evolution based on professionalism, from the attendants, through the auxiliary culminating in NT, considering that the latter two coexist today, however, leaving only the formation of NT.

Legally, the Technical College of Nursing was established by Opinion No. 171 and No. 224 of 1966, the Federal Board of Education, Schools in Anna Nery and Luiza de Marillac, both in Rio de Janeiro¹⁰.

Since then, the scientific nursing was advocated many times, standing out as landmarks of this process in the Brazilian context: the contribution of Wanda Aguiar Horta, in the second half of the 1960s, the first Brazilian nurse talking about theory in the professional field; the enactment of Law No. 7498 in 1986, when the regulation of the nursing profession is updated; Resolution No. 272, established by COFEN in 2002, determining that the NAN should occur in all health institutions, public and private, be formally recorded in the chart of the user; and Resolution No. 358 of 2009 which reaffirms the nursing process as a means to highlight the contribution of nursing care to the population, thereby increasing the recognition of the professional nurse.

In the current scenario, the NAS is recognized as the working tool of solidification of nursing as a profession fostered scientifically, which is able to offer subsidies for the development of interdisciplinary and humanized care actions, establishing conceptual assumptions able to rescue the intrinsic scientific aspects of nursing care^11,19-23. However, it is unquestionable that many challenges remain for such a strategy is nationally recognized and practiced^19-29.

Among these challenges, there is the still obscure participation of NT in NAS, due in large part to the troubled history of fragmentation of nursing care: a professional next higher level planning assistance and other technical professionals that perform, not existing or happening shy way communication between these professionals. As a consequence of this fact, we are witnessing the alarmingly "[...] the possibility of accomplishments care initiatives unrelated to planning, contradicting the reference of NAS"^12:14.

Nonexistent, thus, the cohesion of care, the legal allocation of the NT co-participant in the planning process of care is forgotten, which impairs the quality of NAS, since it does not consist of a theoretical recipe in which planning and execution are independent and fragmented phases, but a continuous process in which careful planning, execution and evaluation are interdependent factors that interact daily. In other words, it is understood that the NAS "[...] will only be effective if practice is discussed and advocated by professional category itself"^30:406.

The literature indicates that the training process of the NT can be the cause or reinforcing element of the perpetuation of this problem, since little or no information about the NAS is glimpsed during their training, which may arise from the difficulty in delineating the jurisdiction and responsibilities of each member of the nursing staff in the operation of NAS^3,12.

Despite this difficulty training, studies seeking to know the perceptions of the NT on the NAS elucidate these professionals recognize the benefits of this tool, highlighting: the broadening of the vision that professionals have about the condition of the patient; optimization of care; ease from work to find records in the course of treatment and care to be provided; the approach of the nursing staff; favoring continuity of care; and the organization of the work^13-14.

However, difficulties are experienced: the imposition of care by nurses, the absence of dialogue between the staff; and failures in nursing prescription, with the mechanization of care and the lack of specific care for each patient^13-14.

However, it is revealed in the literature the lack of the NT about the NAS. A research, in which 77 representatives of auxiliary classes and technical nursing school in a São Paulo hospital were interviewed, alarmingly revealed that 75% of professionals reported that participate in the NAS could not identify which were their participating phases. These act described in NAS: performing care, promoting comfort, following rules, checking the prescription nursing, performing admission of patients, collecting information and providing emotional support and guidance³.

Regarding the perception of nurses related to participation of the NT in NAS, study in the cities of Ribeirão Preto and Brasília-DF identified that 88.8% of nurses have spoken positively about the participation of nursing assistants and technicians in NAS, emphasizing the importance of integration of the nursing staff in care planning as a motivating factor quality of care¹¹.

For these respondents, the nursing assistants and technicians could participate: performing activities related to the phase of data collection (55.5%), restricted to the performance of activities prescribed by nurses (33.3%), using specific tools developed by nurses (11.1%), making the evolution of the patient and/or evaluation of the implemented care (11.1%)¹¹.

It is emphatic, however, a significant gap exists in participation of the NT in NAS, being restricted their role as executors prescription performed by nurses, neglecting thus the assignment legally supported to participate in the planning, programming, guidance and supervision of activities nursing care. It is experienced, thus perpetuating of the Cartesian characteristic of division of labor, with the participation of NT in NAS, an even dark and lacking in depth research field.

It is added further doubt as to the legal support of participation of NT in NAS, hampered by the brought COFEN documents that establish the NAS activity as private nurses, leaving questions about the participation of the other categories.

This concern is brought either by nurses as by nursing assistants and technicians3,11. Study revealed that 70% of members of professional and auxiliary nursing technician mentioned categories do not have conditions and 60% did not have approval of the Board of Nursing to participate in the different phases of NAS³.

Thus, we apprehend that making NAS a base of professional nursing practice requires efforts of all involved, especially the educational institutions that represent the foundation of this process, which should not be restricted to higher education, but to integrate the curriculum all trainers courses nursing professionals, regardless of level of training.

CONCLUSION

It can be diagnosed that the participation of the nursing technician in NAS still constitutes as a dark and needy field for further studies, an aspect which arises from its historical consolidation process when planning and executing activities were consolidated as dichotomous, getting the position of the auxiliary professions.

As a possibility of overcoming these factors it is highlighted the essentiality of the binomial health-education, which should begin in the formation of all components of professional nursing staff and continue through the ongoing education of these subjects, emphasizing the essential critical- reflective aspects to such a profession as a means to promote understanding of the NAS as a scientific tool, which is built up to an individual and humanized care.

So, we hope to contribute to health professionals, to reflect on the state of the art technical nursing participation in NAS, the Brazilian healthcare scenario, thinking to seek ways to consolidate such a tool in their reality, defending the nursing as the science of caring in which permanently crave solidification of health practices that affirm the theory in practice.

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