RESEARCH ARTICLES

Safety performance and risk prevention in intensive care: hard technologies

Eugênio Fuentez Perez Junior^I; Elias Barbosa de Oliveira^II; Norma Valeria de Souza Dantas^III; Márcia Tereza Luz Lisboa^IV; Zenith Rosa Silvino^V

^INurse, Master's in Nursing, Specialist in Higher Education Teaching. Hospital Estadual Azevedo Lima. Niteroi, Rio de Janeiro, Brazil. Email: eugenioperezjunior@gmail.com
^IINurse. Post Doctorate Degree in Alcohol of Drugs. PhD in Nursing, Associate Professor at the Graduate (Masters) and Undergraduate Program, School of Nursing at the State University of Rio de Janeiro. Mental Health and Work, Study Group Leader. Rio de Janeiro, Brazil, Email: eliasbo@oi.com.br
^IIINurse. PhD in Nursing, Assistant Professor at the Graduate and Undergraduate Program, School of Nursing at the State University of Rio de Janeiro. Rio de Janeiro, Brazil, Email: norval_souza@yahoo.com.br
^IVNurse, PhD in Nursing, Associate Professor, Department of Fundamentals of Nursing Anna Nery School, Federal University of Rio de Janeiro, Member of the Center for Nursing Research and Worker Health and the Foundations of Nursing Care Research Center. Rio de Janeiro, Brazil, Email: marcialuzlisboa@gmail.com
^VNurse. PhD in Nursing, Full Professor at the Cavalcanti Aurora School of Nursing, Fluminense Federal University. Niteroi, Rio de Janeiro, Brazil. Email: zenithrosa@terra.com.br

ABSTRACT: This study aimed at investigating factors influencing safety performance of nursing staff in intensive care units with the incorporation of hard technologies. Qualitative and descriptive method, having as its field an intensive care center at a university hospital in Niterói (Brazil). Semi-structured interview technique was used with 25 twenty-five) nursing staff in 2011. Content analysis showed that factors influencing safety performance of nursing staff in intensive care with the incorporation of hard technologies are as follows: knowledge out of training on the care of critically ill patients and on technologies in use; in-service training; and sizing of staff. Conclusions show hard technologies in intensive care must be managed for workers’ safety performance, service quality, and staff’s well-being and satisfaction.

Keywords: Nursing; intensive care; occupational hazards; occupational health.

INTRODUCTION

As we evolve technologically, the demands of safety in the use of equipment in hospital environments increase. Among the factors that affect the safety of the professionals and patients are the hazards involving the use of medical electrical equipment (MEE). Such as the occurrence of hazardous events due to failure of performance of MEE ( drug dosage error delivered to the patient by the infusion pump, non-activation of the alarms on monitoring equipment and life support), inefficiency in the insulation systems and electrical grounding of the MEE, electromagnetic interference, nosocomial infection among others¹.

The growing demand for health professionals able to accompany care and technological development, in many cases, reflects the concern for avoiding the risk to the patient's health, which may be associated with, or not, the occurrence of human errors. In this sense, the management of hospital risk (techno-surveillance) has an essential role regarding the systematization and monitoring of adverse events, performing actions for the control and elimination of their damage. As part of these actions, the techno-surveillance operates in the procedures for the acquisition, use and control of the quality of products and equipment in healthcare, in which the risk assessment given to the patient or to products in use in their care may also reflect on worker safety, minimizing wear and the possibility of errors².

There is the need to support teams with a view on safety in the performance and quality of service offered, being relevant to stress three factors that must be worked by the manager in the work environment: the training of the teams, the support of technicians and the preventive and corrective maintenance of the apparatus. After all, the presence of the nursing professional is imperative in terms management, control, supervision and care to patients requiring, organizational support for conducting work free of risks³.

The production of knowledge on technological innovations in the healthcare sector has brought important contributions to the work process, especially in relation to the use of protocols toward the critical patient care and the use of technological inputs. On the other hand, regarding the implications for worker health, there is evidence of the need for an extension of studies that ratify the importance of safety in performance and risk minimization for the professional practice to consider the ethical and legal implications involved⁴.

With the aim of contributing to research that gives visibility to issues related to the incorporation of hard technologies to work in intensive care nursing, the objective of this study was to analyze the factors that influence the safety performance of nursing workers with the incorporation of hard technologies in intensive care.

LITERATURE REVIEW

In 2001, the concept of hospital risk management (HRM) was introduced in Brazil by the Brazilian National Health Surveillance Agency (Anvisa), by the Ministry of Health, with the Hospital Sentinel project. In order to ensure the quality of the service, the safety of users and staff, the HRM has sought to work with the following projects: the adoption of measures to enhance the quality of healthcare and the rational management of inputs as well as medical and hospital equipment (techno-surveillance). The purpose of risk management is to identify the likely source of adverse events, assess the damage and take appropriate decisions regarding these problems².

It is necessary to stress the importance of risk management in hospital units such as intensive care, because it is a work environment that is characterized by technological density and with increasingly enhanced apparatus to preserve and maintain the life of the patients, especially those at risk for complications. Using equipment such as infusion pumps, monitors, and ventilators with their visual and audible alarms - it is possible to administer diets, medications and control more effectively the patient's respiratory and hemodynamic condition⁵.

The apparatus used in critical patient care are hard technologies or dead work, because they are material resources obtained using equipment such as a work instrument. In a complementary manner, there are light-hard technologies; expressly in the handling of equipment and technological knowledge for their use and the lightweight, identified in the environment of the relations that are characterized by live work in the act, in the direct relation between user and professional⁶.

Despite the incalculable benefits obtained with the incorporation of hard technologies to nursing work, one must consider the physical and mental workloads from noise emitted by equipment and the requirements regarding the implementation of interventions to patients entirely dependent on the team. Regarding the psychological strain, the professionals are subjected to monitoring and the need for memorizing data relating to equipment, with the strain intensified upon unpredictable situations due to patient clinical instability and possible faults in the equipment they connected⁷.

Patients dependent on hard technologies multiply the demands and intensify the workloads, making the manager look at the need for the dimensioning of skilled personnel to intervene with the patient and the equipment. The deficit in human resources and material has been pointed out in the literature as a stress factor generator at work, leading to dissatisfaction, the motivation and the illness of the employee, having as consequences the absenteeism and the decline of the quality of service offered⁸.

It should be noted that the incorporation of hard technologies to nursing work is mediated by working conditions, being the insecure working conditions a factor of psychosocial risk by negatively influencing the performance and producing physical and mental overloads in workers. Thus, the introduction of a new technology, regardless of its nature, is always accompanied by an increase in the intensity of work and the pressure for productivity⁹.

METHODOLOGY

A descriptive study with a qualitative approach in, which the desire to know the facts observed, recording, analyzing, classifying and interpreting them in order to describe the phenomena of a given reality¹⁰. The project was approved by the Research Ethics Committee and filed in National Committee for Ethics in Research with the protocol number 2063.0.000.258-11.

In response to Resolution no. 466/12, after the signing of the consent form, participated in the study 25 nursing workers (11 nurses and 14 nursing technicians) of a public hospital located in the city Niteroi, Rio de Janeiro, Brazil. Criteria for inclusion of subjects were fully employed at the institution and work in the Adult intensive care unit (ICU) for least one year. They were informed that the participation of the subjects would be voluntary and that they would have the right to withdraw from the research at any stage. They were assured that the confidentiality of the data and confirmed that the results would be presented in events and published in scientific journals. In the transcription of the statements, the following conventions were adopted: nurse (letter N) and nursing technician (NT) followed by a number according to the order in the text.

Data collection took place in the second half of 2011, at the workplace, after the selection of the subjects and the invitation. The semi-structured interview technique was used, which combined open and closed questions with the possibility of the individual to talk about the topic in the question favoring the contextualization of experiences and meanings¹¹. As an instrument, a script was used containing questions related to the environment, working conditions and the incorporation of hard technology in ICU, whose responses were recorded in a digital medium.

Upon the transcription, the language was analyzed through the theme content analysis technique that was based in decoding of the text in various elements, which have been classified and formed analog groups¹². In one last time, using the criteria of representativeness, homogeneity, reclassification and aggregation of components of the assembly, came to the following thematic axes: Incorporation of hard technologies and praxis; profile and in-service training; personnel and new requirements.

RESULTS AND DISCUSSION

Incorporation of hard technologies and praxis

With the promulgation of the Law of Guidelines and Bases of Education (LDB/ 96), the alumni of Graduate courses in Nursing, by having a generalist education, are not always able to work in areas increasingly complex, because nowadays with the changes in the curricula were extinct the qualifications, and the theoretical content and practical training in nine periods and maintained the professionalization cycle with emphasis on skills.

With these changes, for the development of skills in fields as diverse, there is a need for a gradual approach to the process of work in the ICU, through praxis and the familiarity with the technological resources, especially in relation to those newly recruited workers. Thus extend the skills and/or ability of the worker act in situations not provided for, using, in addition to the specific technical knowledge, empirical knowledge, practical skills and experience.

[...] Everyone will know the equipment using this material. [...] Everyone just got this knowledge through practice, which I do not think it is very interesting for the people that are just underutilizing the material. (E2)

This knowledge is the improvement of the relationship between the nursing professional and hard technology only works by learning it! Only in direct contact with the machine. (NT 4)

I am not an expert on the monitors, but today I can monitor it! If I'm seeing that the respirator cycling is different from what I am accustomed to seeing, and I don't understand what's going on, I ask for help to examine the respirator. (NT11)

Familiarity occurs through the union of the formal knowledge of the worker with the new, which makes it possible to know the work better, the problems in the task and how to deal with them. However, the desperate worker is facing the unexpected without knowing how to intervene, requiring, in some situations, to seek the aid of the other team components¹³. The previous experiences of the worker in relation to the use of hard technologies in ICU help in meeting of pragmatic knowledge that make up the professional's experience. Thus the experience or technical know-how of the worker, gives the area necessary for the use of advanced technologies and contributes to the quality of work¹⁴.

Profile and in-service training

In relation to the incorporation of hard technologies in critical patient care, the nursing staff in the ICU have ratified the importance of the manager adopt criteria at the time of selecting staff to work in the sector, prioritizing those that can identity with the work in technological environment. From the group point of view, the nursing professional should have training in the area, be responsible and enjoy working in the ICU by caring for critically ill patients dependent on technological resources that require attention and responsibility.
 
I think that the professional, he has to take responsibility above all! Attention! You have to like what you do. First is to select empowered employees, who really love of intensive care, because it is not easy to deal with critically ill patients. (NT6)

Working in intensive care is to know who is going to deal with a series of technological resources. Before, it must be seen by management if the person likes to learn, to know and subsequently use the technology. (N25)

The person has to be careful! Aware. In addition to the liability, the person has to be proactive. (NT9)

According to the testimonies that the new skills and knowledge required by workers, the work situation studied, require attitudes, behavior and personality attributes such as attention, vigilance, sense of responsibility, foresight and work experience, in addition to requiring a technical qualification new and specific¹⁵.

The professionals who work in the ICU are asked to absorb new technologies and new knowledge, and should demonstrate willingness, courage, and a willingness to learn in the face of new incorporated items in care. Not taking into account the profile of the professional to work in areas of intensive care, may lead the worker to behaviors of interest in relation to the acquired knowledge in work, jeopardizing their professional practice and the quality of care¹⁴.

The professional training in service, from the point of view of workers from the ICU is of great relevance for the field of content technical-scientific acquired during undergraduate training, expertise or through refresher courses offered by the institution or outside of the service. In this way, the work to establish the relationship theory and practice in occupational environment has extended the possibilities of care intervention with respect to the use of technological resources and safety performance for themselve and for the client.

\The knowledge of nursing procedures, where I will use the technology, will encourage my work! This, I think is the most important. (N18)

The technology it is an extra support for you to have a better quality of service. Then the professional must first be qualified to be working with a patient in the ICU. (N1)

Good! Knowledge is essential to use any technology, which is replaced by scientific basis of care with the patient. Absolutely, that for you first use a technology you have to have the scientific knowledge. (N1)

This ratifies the importance of the participation of workers in training offered by the organization, as well as to expand the knowledge; the training is of unquestionable importance in terms of praxis update, higher security performance and minimizing errors and iatrogenic events. Critical patient care involves the use of a technological arsenal specific and that requires nursing workers skills, both in that relate to the operationalization of machines as to their suitability to the needs of those who depend on it to provide a quality of service¹⁶.

On the other hand, in spite of the training be a concern on the part of the organization, some testimonials showed a lack of interest on the part of the worker in relation to training for the use of new technologies.

[...] What we see is, sometimes, the organization, the institution offering training and people not getting involved. On the other hand, I think that there is a lack of commitment. The professionals have no desire. (N25)

Several problems have happened! One of them was the lack of interest on the part of the professional! Because, sometimes, there was difficulty in handling the equipment and they didn't have the will power to learn. (NT6)

[...] In relation to the handling of the technology, for me at the moment, and that I see on a day-to-day basis, it is a lack of interest on the part of the professional. (NT3)

As evidenced, it is important that the worker if they are motivated and have clarity as to the responsibilities and the role of the organization. The motivation at work needs to be understood within the actual context in which the worker is inserted, in which the lack of interest in relation to the activities prescribed may be a flag significant for the organization review its management processes and its personnel policy¹⁷.

It is recalled that in the face of technological innovations in intensive care units, there is a need for specialized labor for its use, because the lack of skilled professionals increases hospital costs due to faults and need for replacement of the damaged material. There is also to consider the social costs arising from increased workloads due to technical limitations of the worker, loss of time and insecurity¹⁸.

Personnel dimensioning and new requirements

The workers, when referring to the use of hard technology in intensive care, have ratified the importance of quantitative staff to maintain the quality of care and minimize workloads. The requirements imposed by the organization, regarding the use of hard technologies, intensify the work, cause overload and expose workers to wear, which can affect the quality of care, especially with a staff deficit.

The biggest problem in my opinion is the lack of staff and the workload, which leads to work overload... sometimes there is a piece of equipment, a pump beeps with problem... often takes too much time and it becomes a bad thing for us nursing professionals. (NT7)

Technology hinders service, regarding the lack of labor in nursing itself. There is a course, but has no labor, but there's not enough nursing staff. (NT14)

If you have, multiple patients and suddenly you have a small number of employees, you cannot you be present, so you can figure out what's going on with the equipment. (N17)

The high workload required by patients in ICU, arising from the instability and the need for continuing care should be considered as fundamental for the dimensioning and allocation of human resources information, especially when seeking greater safety for the professional and the quality of service offered¹⁹. The hard technologies, to be introduced in the ICU, replaced some activities recognized as repetitive and, among them: measurement of vital signs, blood gases, administration of diets, infusion of liquids and medicines. On the other hand, its incorporation demand a greater quantity of workers, due to the increase of physical loads and mental work⁹.

Keeping up with the advances of science and the consequent incorporation of hard technologies to the process of work in the health sector, especially in the hospital area, identified that nursing workers have revealed, a new professional profile. From this perspective, new knowledge and skills are required in the area of computer science that go beyond the formal teaching of nursing, centered in protocols, routines and the specific knowledge about patient critical care.
 
To work with this type of technology in intensive care is required that the person is more aware of technology issues! The IT part! You have to have more dexterity in this part! This helps a lot. (N1)

I think that workers have more affinity or ease to use the internet and computer; they can obtain some technological resources in the ICU with more ease. (N2)

[...] The knowledge that everyone should have, in addition to those related to patient care in ICU, are notions of electronics and information systems experience that are very important. (N24)

Information technology is a field of knowledge development in nursing that presents with prospects of work and professional growth, to the extent that its resources and products help at work, in training and in conducting research, with the consequent development of practices and better quality of care²⁰.

Therefore, nursing must incorporate the information technology to meet the needs of the profession in terms of technological development, as well as use technology in computerized assistance, in research, in teaching and in administration, in order to keep up with the demands of technological advances and the globalized labor market²¹.

It is worth pointing out that the small number of participants and the single scenario are study limitations that prevent the generalization of the results.

CONCLUSION

It was evident that, from the point of view of workers, the main factors that influence the safety in the performance of the nursing professional with the incorporation of new technologies in intensive care are: requirement of praxis before the incorporation of hard technologies to work, professional profile consistent with the function to be performed, the in-service training the dimensioning of personnel and expertise in information technology.

Praxis given the incorporation of hard technologies in intensive care is of unquestionable importance, because it allows the worker use the knowledge obtained in the training and/or expertise in the context of real work, having as a result greater field of technological resources available, security and ability to intervene in unforeseen situations.

Thus, the manager must select nurses with suitable profile for the organization's requirements, ie have training in the area, be responsible and enjoy working in the ICU because the worker caring for critically ill patients and use technology resources that require specific knowledge and skills.

The workers have ratified the importance of the professional, to constantly upgrade their knowledge process, including in the area of computer science, which provides greater safety in handling of hard technologies and minimizes the possibility of errors and iatrogenic events. In spite of the hard technologies minimizing the completion of repetitive activities and foster greater clinical control of the patient, it is important to consider the need for personnel. This is because the hard technologies have multiplied the requirements in terms of checks and periodic adjustments of parameters established in the apparatus; mainly in view of clinical changes the patient and / or technical problems of equipment.

In view of the foregoing, it is necessary to emphasize the importance of work organization invest in a policy of prevention of risk in intensive care from the intervening factors pointed out by nursing workers, which can contribute to the quality of the service offered to users, greater safety in the performance and satisfaction of the group.

REFERENCES

1. Florence G, Calil SJ. Uma nova perspectiva no controle dos riscos da utilização de tecnologia médico-hospitalar. Rev MultiCiência. 2005 [citado em 14 set 2013] 05. Available at: http://www.multiciencia.unicamp.br/intro_05.htm

2. Kuwalbara CCT, Évora YDM, Oliveira MMB. Gerenciamento de risco em tecnovigilância: construção e validação de instrumento de avaliação de produto médico-hospitalar. Rev Latino-Am Enfermagem. 2010 [citado em 13 sep 2013] ; 18: 943-51. Available at: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0104-11692010000500015&lng=en. http://dx.doi.org/10.1590/S0104-11692010000500015.

3. Preto VA, Pedrão LJ. O estresse entre enfermeiros que atuam em Unidade de Terapia Intensiva. Rev esc enferm. USP. [Internet]. 2009 [citado em 15 out 2011]. 43: 841-8. Available at: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0080-62342009000400015&lng=en&nrm=iso.

4. Perez Junior EF, Oliveira EB. Incorporação da tecnologia dura no setor saúde: implicações para a saúde do trabalhador. Rev enferm profissional. 2014 [periódico na internet] 1(1):50-9 [citado em 12 fev 2014]. Available at: http://www.seer.unirio.br/index.php/enfermagemprofissional/article/viewFile/3512/pdf_1201

5. Marques IR, Souza AR. Tecnologia e humanização em ambientes intensivos. Rev bras enferm. 2010 [periódico na internet] 63: 141-4; [citado em 10 out 2011]. Available at: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0034-71672010000100024&lng=pt&nrm=iso&tlng=pt

6. Merhy EE. Saúde: a cartografia do trabalho vivo. 2nd ed. São Paulo: Hucitec; 2005.

7. Oliveira EB, Lisboa MT. The impact of noise for the nursing workers health and the work process. Online Brazilian Journal of Nursing, North America, 6, oct. 2007. [cited in 2011 Jan 26]. Available at: http://www.objnursing.uff.br/index.php/nursing/article/view/j.16764285.2007.1237/266

8. Inoue KC, Matsuda LM, Silva DMPP, Uchimura TT, Mathias TAF. Absenteísmo-doença da equipe de enfermagem em unidade de terapia intensiva. Rev bras enferm. [periódico na internet] 2008 [citado em 26 set 2011]; 61: 209-14. Available at: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0034-71672008000200010&lng=pt&nrm=iso&tlng=pt

9. Pires DEP, Bertoncini JH, Sávio B, Trindade LL, Matos E, Azambuja E.Inovação tecnológica e cargas de trabalho dos profissionais de saúde: revisão da literatura latino-americana. Rev Eletr Enf. [periódico na internet]2010 [citado em 8 mar 2011];12:373-9. Available at: http://www.fen.ufg.br/revista/v12/n2/pdf/v12n2a23.pdf

10.Figueiredo NMA. Método e metodologia na pesquisa científica. São Paulo: Difusão editora; 2004.

11. Minayo MCS. O desafio do conhecimento: pesquisa qualitativa em saúde. 9ª ed. São Paulo: Hucitec; 2006.

12. Bardin L. Analise de Conteúdo. 4ª ed. Lisboa (Pt): Edições 70; 2010.

13. Sato LA. Representação social do trabalho penoso. In: Spink, MJ et al. O conhecimento no cotidiano: as representações sociais na perspectiva da psicologia social. São Paulo: Brasiliense; 1999. p. 188-21

14. Silva RC, Ferreira MA. A dimensão da ação nas representações sociais da tecnologia no cuidado de enfermagem. Esc Anna Nery Rev Enferm. 2011[periódico na internet] 15(1):140-8 [citado em 23 fev 2013]. Available at: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1414-81452011000100020&lng=pt&nrm=iso&tlng=pt

15. Santana N, Fernandes JD. O processo de capacitação profissional do enfermeiro intensivista. Rev bras enferm. 2008 [periódico na internet] 61: 809-15 [citado em 12 dez 2013]. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0034-71672008000600003&lng=pt&nrm=iso&tlng=pt

16. Santana N, Fernandes JD. O processo de capacitação profissional do enfermeiro intensivista. Rev bras enferm. 2008 [periódico na internet] 61 (6): 809-15 [citado em 12 dez 2012]. Available at: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0034-71672008000600003&lng=pt&nrm=iso&tlng=pt

17. Schwonk CRGB; Lunardi Filho WD; Lunardi VL; Santos SSC; Barlem ELD. Perspectivas filosóficas do uso da tecnologia no cuidado de enfermagem em terapia intensiva. Rev Bras Enferm 2011[periódico na internet]; 64: 189-92. [citado em 08 dez 2011]. Available at: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0034-71672011000100028&lng=pt&nrm=iso&tlng=pt
 
18. Lopes AL, Dyniewicz AM, Kalinowski LC. Gerenciamento de materiais e custos hospitalares em UTI neonatal. Cogitare Enferm. 2010 [periódico na internet]15:278-85 [citado em 13 jan 2014]. Available at: http://ojs.c3sl.ufpr.br/ojs2/index.php/cogitare/article/view/17862/11654
 
19. Gonçalves LA, Padilha KG. Fatores associados à carga de trabalho de enfermagem em Unidade de Terapia Intensiva. Rev esc enferm. USP. 2007 [periódico na internet] 41: 645-52 [citado em 09 jul 2012]. Available at: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0080-62342007000400015&lng=pt&nrm=iso&tlng=pt

20. Marin HF, Cunha ICKO. Perspectivas atuais da informática em Enfermagem. Rev bras enferm. 2006 [periódico na internet] 59: 354-7 [citado em 07 jul 2013]. Available at: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0034-71672006000300019&lng=pt&nrm=iso&tlng=pt

21. Baggio MA, Erdmann AL, Sasso GTMD. Cuidado humano e tecnologia na enfermagem contemporânea e complexa. Texto contexto - enferm. 2010 [periodico na internet] 19: 378-85 [citado em 12 nov 2013]. Available at: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0104-07072010000200021&lng=pt&nrm=iso&tlng=pt