RESEARCH ARTICLES

Visibility of nursing work in the context of the clinical model of health care

Lenice Dutra de Sousa^I; Wilson Danilo Lunardi Filho^II; Maira Buss Thofehrn^III

^I Nurse. Ph.D. in Nursing. Professor of the Nursing School at the Federal University of Rio Grande, Rio Grande do Sul, Brazil. Study and Research Group in Nursing and Health Work Organization. E-mail: lenicesousa@furg.br
^II Nurse. Ph.D. in Nursing. Professor of the Graduate Program in Nursing at the Federal University of Rio Grande. Rio Grande, Rio Grande do Sul, Brasil. Study and Research Group in Nursing and Health Work Organization. E-mail: vlunardi@terra.com.br
^III Nurse. Ph.D. in Nursing. Professor of the Nursing and Obstetric School at the Federal University of Pelotas. Pelotas, Rio Grande do Sul, Brazil. E-mail: mairabt@ufpel.tche.br

DOI: http://dx.doi.org/10.12957/reuerj.2015.6100

ABSTRACT

This qualitative, exploratory case study examined the visibility of nursing in clinical practice in a surgery unit. The unit of analysis was a group of six nurses, and data were collected through non-participant observation and in-depth interview. Data was collected from October 2012 to January 2013, and were analyzed using discursive textual analysis. It was apparent that, as a field of knowledge, clinical practice makes the nurse's work more visible to the various people involved in the healthcare process. Therefore, the fact that the nurses incorporate clinical practice into their work needs to be acknowledged. That way, clinical practice can be an instrument that enables nurses' work to be acknowledged and consequently gain visibility, contributing to discussions, negotiations and transformations.

Keywords: Clinical competence; nursing; work; perioperative nursing.

The clinical/biomedical model is an important reference in the organization of health services in the care provided and in the very common sense of the population¹. In this context, the role of nursing may be limited to the support of medical practices, considered as a complementary and little recognized work².

However, this care model is based on an indivisible reference of knowledge of professional nursing practice: clinical knowledge - the clinic. Thus, although there is a contrast between an integrative do and fragmented do of the clinical/biomedical model, nurses can find in this health care model, means to provide a resolutive care.

Threfore, it is highlighted the rescue of the scientific basis of care to surgical patients as an important aspect in nursing work. However, nursing care cannot get away from the needs of patients and should be evaluated for their quality and validity of each proposed surgery³.

The production of nursing knowledge in Brazil indicates a distancing of Nursing in clinical knowledge that may have weakened the theoretical area of nurses about the clinic as instrument to the realization of their work⁴. Thus, there may have been a break with some elements of clinical contributing to sustain the profession, constituting a solid theoretical construct for nursing work.

It is necessary to clarify the knowledge constructed and used in clinical nursing practice, so the professional recognition might be justified by concrete actions, in addition to the skills acquired in formal training⁵. Thus, this study aimed to analyze the nursing work visibility based on the exercise of the clinic.

THEORETICAL REFERENCE

In this study, clinic is understood as an area in which practical and biomedical or not biomedical knowledge interact to promote new compositions and methods to perform in health⁶. It is understood that to view the individual establishing full relationships with the environment and intervene on their needs, it is necessary to meet those that are indispensable for the maintenance of life.

Therefore, it is necessary a clinical knowledge to support the work in nursing and to seek, through a larger view, comprehensive care. Thus, it is considered that when the nursing is apart from the science base that supports the clinic, it weakens their knowing and doing, weakening the connections that can lead to comprehensive care and to its use as a discipline.

It is understood that solving the nursing work can occur even if it acts under the clinical/biomedical model assistance without losing the intrinsic characteristics of a complex and wide nursing work. The recognition of nurses' work reflected in its visibility. Therefore, it is important that when carrying out care practices, nurses demonstrate knowledge and expertise associated with the intersubjective and dialogical relationship developed with the staff, clients, family and institution⁷.

Based on the ideas presented, it was opted to use in this study, a theoretical-philosophical reference that would allow conceptual approaches causing reflections about the study subject. The choice by Deleuze and Guattari occurred due to their assertions, about a multiple and interconnected think. Thus, the concepts of lines of flight and war machine are incorporated into the study in order to anchor the findings to the conceptions that do not take outlining limits on clinical practice of nurses⁸.

MEHTODOLOGY

It is a qualitative research, exploratory case study with data collection performed from October 2012 to January 2013. Case study was used, since it contributes to the knowledge of the individual, organizational, social, political and group, and other related phenomena⁹. It was conducted in a surgical inpatient unit of a university hospital with unit of analysis a group of six nurses from the same unit who were identified with letters and numbers where S is the shift and P, the professional.

The data were collected through non-participant observation (200 hours) and in-depth interview. The observations was in a surgical inpatient unit, divided into periods of at least 4 hours straight and similarly between three shifts. Based on observations, the issues for in-depth interviews emerged, from an initial analysis of the observed events.

The data were analyzed according to discourse textual analysis. This method allows to identify and isolate the listed contents, categorizing the statements, and producing texts, to integrate description and interpretation¹⁰. Analytical units of the study were identified, the synthesis of the similar constituent units into categories and reintegration was carried out.

The implementation of research was submitted to the Research Ethics Committee at the Health Area and approved by Opinion Number 87/2012, and operationalized, according to the guidelines and requirements of Resolution Number 466/2012 of the National Health Council¹¹.

RESULTS AND DISCUSSION

This study showed that the resolution of patient needs as well as a broader conception of care, result in nurses´ work visibility for different subjects of the health production process. Therefore, the product of operationalization of this research is organized into two distinct periods, as described below.

The resolution of the nursing work based on emerging needs

The patient of a surgical inpatient unit arrives at the hospital with a special expectation: performing a surgery. Therefore, bringing with him expectations of the surgical procedure and the care undertaken during the perioperative period.

Health needs are recognized by patients and they require the resolution of the problems. In addition, nurses, although guided the clinical model, plays an important role to meet such requirements contained in the biological aspects.

Patient with rectal cancer concerns, during the time of professional visit, he wants to do surgery to solve the problem and that's what bothers him at this time. (observation S2P2)

The pursuit of comprehensive care is not only in reaching elements that the clinical model does not include. To question the clinical model of its limitations, not contemplating the whole of care, it is not intended to reject it and replace it. However, it is expected to value its good points through theoretical reconstructions and techniques to be incorporated so that the view of healthcare acquire a political, social and cultural competence enabling a more contextualized identification and application of more resolving behaviors⁶.

The integrality brings, intrinsically, a commitment to solving those urgent care needs. In this sense, the clinical assessment of the nurse can support patient care, in a resolutive way by the identified problems and guide the conduct of other health team professionals, offering means to better care.

The professional, when evaluating patients, checks drainage in surgical wounds and examines the possibility of opening stitches; thus requests the presence of the resident doctor to discuss the action to be taken. Resident doctor performs the procedure in patients referred by the nurse. (observation of S2P1)

The clinic involves knowledge that incorporated by nurses offering knowledge about the actions to be undertaken to resolve the needs and determine how far their behavior may be resolving or not.

A nursing technician informs the nurse that a patient still has fever and has also introduced changes in blood glucose levels; the nurse mentions: "He will remain so, until the problem is solved. While they do not do the amputation, he will continue septic and changes in blood glucose, blood pressure, respiration ..." (observation S1P1)

The clinical knowledge of nurses interfere with the therapeutic process when he implements care interventions or even when forwarding to other professionals do it. Therefore, the nurse creates connections with other members of the health team that is, establishing lines of flight able to achieve the proposed objectives and contribute to comprehensive care. Therefore, these lines of flight are interconnections that, supported by the clinical knowledge, act as health-care; promoting multiplicities of transformation that structure and creating new paths⁸.

However, the effectiveness of these interrelationships requires establishing of connections and, given the need for intervention of other professionals, the nurse in the recognition and valuation of their clinical judgment, found the necessary connection for this. In addition, recognition of the work performed by nurses encourages and mobilizes the professional, encouraging his doing¹².

Recognizing that the nurse has clinical knowledge and that his performance is guided in the resolution of concrete needs, knowing to prioritize their actions and establishing multi-professional relations, when required, other professionals began to consider the opinion of the nurse.

If I need someone urgently ... I do not want to today. I want to yesterday. [...] Not everyone has it, to impose, at the time you need. [...] If I see that things are getting ugly, I or another nurse ... Over time, we got respect. When you need, but there is no specific medical call, anyone comes here [...] (S1P1 interview)

Communicating the doctor an emergency and request his immediate presence requires the nurse to identify the necessary knowledge that his performance alone no longer holds the patient´s needs. However, if the nurse does not know to identify an occurrence of emergency among those that require mediate interventions, this professional weakens the bonds of their lines of flight.

Domestic production of the nursing work is set before important challenges such as the consolidation of issues related to inter-subjectivity at work ¹³. Thus, these interpersonal relationships in the labor sphere are little explored in relation to the production of knowledge and, therefore, these results still require further discussion in the scientific community.

Knowing how to deal the establishment of lines of flight to the interrelationships with other professionals is important in recognition of his knowledge/doing. In addition, the establishment of priorities and the identification of the most important clinical changes can reflect in a resolution and recognized clinical practice.

However, sometimes the resolution of the nursing work can find limitations in the posture of other professionals or in the organization of the institution´s work. This aspect can demonstrate a conception of the clinic´s medical appropriation and therefore is not essential tool for the job in nursing.

In the shift change, one nurse informs to the other that there was a hospitalization with a diagnosis of acute abdomen. He indicates that there is suspected appendicitis, but the patient has no fever. Also adds that laboratory tests were not able to assess because they were in possession of medical resident. (observation S2P1 and S3P1)

The medical professional practice out of the multidisciplinary team may reflect the very organization of work in the institution, which does not establish norms to the information to be made available in the patient. Study of nurses in primary care in São Paulo found similar findings that indicate discomfort by nurses before the non-recognition of the clinical work of nurses within the organization and management¹⁴.

In this scenario of action, clinical competence of nurses can be enhanced through training. However, it is not aware of what the expectations of other professionals and the administration of health services in this regard. In this sense, the history of each professional category can intervene in this process, as well as the management of health services cannot understand the importance of multiprofessional and stay focused on the doctor⁵.

The nursing work visibility as strengthening mechanism in the health production

The professional profile of the nurse manifests, through his scientific knowledge, his participation in decision-making related to patient care or in management activities⁷. Thus, the clinical knowledge can be a tool that enables visibility of nurses´ work and contribute in discussions, negotiations and changes in health care scenarios.

Therefore, making the nurse´s work visible means creating lines of flight which, according to Deleuze and Guattari, composes a map. According to these authors, making a map is different from making a decal because this comes from a simple reproduction⁸.

The nursing work does not need to reproduce the clinical model, he should construct through a map the search for integrality. Map features are open, collectible in all its dimensions, removable, reversible, susceptible to receive modifications that support individualized and resolution care⁸.

Nurses recognize that clinical as field of knowledge makes their work more visible to the different subjects involved in the healthcare process.

The clinical knowledge makes the work more visible to the nurse, to co-workers, for nursing technicians who respect you more and the resident doctor will also respect you more. (S2P2 interview)

The domain knowledge is a condition that supports the development of the clinical role of the nurse and thus essential for nursing interventions ¹⁵. Thus, knowledge sustains the professional practice and results in benefit to the patient, and thereby acknowledges it. Similarly, other professionals may also recognize their work, to realize that the actions taken are resolving and transmit scientific knowledge.

The way of organization of the professions and the work historically has been modeled in a fragmented approach. However, it is necessary to obtain a more inclusive work because there is the need for multiple looks, including meeting what advocates the National Health System, pointing integrality as one of the health care support pillars¹⁶.

So, how to make the work more visible? It is understood that this can occur through individual daily activities of nurses, which are extended to the public and reflect in the nursing workplace more extensively.

The nurse asks the resident doctor of traumatology, if the x-ray of a patient indicates osteomyelitis; diagnosis that professional said he suspected, after evaluation of the patient's wound. Resident confirms the diagnosis of osteomyelitis. (observation S2P1)

Two nurses request medical evaluation of a patient. After evaluation, doctors are questioned by one of them about the action to be taken and identified diagnosis. Clinical discussion about the case remains at the nursing station. A third nurse comes to the nursing station for passing on call and receive information without questioning. At the nursing station, doctors again return to the clinic discussion for at least 30 minutes. S3P2 remains, throughout the period, oblivious to the discussion, not keeping any communication with the medical staff. (observation S2P1, S2P2, S3P2)

The construction of clinical nursing role requires active participation, so they can assume their performance, giving particularities to the interactions developed with the patient and with other health care providers. Thus, even if the environment is favorable for the performance of the clinical role, the interaction of the nurse construction is crucial¹⁵.

The attitude of the nurse can make their knowledge more or less visible in the relationship with other professionals. Individual attitudes contribute to build the professional status of nurses and, in turn, are reflected in the expansion of social interventions, more significantly, in the occupation of spaces that give margin and recognition of nursing¹.

It is observed that nurses can also make their work more visible when explains the data derived from their clinical judgment. In this way, when the nurse provides certain information, he performs a refinement indicating what is most relevant to each case showing knowledge of the most relevant aspects.

A nurse asks for resident´s evaluation for a patient with gangrene in his leg, for suspicion of sepsis; tells the resident medical signs and symptoms of the patient and stresses elevation of body temperature, referring such suspicion. The doctor went to carry out the assessment and believes that the patient is really septic. (observation S1P1)

When establishing with the medical staff concrete flight lines that establish a flow of interaction for the benefit of the patient, the nurse, in some way, contributes to the health scenario context being favorable to multiprofessionality. However, in this context, not all other health professionals perceive to be autonomous, as well as nurses, establishing lines of flight with medical professionals.

It can be observed that, given the need for interaction with medical professionals, other professionals create lines of flight with the nurses, then, established with the medical staff.

The physiotherapist tells the nurse that a patient is with venturi mask, saturating well but tachypnea and that it judges necessary to raise the oxygen concentration. The nurse says he agrees and explains that the patient is like this because he is septic. It guides the physiotherapist phone to the doctor and discuss with her the behavior. The nurse: "_She [physiotherapist] comes to talk to me about things that are none of my conduct. I agree with her, but when I have to talk to the doctors, I talk ... I do not understand why she comes to talk to me ... She wants me to talk to them. This girl is good, but she says things just for me". (observation S1P1)

Recognizing, in nursing work, the necessary clinical knowledge that gives cross relations in the multidisciplinary team, some health professionals can give the nurse a reference for creating lines of flight. There is evidence that the nurse has been recognized by health professionals as an articulator in health care too, because his knowledge involves the broader social context².

The clinic can still be perceived by some patients as the medical area and therefore nurses can be confused with this professional, when they have their work recognized and valued.

A family concerns being very well attended in the institution and wish they had a means by which to put on record their opinion. They commends the work of the nurse and the doctor calls. She clarifies she is a nurse and the family then concludes: "_For me, you are a doctor". (observation S2P2)

The study of nursing history leads to understand that the clashes against the prejudices imposed by the collective imagination, through knowledge are important for the acceptance and recognition of the nurse. However, in real practice nurses can even be confused with other professionals¹⁷.

The fact that nurses be confused denotes a non-recognition of their knowledge and do as a nurse. Thus, even if the knowledge is recognized and visible for some patients, the myths built, throughout history, can make their image invisible as a professional holder clinical knowledge in the care of production spaces.

Patients may recognize that nurses in their work use a clinical body of knowledge. However, perhaps the challenge is to make it visible with collective aspects. The visibility of the work has to extrapolate the individual limits and contribute to the visibility of the nurse´s figure as an independent and clinically competent professional.

In that sense, the nurse is his own outdoor and therefore working his human posture is important for the visibility of his knowledge. However, it is emphasized that care must be taken so that the construction of the professional image consistent with their knowledge and not only made the appearance of a good professional¹⁷.

The clinic can be configured as a war machine, working to strengthen the image of the nurse as competent and qualified clinically. A war machine corresponds to the result of subjective processes that create an abstract machine, a means of acting against the established, a way of nurses provide care that confronts the established model without, however, deny it⁸.

CONCLUSION

Based on the philosophical reference of Deleuze and Guattari, it was found that, in clinical practice, the nurse directs his actions to care for the patient or creates escape routes with the other members of the health team, contributing to the integrality of care. Therefore, as a knowledge area, clinic makes the nurse´s work more visible for the different subjects involved in the healthcare process.

The study has limitations, because it is a case study, although developed with a group of nurses in a specific area of application. However, it identified that nurses can be considered the professional reference for the creation of lines of flight. Therefore, the recognition that this professional incorporates clinical knowledge for the establishment of joint and cross relations in multi-professional team is needed. Thus, the clinic can contribute in the discussions, negotiations and changes in health care scenarios, contributing to a more multi-professional effective act.

Although the nurse´s performance takes place in the clinical /biomedical assistance model, the professional search in the exercise of clinical, means for care in broader health and, likewise, uses it as a tool for solving and visibility of the work in nursing. Thus, the clinic can set up as a war machine created from lines of flight - a potential strength - opposite to hierarchical approach and acting to strengthen the image of the nurse as a competent professional and clinically qualified.

REFERENCES

1.Dal Pai D, Schrank G, Pedro ENR. O enfermeiro como ser sócio-político: refletindo a visibilidade da profissão do cuidado. Acta Paul Enferm. 2006; 19: 82-7.

2.Erdmann AL, Fernandes JV, Melo C, Carvalho BR, Menezes Q, Freitas R, et al. A visibilidade da profissão de enfermeiro: reconhecendo conquistas e lacunas. Rev Bras Enferm. 2009; 62: 637-43.

3.Christoforo BEB, Carvalho DS. Cuidados de enfermagem realizados ao paciente cirúrgico no período pré-operatório. Rev esc enferm USP. 2009; 43: 14-22.

4.Sousa LD, Lunardi Filho WD, Lunardi VL, Santos SS, Santos CP. A produção científica de enfermagem acerca da clínica: uma revisão integrativa. Rev esc enferm USP. 2011; 45: 494-500.

5.Basto ML. Da (in)visibilidade do trabalho das enfermeiras à produção de saberes em enfermagem: cuidados prestados num centro de saúde. Revista Portuguesa de Saúde Pública. 2005; 23: 25-41.

6.Favoreto C. A prática clínica e o desenvolvimento do cuidado integral à saúde no contexto da atenção primária. Revista de APS. 2008; 11: 100-8.

7.Castanha ML, Zagonel IPS. A prática de cuidar do ser enfermeiro sob o olhar da equipe de saúde. Rev Bras Enferm. 2005; 58: 556-62.

8.Deleuze G, Guattari F. Mil Platôs: capitalismo e esquizofrenia. v.5. São Paulo: Editora 34; 2000.

9.Yin RK. Estudo de caso: planejamento e métodos. Porto Alegre (RS): Bookman; 2005.

10.Moraes R, Galiazzi MC. Análise textual discursiva. Ijuí (RS): Unijuí; 2007.

11.Ministério da Saúde (Br). Conselho Nacional de Saúde. Resolução nº 466/2012. Dispõe sobre pesquisa envolvendo seres humanos. Brasília (DF): CNS; 2012.

12.Sprandel LIS, Vaghetti HH. Valorização e motivação de enfermeiros na perspectiva da humanização do trabalho nos hospitais. Rev Eletr Enf. [Internet]. 2012; 14: 794-802.

13.Mandú ENT, Peduzzi M, Silva AMN. Análise da produção científica nacional sobre o trabalho de enfermagem. Rev enferm UERJ. 2012; 20: 118-23.

14.Matumoto S, Fortuna CM, Kawata LS. A prática clínica do enfermeiro na atenção básica: um processo em construção. Rev Latino-Am Enfermagem. 2011; 19(1):[08 telas].

15.Mendes MA. Papel clínico do enfermeiro: desenvolvimento do conceito. [tese publicada]. São Paulo: Universidade de São Paulo; 2010.

16.Gelbcke FL, Matos E, Sallum NC. Desafios para a integração multiprofissional e interdisciplinar. Revista Tempus Actas de Saúde Coletiva. 2012; 6: 31-9.

17.Gentil R. C. O enfermeiro não faz marketing pessoal: a história explica por quê? Rev Bras Enferm. 2009; 62: 916-8.