Competencies of the nurse specialist in nephrology
Nathalia Billo de OliveiraI; Frances Valéria Costa e SilvaII; Luciana Guimarães AssadIII
Nurse. Specialist in Nephrology by the Nursing School from the State University of Rio de Janeiro. Supervise Nurse in the Nephrology Center Mageense. Rio
de Janeiro, Brazil, E-mail: firstname.lastname@example.org
II Nurse. Ph.D. in Collective Health. Professor at the State University of Rio de Janeiro, Nursing School, Department of Nursing Fundamentals. Nephrology Nurse at the University Hospital. Rio de Janeiro, Brazil, E-mail: email@example.com
III Nurse. Ph.D. in Nursing. Professor at the State University of Rio de Janeiro, Nursing School, Department of Nursing Fundamentals. Nursing Training Head of the University Hospital. Rio de Janeiro, Brazil, E-mail firstname.lastname@example.org
This quanti-qualitative, descriptive study discussed nurses' understanding of the duties and competencies of the specialist in nephrology. In July and August 2012, semi-structured interviews of 11 nurses were conducted at the hemodialysis unit of a university hospital in Rio de Janeiro city, recorded and later transcribed. The data were formatted as an electronic data base, grouped by values of the same kind and subjected to content analysis. The results showed that the professionals' understanding of their duties and competencies are not well defined. They had difficulty giving complete, consistent answers, which may perhaps be attributed to lack of thinking on the subject. The study provides food for thought for professional nurses in hemodialysis about their activities, with a view to improved performance, competence-based practice and postures derived from knowing how to think and how to do.
Keywords: Nursing; clinical competence; professional competence; renal dialysis.
The development of nephrology as a specialty is associated with the discovery and improvement of dialysis and kidney transplantation techniques. In this sense, nurses needed to learn the management of equipment and the best way to take care of patients with chronic renal failure1.
IN 1983, the foundation of the Brazilian Nursing in Nephrology Association (SOBEN), reference for the specialty, aimed to contribute to "improve the nursing care provided to individuals with renal failure"2:1. However, the specialist title of concession in nephrology nursing began in 1996, after the creation of the Department of Specialization and Titles to Nephrology Nurses (DETEN), responsible for titles conferred by SOBEN through accreditation tests.
It also contributed to the growth of specialty Resolution number 154/2004 of the Executive Board Collegiate of the National Health Surveillance Agency, dealing with the "need to redefine the minimum criteria for the operation of dialysis services".3:1 The regulation establishes the obligation of specialist nurses in nephrology to assume technical responsibility for the nursing services of dialysis centers3.
The interest of research of abilities of nurses in hemodialysis are justified because this is a recent specialty and with strong expansion. The study of this topic implies the effort to understand the professional abilities of the nurse specialist in nephrology in the development of their actions and subsidizes the planning of professional training policies for specialization.
The research had as object the abilities of nurses' nephrologists in hemodialysis and their goal was to discuss the understanding of these professionals about their attributions and abilities.
The research was based on theoretical concepts about the meaning of nursing professionals' abilities and their description related to specialization in nephrology according to SOBEN1,2.
From a conceptual point of view, the term ability is understood as "capacity to act effectively in a situation, based on knowledge, but not limited to them"4:7. It is also defined as "a set of knowledge and skills that professionals incorporate by training and experience, together with the capacity to integrate them, use them and transfer them in different professional situations"5:79.
All know-how is an ability, which is more complex by being combined with theoretical knowledge. "From the moment that the individual does what must be done without even thinking because he already did it, it is not talking on an ability anymore, but skills or habits"4:27.
"Skills are the results of the construction of basic abilities that are consolidated in the form of habitus, or the know-how, which are also deployed in the construction of professional abilities"5: 166.
The basic abilities are general and constructed by the individual to face life, the intellectual abilities are true meanings attributed to their attitudes, providing analysis and problem solving, decision-making capacity and adaptation, while the professionals' abilities are developed during vocational education of technical level until graduation4-6.
Professional abilities are understood as the capacity to mobilize, articulate and put into practice values, knowledge and skills necessary for the efficient and effective performance of activities at work7.
Another developed ability is about the specialist "when the individual is able to dominate very quickly and with security the most common situations, having action schemes that with a reasonable effort of reflection, quickly mobilizes his knowledge to face unreleased situations"4:26.
SOBEN describes the abilities of nephrologists' nurses grouping them into four areas: administrative, care, education and research. Each professional is guided by a profile and a stance provided by the formation of his catergory8.
It is a quantitative, qualitative, and descriptive research. It was held at the hemodialysis unit of a university hospital in Rio de Janeiro, characterized as reference unit treating severe kidney disease and vocational training center in the health area.
As subjects, there were higher-level nursing professionals, crowded in the sector in the period between July and August 2012. There were 11 participants from 12 nurses inserted in the service. The absence of one of the subjects was due to his inability to answer the interview. To maintain anonymity, numbers were assigned to the participants of the interviews (N1, N2,... N11).
To collect data, semi-structured interview was used and a closed instrument to identify the activities and general responsibilities of these professionals in the area. The interview was recorded in digital media and the speeches were transcribed for further treatment.
Transcripts data were texts submitted to the technique of content analysis, with aggregation, synthesis, sorting and classification of data, categorized by content similarity, repetition and absences9.
A document provided by SOBEN about the abilities of nurses in nephrology8 was used as a matrix for categorizing data. Four categories were built: care, administrative, educational and research abilities.
The research followed the principles of Resolution 196/1996, providing opportunities for professionals choose to participate or not of the study. All participants signed a consent form. The research was submitted to the Ethics Committee of Rio de Janeiro State University/SR2, approved on 28/06/2012 with Protocol 026.3.2012.
RESULTS AND DISCUSSION
Profile of participants
The study group was predominantly female with 7 (63.6%), an average age of 39.3 years (+5.9), with extremes from 28 to 48 years old. The average training time was 9.1 years (+5.7) and ranged from 3 to 19 years. Regarding the educational institution, 6 (54.5%) participants were from of private institutions and 5 (45.5%) of public universities.
Regarding graduate, 9 (81.8%) had additional training, while 2 (18.2%) denied such a condition. Among those with graduate degrees, 6 (67%) had specialization, 2 (22%) specialization and residence and 1 (11%) residence. Among the specialists, there were 7 (78%) with training in nephrology.
The working time of the service ranged from 1 month to 5 years, 4 (36.4%) with less than 11 months, 4 (36.4%) between 12 and 47 months, and 3 (27.3%) with 48 months or more. Previous experience in the area existed in most of the studied group - 7 (63.6%), with time ranging from 2 to 15 years.
There were 7 professionals (63.6%) considering themselves specialists in nephrology, but few of them associate this condition to their formal title, by the fact of practical experience in addition to working time. Considering the reasons not to consider specialist in the area, the answers ranged from not having title and working for a short time in the area. SOBEN determines for the title of specialist by evaluation, the proof of 5 years of experience as a nurse in nephrology and approval in the theoretical evaluation organized by them or attend a post-graduate study in nephrology with registration in the association2.
Most of the abilities listed by SOBEN8 assistance were contemplated in the statements, whether as a proper assignment or as ability, showing the strong bond of the group with activities associated with patients´ care. It could be observed that nurses mobilize knowledge through action schemes during care, enabling knowledge used to generate specific abilities for the professional in nephrology, which is only possible when they are translated into actions. Action schemes are important because they link the subject to the environment, since they are associated with perception, judgment and decision making during care10.
The care activities contemplated direct care, guidance and education to patients and families, contributing to the nurse create spaces for active interaction allowing the individualization of care.
The orientation with the client and family is an activity developed by 8 (72%) professionals, and 3 of them (28%) admit that the dynamics of work at night, the management function and the intense routine lead them to distance this function but merely to guide when approached.
Education is primarily addressed to newly admitted patients, aiming to answer doubts about chronic kidney disease and renal replacement therapy, and reduce the fear of hemodialysis machine. There was reference to the use of educational resources such as brochures and lectures when possible. A professional mentioned that he investigates other health problems that may be affecting these patients, not paying attention exclusively in chronic kidney disease. In this scenario, there is the importance of producing a collective knowledge that translates into autonomy and emancipation of individuals and their families 11.
The care and handling of catheters and fistulas were present in all the lines, denoting the importance attributed by nurses to the maintenance of hemodialysis access, since without them the procedure cannot be performed.
Care with fistulas and catheters every day. (N6)
Punching fistulas, a nurse, who is not hemodialysis, has no ability to this; he must know to avoid problems. (N7)
The interpretation of laboratory tests as well as the identification with the doctor, individual and family about the best method of dialysis for the patient is expressed as an ability by SOBEN8 existing 2 (18%) references to these actions. In this context, it is relevant to point out the knowledge and professional autonomy as an element that gives the professional a job12.
[...] Discussion about the exams of patients, assessing the adequacy of dialysis and intervening at any time. Keep communication, better interaction with doctors to be more aware about the current condition of patients [...] (N6)
[...] To see the results of tests to know if they are good or not, evaluating the patient to dialysis, if he can go to other therapy. (N3)
The specialist in nephrology must be able to prevent, identify and treat complications presented by patients before, during and after dialysis according to SOBEN8. Nurses understand that realizing complications during the dialysis procedure, it is possible from practical experience 9 (56%), scientific knowledge 5 (32%), and attention and agility in understanding risk situations 2 (12%).
In care action of the nurses, there are six areas of practical knowledge that can be analyzed to understand the skills developed. We highlight the top ones that are the instructions provided by specialists, not making sense to anyone else, unless the person already has deep knowledge of the situation or it has the extensive experience in the area13.
Abilities further described deal with in-depth knowledge, critical thinking, directing the care and the theoretical basis in the actions. They admit that the specialist in nephrology has extensive knowledge about kidney disease and renal replacement therapies, and through them, they are able to guide better care and have theoretical basis in the actions.
In this context, the CNE/CP number 29/2002 if MEC is highlighted, which states that the abilities include: intuit, sense and risk, based on previous experience and knowledge, skills and values articulated and mobilized to address the challenges of professional life always requiring new, original, creative and enterprising responses14.
Some abilities described by SOBEN8 were not mentioned - nursing consultations, guidance and supervision of procedures for disinfecting equipment and reprocessing of dialyzers. The absence of references cannot be understood as actions not carried out, but as non-recognition of action as an ability. They may also be recognized as administrative, including the understanding of the nurse´s action as a supervisor.
"Historically, the nurse is a caregiver agent, however, in contemporary times he has been established as care manager"15:554. Ideological and theoretical bases of nursing administration include four areas of the act of managing: planning, decision-making, supervision and auditing16. Among these areas, respondents mentioned three of them; they did not cite the auditing. Other responses were obtained as registration in the medical records, provision of material, organization, supervision and control of dialysis water quality.
[...] Service organization, decision-making, management, designated service assignments exclusively to nurses. (N4)
[...] Staff supervision; interact with patients; provision of materials and supplies, operating machinery and provide assistance. (N6)
[...] Complications records in electronic medical records or not, that facilitates communication and lets them know what happened to the patient on the other days. (N3)
The work of nurses must be based on the capacity to make decisions to ensure an effective result, without wasting resources. To this end, they shall possess skills to assess, organize and decide the more appropriated behavior7, highlighting the leadership as the ability to be developed 17.
Administrative abilities proposed by SOBEN8 were not mentioned promoting meetings with the team; the development of nursing protocols, minimization of adverse events; implementation, planning, organization, execution and evaluation of the systematization of nursing care (SAE), among other proposed items. In this context, it is relevant to mention the construction of a professional ability matrix of the nurse18 exploring the basic abilities of nurses in a specialty scenario, highlighted to the need for a standardized system for defining language abilities. Therefore, the absence of expression of nurses about their own abilities can be related to the lack of a language that is able to clearly measure what is meant.
In the space of administrative abilities, a study is highlighted also exploring skills and abilities of nurses in specialized scenario, with a relevant finding of a managerial dimension in the testimonies19.
The responses of the nurses related to this category consider education as a process directed to patients and professionals. It is noteworthy that such patients' education and family activities are also mentioned in the document of SOBEN as care abilities. As educational assignments nurses recognize education activities with patients and the coordination and preceptorship residents and interns, and cite as abilities to clarify questions of therapy, production of explanatory material, teaching, receiving trainees and transmission of knowledge.
Rather than managing the sector, we had to link this specialist to work with patient´s education, guidance to his illness, making this moment a little more quite, with that, you would have a much better service, you would meet this patient in other way [...]. (N11)
SOBEN describes the promotion of patients and family education activity as an ability of the nurse specialist in nephrology, related to improved quality of life, which can be done through guidelines and the formulation of educational handbooks suited to their social reality8.
It is up to the nurse, first, to welcome the patient with renal disease and try to clear the sea of doubt where they usually are immersed, being able to do this with various strategies that should be added, since the direct approach through interviews and also by production of printed information materials, or the formulation of electronic media and groups taking advantage of time and space available so that they can listen to and educate the patient. (N11)
Other educational abilities established by SOBEN to provide conditions for the improvement of nursing professionals acting in the area through courses and internships in related institutions, to participate and encourage the participation in scientific events, updating the area, to participate in the development of internship programs, training and development of nursing professionals at different levels of training and to supervise staff of nursing internships at nephrology8. Such activities were also present in the interviewees´ reports.
The answers obtained in this category showed that respondents recognize the educational activities with patients, with the entry-level professionals and their own update, whether in the form of training or continuing education, as part of their attributions and abilities. Nevertheless, they argue that their upgrade is limited for private reasons and actions directed at patients and entry-level professionals are often suppressed by not being part of a planned and controlled work process, being open to the initiative of each nurse.
In speeches obtained, the subjects of the study did not include abilities related to research. SOBEN describes the research as an important professional ability, presented as establishing "[...] technical-scientific relationships with related units, developing investigational studies and research [...]", as well as participation "[...] of the evaluation of new products in nephrology [...]"8:2. These findings indicate the need to strengthen the incentive to develop investigations, seeking scientific evidence to the practice of nurses in nephrology.
Ability is understood as the capacity to act effectively in certain situations, based on knowledge and skills that can be incorporated into clinical through training and practice, together with the capacity to integrate them and use them in their attitudes. Therefore, it can be said that abilities has three main elements: knowledge; ability characterized by know-how and the attitude of want-to do.
Regarding the understanding of the professionals about their attributions and abilities, it may be noted that they do not have them well defined. It was difficult to give consistent and complete answers, a fact that might be attributed to the lack of reflection on their professional practice, or even the study limitation due to its application in just a nephrology service.
The study provided reflection and understanding about the abilities and attributions of nursing specialists in nephrology in the hemodialysis area. Questioning specialist nurses in practice about their schemes and mobilized knowledge during care, it was one of the means to clarify the professional abilities to be acquired in a training system.
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