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Conceptions and challenges in the systematization of nursing care


Révia Ribeiro CastroI; Antônia Liria Feitosa Nogueira AlvinoII; Emilia Soares Chaves RouberteIII; Rafaella Pessoa MoreiraIV; Rafaelle Lopes de OliveiraVI

I Nurse. Specialist in Health Management and Public Health and Hospital Management. Master in Health and Society. Limoeiro do Norte-CE-Brazil. E-mail:
II Nurse. Master in Nursing. Assistant Teacher II of the State University of Rio Grande do Norte. Brazil. E-mail:
III Nurse. PhD in Nursing. Adjunct Teacher of the University of Luso-Afro-Brazilian Integration. Fortaleza, Ceará. Brazil.E-mail:
IV Nurse. Adjunct Teacher, University of Luso-Afro-Brazilian Integration. Fortaleza-Ceará. Brazil. E-mail:
V Nurse of the City Hall of Fortaleza. Master in Family Health. Fortaleza-Ceará, Brazil. E-mail:





Objective: to investigate the understanding and implementation of the systematization of nursing care at a hospital in the city of Mossoró, Rio Grande do Norte, Brazil. Method: in this qualitative study, data was collected by participatory observation and semistructured interviews of five nurses conducted between January and March 2012. Data was analyzed by the content analysis technique proposed by Bardin. The study was approved by the research ethics committee of Rio Grande do Norte State University (No. 077/11). Results: it was possible to organize and group the data by the following categories: nurses' understanding of the systematization of nursing care; operationalization of care systematization through the nursing process; and difficulties in implementation. Conclusion: the systematization of nursing care is understood by nurses as synonymous with the nursing process; the process is not understood to be one of the methodologies for implementing systematization.

Keywords: Nursing; assistance; process; methodology.




In order to understand the human being in a broad and comprehensive way, it is necessary to establish new professional relationships and interactions, as currently the health sector is characterized by increasing specialization that leads to fragmentation of knowledge and care. Thus, there is a trend in nursing to reflect on the health practices offered, seeking autonomy and safety when offering care1,2.

We understand that the construction of knowledge and the qualification of the profession are decisive for achieving professional freedom in any category2.

Nursing, as a developing profession, is in the process of building the identification of its own base of knowledge, in which concepts, models and theories have been defined3. In order to make an assistance based on theoretical precepts pevail, discussions about the systematization of nursing care (SNC) started in the 1950s.

The SNC is a methodological tool that, besides promoting and guiding nursing care, provides the conditions for the nursing work organization 1. It promotes nursing actions, greater ease of assistance and benefits, especially for the patients who receive personalized, individualized, efficient and effective service4.

Through the SNC, the professionals apply their technical-scientific and human knowledge in the service and characterize their professional practice, intensifying their role in an autonomous manner1,2,5.

Although exclusive of nurses, SNC provides a methodology for organizing, planning and executing systematized actions, which are performed by the team while the client is under nursing care1.

Nurses need to use a proper methodology to implement the systematization of care, and a tool that can be used to achieve this goal is the Nursing process (NP)1,6. The Nursing process is a systematic tool composed of five sequential and interrelated stages, based on the conceptual model of Wanda de Aguiar Horta4,7.

Understanding SNC through the NP is very important to broaden the view beyond prescriptive and normative formulas and models instituted as guides of a human-centered assistance.

The interest in developing research on this subject emerged from the need to know how the SNC works through the NP in health services, since, according to Resolution 358/2009 of the Federal Nursing Council (COFEN), the implementation of SNC is mandatory8.

The objective of the study was to investigate the understanding and operationalization of SNC in nursing actions in a public hospital in the city of Mossoró, Rio Grande do Norte, Brazil.



The nursing process (NP) is the methodology used to systematize and organize the nursing care, with a view to optimizing the care and assistance to the needs of the patients, families and community9.

The phases of the Nursing process are: - nursing history - deliberate, systematic and continuous process carried out with the aid of varied methods and techniques that have the purpose of obtaining information; nursing diagnosis - interpretation and grouping of the data collected in the first stage, culminating in decision-making and that representing the basis for selection of actions or interventions; nursing planning - determination of expected outcomes; and nursing actions or interventions that will be performed; implementation - implementation of the actions or interventions determined in the planning stage; nursing assessment - deliberate, systematic and continuous process of change verification to determine if the actions or interventions reached the expected result, and verification of the need for changes or adaptations in the stages of the nursing process10.

The application of the NP has contributed to the development of nursing classification systems for the elements of professional practice, such as the NANDA International taxonomy and nursing diagnosis, the Classification of Nursing Interventions, the Classification of Nursing Outcomes, the Omaha System, the Classification of Home Health Care and the International classification for Nursing Practice11. Until 2002,NANDA was an acronym for the North American Nursing Diagnosis Association. However, this is no longer the name of the organization. In 2002, it officially became NANDA International, taking into account the significant growth of the association outside of North America.

Egalitarian difficulties have been faced in the implementation of the NP, regardless of the institution in which the process is established. Each institution has its particularities, but in general, the problem is repeated12.

In several theoretical-practical experiences, the implementation of the NP has been slow and difficult. There is resistance from nurses, often due to lack of previous experience in other services, the view that the process is complex, time-consuming and not feasible in daily practice12. It should be reminded that the SNC must be present in all situations in which nursing care is developed.



This paper is a descriptive, cross-sectional and qualitative study and it was developed from January to March 2012.

The research was developed in the medical clinic of a public hospital in the city of Mossoró - Rio Grande do Norte - Brazil. This unit was chosen because it is a reference I all western region of the state of Rio Grande do Norte in urgencies and emergencies, and treatment of chronic pathologies.

Research participants were all the nurses working in the mentioned sector, totaling five nurses.

To collect the data, we used participant observation and semi-structured interviews guided by a script composed of eight questions.

The collection instrument was elaborated from adaptations of models from other studies1,4,5, seeking to identify: the understanding professionals have on SNC; the operation of the SNC; the existence of elements that could facilitate and/or hinder the SNC implementation.

Data were submitted to the Bardin content analysis, which is carried out in two steps: pre-analysis and treatment of results obtained and interpretation. In the pre-analysis, a survey of categories is performed through the classificatory operation of the subjects' speeches. In the second moment, an interrelation of the participants' speeches is made with the theoretical framework designed with the purpose of revealing interpretations13. From the content analysis of the reports, three categories emerged and explored with in the Results section.

To preserve the anonymity of participants, speeches are identified by alphanumeric codes in which the letter N represented nurse and the number indicated their order in the sequence of interviews.

The research was approved by the Research Ethics Committee (REC) of the State University of Rio Grande do Norte, registered under the number CEP/nº077/11.



Based on the understanding that SNC is a methodological instrument that, besides promoting and guiding nursing care, provides the necessary conditions for the organization of nursing work14, it was possible to group the information in three categories of analysis, discussed below.

The understanding of nurses of SNC

For the professionals participating in this study, the understanding of the SNC is parallel to classic concepts of nursing care systematization. According to the perception of these subjects, for nurses to develop their duties, it is not necessary to apply the whole nursing process, but at least part of it.

The SNC was considered important by all participants, and it was verified that its application involves more than the fulfillment of steps to be followed. It requires from the professional, besides the knowledge of the sequence of the steps inherent to the NP, also a critical view of the process and sensitivity to adapt the patient's needs to the working conditions.

[...] it is extremely necessary. When there is no systematization, each one does his work, in his own way, but doing so, we do not speak the same language. (N-1)

[...] the organization of nursing work in order to make it more effective, with better results at the end of the care provided. (N-3)

When discussing the importance of SNC, some aspects are taken into account; the quality of the service from the managerial point of view and the quality of the assistance provided.

The concern with the quality in the health area is not a new topic. However, the proposals of systematization and organization of the services are recent in the administrative context. In this perspective, the SNC is pointed out as a relevant tool for the improvement of institutional performance, even necessary for the implementation of the principles that guide health policy15.

The application of the SNC promotes an improvement in the quality of care because it directs and organizes the work, allows auditing, favors professional visibility and effective participation in care and decision making, favoring an individualized assistance16.

[...] the SNC involves a lot of things: the planning of nursing actions, prescription, nursing care, evolution and reevaluation... But we have to give priority to the most serious cases. (N-2)

In relation to the previous speech, one can make significant inferences. The first refers to the fact that nursing professional understands SNC as the NP itself, since this consists of a methodology to implement the SNC, but it is not the only instrument to make SNC effective in the in the services6.One of the respondets refers to the steps inherent to the NP, such as the construction of the care plan, the implementation, without, however, mentioning an important step - the nursing history performed through the collection of data of each patient.

Thus, it is understood that for the elaboration of a care plan, the professional would carry out an investigation, but the omission of the nursing history step suggests that the data collection is not so relevant or necessary to support the collection of accurate and reliable diagnoses.

When the nursing history is not mentioned, the NP is only partially contemplated. Data collection is presented to SNC as an essential step for the construction of the assistance. In order to provide quality care, nurses must be inserted in the concrete reality in a conscious, competent, technical and scientific way3.

Regarding the organization of care, nurses recognize the importance of dedicating themselves to the patients in most severe situations. However, they stress that, detailed information, acquired through a nursing history, is necessary to identify the most serious patients and to provide adequate assistance for each case.

It is emphasized that the professionals perceive the importance of the SNC for the practice of a targeted, organized, continuous and, thus, more effective assistance for the clientele. The interviewed nurses' understanding of SNC indicates that they see it as an instrument capable of organizing care from critical decision-making and not merely based on an endless sequence of trials and errors.

However, the consolidation of the process depends on several factors. Among them are the commitment of the team, of the institution, and economic and social factors that precede and sustain the professional determinants5.

Operationalization of the SNC

The implementation of the NP in health services is seen as a challenge by COFEN, which made this work process mandatory in 2002 through a normative resolution, in order to reinforce the need to plan and evaluate the care 8.

Since the beginning of the implementation of the SNC in the health services, some difficulties have been observed: complexity and lack of uniformity in the establishment of its stages, insufficient teaching-learning process in undergraduate and postgraduate courses, insecurity of professionals to carry out the activities inherent in the process and insufficient number of nurses. Due to these factors, many nurses fail to systematize their care, and ultimately fragmenting it 17.

The interviewees' statements showed that the way of acting symbolizes the execution of one or two components of the nursing process at a given moment, but not in the whole, neither in all circumstances. The interaction between nurses and the SNC depends not only on the ethical monitoring of care, but, above all, on the oscillations of the professional environment. Thus, nurses interviewed reported that the operationalization of the SNC is perceived, but not always fulfilled in its totality.

In a way, we perceive some phases of the SNC in our work process, especially with regard to data collection and physical examination, performed at the admission and/or evolution of the user, although not in the well elaborated and structured format of the SNC. However, the other steps of the NCS are lost in the moment of assignments delegated to the nurses, as well as to the entire nursing team. (N-3)

[...] I do not regularly carry out the SNC; I do not observe a plan of action, of care. But I try within the possibilities to provide nursing care with excellence to those in worse conditions or to patients [...] who need more complex care. (N-2)

It is identified that the SNC has not been implemented. However, the statements denote that one of the important stages of this process, the care/action plan, is not put into practice by the professionals of the unit. Thus, the quality of the care that omits the care plan is questionable.

Study showed that among the many factors that have hampered the operationalization of SNC, according to the perception of nurses of an obstetrics service, are the lack of credibility of nursing technicians on the SNC, the work overload of nurses, the little motivation of managers to implement the SNC, and the unawareness of the functioning of the process by nursing professionals17.

When the NP is not put into operation at all stages, the work is no longer systematized. The professionals understand the SNC as synonymous of NP. In this unit, professionals do not understand that the process is one of the methodologies for the systematization of assistance.

Difficulties for implementation of the SNC

The continuity of the service is very important to the nursing team. Flaws in the application of the NP may bring consequences. There are many challenges to the implementation of the SNC, but the interruption of the systematization of care due to the work overload of nurses stand out, as reported by the participants.

Excessive work hours make it difficult to implement the SNC; if a day-care nurse were available, this would help. There is lack of investment of the hospital. (N-4)

[...] one difficulty here in the sector is the lack of a day-care nurse, because if there were such a professional, it would make it easier, because in this way I would be able to visualize the routine of the sector. There is a lack of time [to work], the nurse is too overwhelmed. And there is a lack of investment on the part of the hospital, because if they invested more, for example, by paying extra hours for us to come at times out of our shift, to try to do this systematization. (N-5)

Some institutions have sought better working conditions with a view to implementing methods of organizing nursing care, not as an end in itself, but as a means to achieve the highest goal: providing quality care and helping patients to return to their families and social life.

However, it is observed that devoting more work hours to nurses and paying them adequately does not seem to be relevant for most health institutions18. A nurse stresses this information by mentioning that she finds it difficult to implement the SNC in the unit where she works due to the insufficient number of the workforce.

[...] a sufficient number of professionals to carry out the activities is necessary. Overworking; for example, a sector with 30 patients and only one nurse to solve the whole bureaucratic tasks, provide nursing care and coordinate the services of the team is humanly impossible. (N-2)

It was verified that the work overload makes it difficult to carry out the NP, but other obstacles were also pointed out. These include the lack of personnel (administrative problem), and the lack of investment by the hospital itself.

In view of this, it can be seen that the difficulties to implement the SNC can also be related to the size of human resources of the health institutions available to perform all the activities required by this methodology, which requires time to record and analyze the data.

The subjects of this research, understanding the non-compliance of the SNC, indicate alternatives of interaction with other services, with a view to overcoming the difficulties.

[...] that the hospital would invest in people coming from other places where the SNC was deployed through the NP, to help the local hospital staff to implement it. (N-1)

There is a need for professional training. (N-2)

The high demand of clients also appears as a challenge, since this situation increases the work overload and reduces the time nurses have to systematize an appropriate assistance for the clientele14.

The difficulties are endless. In my opinion, the main difficulty is the high demand of internal users in the medical clinic, which hinders the quality of nursing care, which is dispensed only to the critically ill patients. Also, the high number of activities delegated to nursing professionals who, besides nursing assistance, have to solve problems that are not their competence, such as, optimization of exams, transportation, among others. (N-3)

Other professionals in the medical clinic were also cited in the reports. In their speech, participants do not report specific categories, but they mention the lack of commitment of some professionals. The lack of initiative was the most cited difficulty.

[...] the difficulty of this operationalization is the lack of initiative (N-1)

[...] interest of professionals and lack of training (N-4)

[...] one difficulty is the lack of initiative (N-5)

It is evident that the challenges to the implementation of the SNC through the NP are many and diverse. The main impediments to this implementation are: lack of knowledge about the NP methodology; high demand for activities assigned to nurses; reduced number of human resources; influence of the biomedical/cartesian model.

In a study that had as one of the objectives to identify the difficulties for the implementation of the SNC in family health, the mainly cited factors were time, lack of human resources and lack of material for its applicability19.

In another study, the greatest difficulties for the implantation of SNC were the lack of knowledge and theoretical-scientific basis by the nurses, lack of resources and lack of time20.

COFEN considers the SNC as a exclusive assignment of nurses and says that its application is related to some aspects necessary for its implementation: nursing education, structure of nursing work organizations and elements that contain, besides beliefs and values, knowledge, skills and practices of nurses8.



Based on the findings, it was possible to identify that professionals understand the SNC as a synonymous of NP. There is no understanding that the NP is one of the methodologies for implementing the SNC. Therefore, the understanding of SNC is limited, as well as, the steps that comprise the NP are partially expressed. They indicate that the SNC and the NP are not perceived by professionals as they are expressed in the literature.

Professionals understand the SNC as important to support and improve the care provided by the nursing team. However, they indicate the lack of effectiveness of the SNC in the medical clinic, the place where they work. This lack of effectiveness was justified by the reduced number of professionals, lack of qualification and adequate investment into the SNC operationalization and lack of commitment of work colleagues.

It was observed that professionals try to apply the SNC as close as possible to what they consider to be appropriate. However, they find justifications for not doing so.

It is clear that the challenges to SNC implementation permeate, in addition to the quantity of personnel and the individual commitment to fulfill its steps, to know and understand what the SNC is, and which are the ways to implement it. It is necessary, before operating the SNC in this hospital unit, to (re) build the knowledge about this systematization and about the NP, understanding its importance and its implications in the work dynamics of professionals.

It is important to emphasize that this (re) construction of the SNC promotes a reflection on the professional practice of nurses and also indicates the need for changes in their professional practices. As for this aspect, another great challenge for the implementation of the SNC through the NP is identified: the change of professional practices. This is because the professional activities are closely linked to other social, economic and cultural factors.

The change in professional practice requires the break with certain conceptions about the health/disease process that permeate health care, and which are deeply rooted in health care as a whole.

The study of a single unit, which prevents the generalization of the results, is considered a limitation of this research.



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Direitos autorais 2016 Révia Ribeiro Castro, Antonia Líria Feitosa Nogueira Alvino, Emilia Soares Chaves, Rafaella Pessoa Moreira, Rafaelle Lopes de Oliveira

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