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Hospital nursing: the dialectics of adapting and improvising in practice


Luana dos Santos CunhaI; Norma Valéria Dantas de Oliveira SouzaII; Francisco Gleidson de Azevedo GonçalvesIII; Déborah Machado dos SantosIV; Liana Viana RibeiroV; Ariane da Silva PiresVI

I Nurse. Master in Nursing. Faculty of Nursing of the Rio de Janeiro State University. Brazil. E-mail:
II Nurse. PhD in Nursing. Associated Professor. Faculty of Nursing of the Rio de Janeiro State University. Brazil. E-mail:
III Nurse. Master in Nursing. Faculty of Nursing of the Rio de Janeiro State University. Brazil. E-mail:
IV Nurse. PhD student in Nursing. Faculty of Nursing of the Rio de Janeiro State University. Brazil. E-mail:
V Nurse. PhD student in Nursing. Faculty of Nursing of the Rio de Janeiro State University. Brazil. E-mail:
VI Nurse. PhD student in Nursing and Assistant Professor. Faculty of Nursing of the Rio de Janeiro State University. Brazil. The e-mail:





Objective: to identify nursing professionals' views on adapting and improvising materials in hospital work, and analyze the advantages and disadvantages of this practice for health work and nursing. Method: this qualitative, descriptive study involved 20 nursing workers at a Rio de Janeiro public hospital. Data were collected in July 2009 by the technique of semi-structured interview, and analyzed by thematic content analysis, after approval by the Research Ethics Committee (No. 2355/2009). Results: it was shown that the practice of adapting/improvising is dialectical, and involves feelings of pain and pleasure: while ensuring care, it also places patients' and workers' safety at risk. Conclusion: adapting/improvising materials has the potential to emerge relevant creations with patents opportunities for the profession.

Keywords: Occupational health nursing; working conditions; material resources in health; occupational health.




This paper studied the perception of nursing workers on the practice of adapting and improvising materials in hospital work. The desire to investigate such a subject emerged from the experience as nursing professors at a public university in Rio de Janeiro, where there was an increasing precariousness of working conditions that impelled workers to constantly improvise and adaptat materials.

The work in public hospitals has been marked by this intense shortage of hospital supplies. This unusual situation involves political and economic injunctions, all strongly linked to the neoliberal model1. Amid this context of precarious working conditions, nursing professionals find themselves facing complex situations where the customer needs care while the material and human apparatus available are not always adequate to provide such care. So, professionals make use of tricks and task rearrangements in order to guarantee the provision of care. Adaptations and improvisations of material and, often, also of the staff are common solutions to face this problem2.

The expression "to adapt" here means to adjust, to become more able to do something and able to survive in the environment in which one lives. In turn, improvising means to prepare or hastily invent, unexpectedly or without premeditation3.

Improvisation in hospital work arises from a need for urgent care, where workers' creative capacities are quickly mobilized to achieve an immediate practical solution for problems. This urgency give rise to new operative and instrumental modes, which. If the effectiveness of such modes is confirmed in the professional environment, they are perpetuated and established in the form of adjustments that will come to be used in circumstances similar to those of their creation and propagated as efficient solutions. We conclude, therefore, that an adaptation arises out of an improvisation, but not every improvisation is established as adaptation2,4.

However, it is not always that adaptations and improvisations represent viable creations to the execution of the work, considering, for example, the economic cost, respect for scientific principles of the profession and the reasons for which they are created. Thus, having to adapt and improvise on behalf of an organization of work that does not provide adequate means for the execution of activities, and having to adopt this practice in urgent situations can often result in negative effects to the safety of patients, the workers' health and the quality of care.

We seek through this study to contribute to the enrichment of the debate about the health of nursing workers from the perspective of subjectivity. Moreover, we considered that this study may contribute to the increase in research on adaptations and improvisations performed by the nursing staff in hospital settings, from the perspective of creative professionals and commitment of the nursing staff with the guarantee of quality of the care provided. To this end, this study set the following objectives: i to identify the point of view of nursing professionals on adaptation and improvisation of materials in hospital work and to analyze the advantages and disadvantages of this practice to the work in health and nursing.



The study is based on psychodynamics of work concepts, which studies, among other issues, the contradictions that pervade the world of work, with special focus on the pleasure and suffering caused from the employee's experience in labor organization.

The psychodynamics of work emerged in the late 1970s. It was published by the French doctor Christophe Dejours, psychiatrist and occupational health assistant at the Faculty of Medicine of Paris. Doctor Dejours' concepts are centered on the analysis of the relationship between mental health and work, stating that the work is never neutral regarding health workers. Dejours' studies have origin in his involvement with the psychopathology of work. However, the concepts of psychodynamics of work went beyond the psychopathological proposal for identification of specific mental illnesses related to the profession and to work situations; they are concerned with the origin of suffering and its transformation, which is built by the worker and aims at enjoying work5.

Studying different responses of employees to work organization, Dejours and colleagues have developed a theoretical body that deepens in the study of collective defense strategies that are tactics engendered by workers, often unconsciously, which are intended to contain, minimize or anesthetize the pain that result from work situations6. It is noteworthy that, in the working world, man seeks what he wants to achieve. When the work is able to favor the achievement of his objectives, it plays an important role in personal fulfillment. But when work creates obstacles, leads to suffering and its transformation is not directed to the achievement of pleasure, then the work can be considered harmful to health7.

Adaptations and improvisations in the hospital arise in a scenario where there is a shock between the actual working conditions and the prescribed work, whose labor organization should ensure the means for implementation of activities. This conflict between the prescribed and the reality generates subjective reactions in the professional group, which can provoke pleasure or pain, health or disease.

Thus, adverse working conditions can generate different responses from workers who experience this phenomenon. These goes from inertia to alienation and to illness, or otherwise, to the development of creative and inventive skills and resistance from the use of different coping tactics to face the difficulties of the working world. Thus, the clash between the organization of the prescribed and real work organization can be either beneficial or harmful to the workers' health5.

It is noteworthy that, on one hand, the adaptive capacity of the nursing staff facing the paucity and inadequacy of resources, particularly in the hospital environment, favors learning, creativity, inventiveness, and can even enrich professional experiences. On the other hand, this can represent dangerous actions that jeopardize the health of workers, working in synergy with the nature of nursing, which is often recognized as an unhealthy and dangerous profession2.



Descriptive research with qualitative approach carried out in a public university hospital in Rio de Janeiro state. We selected the following sectors for data collection: an intensive care unit (ICU) specialized in cardiac surgery and four surgical ward units (general surgery, thoracic surgery, neurosurgery and vascular surgery).

These scenarios were chosen because they are sectors with special characteristic of care to critical and post-operative customers, demanding a greater number of procedures that require from the nursing staff hard and uninterrupted work. In these scenarios, the daily performance of adjustments/improvisations is materialized due to the high demand from material resources.

Participants were 20 workers of the nursing staff: 11 nurses, three nursing assistants and six nursing technicians. Eleven participants worked in the cardiac ICU, four in general surgery wards, two in vascular surgery wards, two in neurosurgery wards and one in the thoracic surgery ward. The inclusion criteria were: willingness and availability to participate in the study and a minimum time of six months of professional experience in the abovementioned wards.

Data collection took place in July 2009, in the morning and afternoon, using a semi-structured interview script. The technique for treating data adopted was thematic content analysis. This process carefully and systematically transforms the empirical material, encoding it in units that allow an accurate description of the characteristics relevant to the content of the analyzed speeches8. The following category emerged from the analysis: positive and negative side of adapting/improvising

This research followed the ethical requirements for research involving human subjects. Thus, the project was approved by the ethics committee of the hospital under protocol nº 2355/2009. The anonymity of subjects was assured by coding each nursing worker who participated in the survey. Thus, interviews were transcribed and participants were assigned with codes, with the letter W to make reference to the term worker and the sequential number of the interview, from 1 to 20, besides the identification of the nursing category (first letter) to which they belonged.



Positive side and negative sides of the adapting/improvising

The disclosed results allow the discussion of the contradictions that surround the phenomenon of adapting and improvising. Such contradictions include pleasure and suffering, satisfaction and dissatisfaction, utility and futility, and the dialectical character that emerged from the analysis of statements of participants.

As for the dialectical character of the phenomenon, we sought theoretical support for certain assumptions of dialectical materialism. However, we emphasize that the own psychodynamic of work, adopted as the theoretical framework of this study, relies on the dialectical analysis of suffering and pleasure originating from work and the transformation of one toward the other5.

Contradictions between good and evil, pleasure and suffering, and satisfaction and dissatisfaction permeated the participants' perception and reveal dynamic values, feelings and emotions about the experience of adapting/improvising in nursing work. These contradictions, however, are not mutually excludent, they exist one close to the other in a typical union of opposites in search of wholeness. They are the different and opposite sides of the same coin, the heads and tails, which, when united and inseparable, make up the coin. This situation is linked to the law of unity and struggles against the dialectics9.

Thus, we initially highlight one negative aspect of the adapting/improvising practice regarding the disrespect of scientific principles of nursing, evident in the speech presented below.

Improvised assistance is very bad, because you end up breaking the technique and at the same time, this causes stress to the professional because he wants to work correctly, according to the technique. (T2-E)

The participant lists the effects of adapting/improvising to health, showing the dual and contradictory character. Also, participants critically explain with detail these effects on their physical and psychosocial dimensions.

Despite the negative character of adapting/improvising, regarding the disrespect for technique and the subsequent oversight, due to the great frequency with which this practice happens, the participants also highlight a positive aspect, when they affirm that it is possible to develop creativity, adaptive capacity and even the creation of new instruments of work, which end up valuing and giving visibility to the profession.

I think it enriches our creativity, because many things are important, because they do not bring any harm, neither for the patient nor for the worker. We know there are some projects, some things, even materials that have been patented by nurses. (T7-E)

The dialectics of the investigated phenomenon is clear, in which, from necessity, creation is born. And if this creation is consecrated among the professionals of the area, the satisfaction of the worker-creator is contemplated, and this rescues the social value of the work that could be lost amidst the adversities of labor contexts, sometimes so much filled with suffering and exploitation5.

It was evident that adaptations and improvisations foster the worker's creativity and, in some situations, favor the nursing work process. However, the detailed analysis of results shows another dialectical situation. Despite the creative potential of the adaptations/improvisations and all the advantages that facilitate the dynamics of the work, allowing the quick resolution of assistance problems, they also consume the time of workers generating them.

[...] at the end of this task, the worker faces this barrier, which is the lack of adequate material, so he has to stop his work and run after that material, run after that adaptation, to execute the task. This causes delay. (T16-E)

It is evident that nurses' work rhythm becomes intense as they have to deal with situations of quantitative shortage of team members and materials, equipment and instrumental work. This leads to waste of time that is often already short, looking for resources in other units, or assuming the work that the co-worker who was absent in the team should carry out10 .

Participants consider that the need to adapt/improvise contributes to increased work pace and also to increased physical effort, since they need to make a pilgrimage from one sector to the other, searching for materials. This has to be combined with the physical effort that is already inherent to the nursing work, especially when taking care of bedridden clients. This calls attention to the danger of exposure to ergonomic risks, in addition to other types of risk in the practice of adapting/improvising.

So, you can cause some risks by increasing the workload of the nursing staff. It's like that grid that does not go down any more, because you tie it with a bandage, then you will make a greater effort. (T5-E)

Authors characterize nursing work as an activity that requires multiple movements of loads that may culminate in musculoskeletal and tendon injuries, due to overload and/or misuse of these structures. Nursing professionals perform their activities, mostly in standing position and with their spine bent down, even to perform the records. This condition is uncomfortable and causes fatigue11,12.

In addition to these difficult conditions, the insufficient number of workers, the lack of physical space, poor ergonomic conditions, improvisations and inadequate equipment lead to the conditioning of incorrect positions and postures, contributing to the fatigue and high occurrence of diffuse pain in the whole body of these professionals11.

In addition, the negative implications of the adaptations/improvisations to the physical body of the workers include either the development of new pathologies or the aggravation of those already installed, either due to previous work activities or due to other causes.

Many colleagues, trying to adapt, make an effort. The body is not prepared for it and they suffer... they went to other sectors because they could not follow that rhythm of improvisation, sometimes even because of the diseases they already had, and which were worsened by these adaptations. (T18-TE).

In this perspective, nursing workers are harmed by adaptations/improvisations, the institution and the rest of the team, simultaneously, also suffer losses due to possible absence of the workers affected by diverse diseases.

[...] that creates anguish in him, and he ends up losing some of his energy, his strength to work. So we lose an employee, who will soon get sick and we will feel the effect of that, there will be one less here (T14-E).

Thus, this situation creates a vicious cycle. The abusive and deteriorating practice of adaptations/improvisations contributes to further reduced human resources, intensifying the plundering of those workers who resist to toil under those conditions, which have probably also had negative effects on their health, increasing the statistics of absenteeism. Therefore, the insufficient number of human resources has an impact on the quality of the care provided, because workers who resist this situation are overloaded, gradually developing decreased physical, cognitive and psychological capacity to deal with the task4,11.

The negative implications on the mental health the nursing worker were also mentioned. Imbued with a strong commitment to provide care, these workers proved to be burned out, experiencing feelings such as anger, anguish, anxiety, demotivation and stress. They were hampered by problems related to poor working conditions, which led them to adapt/improvise.

The worst harm to the nursing professional is on the issue of stress. And stress, we know it will affect other diseases. Hypertension, cardiovascular diseases, gastritis, insomnia and so on. (T11-E).

Another dialectic situation emerged from the participants' speeches. It was learned that adaptations and improvisations were well elaborated and could bring well-being and improvement to the health of clients, but when exposing them, their often iatrogenic nature becomes clear. The issue that needs to be reflected is that the creative potential of nursing workers exists, commitment to care is a fact, but these adaptations and improvisations emerge in a chronic context of precariousness, preventing the workers from making daily adjustments in their work process, which also includes the instruments of work, resulting in wear and tear, dulling of the evaluation capacity and even alienation.

The greatest risk is the danger of causing a problem to the patient's health. So these adaptations, if not well done, can cause some harm to the patient. As, for example, some adaptations with respect to venous catheters, if they are not well done, can cause a very serious damage to the patient, regarding infection. (T9-AE).

It is important to note the need of nursing, in this context of duality between not having and doing, to ally science to ethics, sensitivity, knowledge and intuition, when using artifices that can really collaborate to the provision of care, meeting the customer's demands for comfort, safety and well-being13.

Although the practice of adaptations and improvisations ensures that assistance be provided when materials are missing, they dialectically lead to excessive expenditures of numerous materials necessary for adjustment, revealing an irrational waste that may culminate in an intensification of lack of material resources14. Furthermore, when poorly designed, they can disqualify the care provided, but they can also be so detrimental to the health of nursing workers that they end up affecting the quality of care offered, given the possibility of demotivation, lack of affinity and commitment with the work to be performed.

You work without a procedure glove, and then you use a sterile glove that is more expensive to the hospital. We work [...], improvising with the mask of the nebulizer, attaching with the surgical mask. When we need the surgical mask, we do not have it because we use it to attach the nebulizer. (T11-AE).

In this sense, an important administrative issue can be deduced from this problem, in which the prediction and provision of material resources are essential and have repercussions on the quality of care and the good performance of the nursing worker. This worker can even be considered as an artist, who assumes his commitment to care, an art, through the adversities of the environment. But organizational logic does not transform the difficult reality of the work context into a magic, in which problems disappear inexplicably in an instant. Good administrative work requires practical and theoretical knowledge15.

The nurse should develop the functions of material management with the aim of improving patient care and the working conditions of nursing staff and other workers, not for the purpose of mere bureaucratic activity, with the sole purpose of preserving the financial interests of the institution. Attention should be paid to the quality of the material and the satisfactory quantity, in order to minimize the risk of discontinuing the care to the patient15.



We conclude that the perceptions of nursing workers about the implications of the practice of adapting/improvising on their health reveal a picture of the dialectics of the working world, in which the worker reacts to daily practice with responses of suffering and pleasure; satisfaction and dissatisfaction; motivation and demotivation, awareness and alienation; careful and careless attitude towards each other and with oneself. These responses, in turn, represent binomials, opposing faces that are united in the same reality, on which there is still much to be understood. Therefore, research constitutes a fundamental strategy to reveal the multiple facets of this reality.

Dialectically, while facilitating the work process, adaptations/improvisations stimulate creativity cause the workers to be plundered, since the incessant search for material resources for adaptations/improvisations and the mental and physical exhaustion for the elaboration of these creations on a daily and frequent basis generate negative repercussions for the workers' health-disease process. Thus both the cognitive ability and the physical capacity of the workers are exploited and sometimes even exhausted.

However, the positive and pleasurable side of the practice of adapting/improvising should be considered, since the nursing workers turned out to be artists and warriors, committed to caring. Creators and (re) creators of diverse ways of caring, they gain freedom and space to put into practice their artistic, creative and inventive capacities, which, often, can culminate in the consecration of new technologies that socially exalt the identity of the profession, besides contributing to the improvement of care techniques and the emergence of nursing patents.

In contrast with this positive side, the normalization and the abusive frequency of circumstances that require the materialization of adaptations/improvisations make the act, instead of pleasurable, an obligation, depriving workers from their freedom of action, making them suffer, both physically and psychically.

Among the limitations of the research, we can highlight the fact that the study was performed in only one public health care setting, which prevents the generalization of its findings.



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