Poder interprofissional em cuidados intensivos: reflexão filosófica a partir de perspectivas foucaultianas e críticas / Poder interprofesional en cuidados intensivos: reflexión filosófica a partir de perspectivas foucaultianas y críticas / Interprofessional Power in Acute Care: Philosophical Reflection using Foucauldian and Critical Perspectives

Resumo Objetivo Discutir as relações de poder entre profissionais de saúde em ambientes de cuidado intensivo e sua interferência no processo de construção do conhecimento. Métodos Neste artigo filosófico, exploramos a influência das relações de poder na construção do conhecimento, a partir das perspectivas foucaultiana e crítica de Gramsci e Freire em relação às práticas de enfermagem e cuidados de saúde. Resultados Há quatro fontes de poder organizacional (tomada de decisão, critério, controle de recursos e controle de conhecimento/rede) que atuam em diferentes níveis das organizações de saúde. As unidades de terapia intensiva são um importante segmento do ambiente de saúde, e a complexidade no cotidiano dos profissionais desse setor pode dificultar as relações de poder no processo de construção do conhecimento. Por exemplo, quando profissionais externos à equipe da UTI, que detêm conhecimentos específicos, precisam ser contatados para auxiliar em casos, como durante o processo de doação e transplante de órgãos. Nesta situação, é necessário desconstruir o poder competitivo para construir o poder colaborativo. Conclusão Usando as perspectivas de Freire e Gramsci, argumentamos que a falta de conhecimento contribui para o poder competitivo, que pode ser superado se os indivíduos envolvidos participarem no processo de aprendizagem em direção ao poder colaborativo. Portanto, as estratégias ou ações para lidar com os desequilíbrios de poder interprofissional podem contribuir para a transformação e mudança mútua.

Resumen Objetivo Discutir las relaciones de poder entre profesionales de salud en ambientes de cuidado intensivo y su interferencia en el proceso de construcción del conocimiento. Métodos En este artículo filosófico, exploramos la influencia de las relaciones de poder en la construcción del conocimiento a partir de las perspectivas foucaultianas y la crítica de Gramsci y de Freire en relación con las prácticas de enfermería y los cuidados de salud. Resultados Hay cuatro fuentes de poder organizativo (toma de decisión, criterio, control de recursos y control de conocimiento/red) que actúan en distintos niveles de las organizaciones de salud. Las unidades de cuidados intensivos son un importante sector del ambiente de la salud, y la complejidad en la labor cotidiana de los profesionales de ese sector puede dificultar las relaciones de poder en el proceso de construcción del conocimiento. Por ejemplo, cuando profesionales externos al equipo de la UCI, que tienen conocimientos específicos, tienen que ser contactados para auxiliar en algunos casos, como durante el proceso de donación y trasplante de órganos. En esta situación se hace necesario deconstruir el poder competitivo para construir el poder colaborativo. Conclusión Usando las perspectivas de Freire y de Gramsci, argumentamos que la falta de conocimiento contribuye para el poder competitivo, que se puede superar si los individuos involucrados participan en el proceso de aprendizaje en dirección al poder colaborativo. Por lo tanto, las estrategias o las acciones para hacer frente a los desequilibrios de poder interprofesional pueden contribuir con la transformación y el cambio mutuo.

Abstract Objective To discuss the power relations among health care professionals in acute care settings and its interference in the process of knowledge building. Methods In this philosophical paper, we explored the influence of power relations on knowledge building using a Foucauldian and critical perspective of Gramsci and Freire related to nursing and health care practices. Results There are four sources of organizational power (decision-making, discretion, control of resources, and control of knowledge/network) that act at different levels of healthcare organizations. Intensive care units are an important segment of healthcare setting, and the complexity involved in the daily activities of professionals in this sector can lead to difficult power relations in the process of knowledge building. For instance, when professionals external to the ICU team that hold specific knowledge need to be contacted to help in cases, such as during organ donation and transplantation process. In this situation it is necessary to deconstruct the competitive power in order to build the collaborative power. Conclusion Using Freire's and Gramsci's perspectives we argued that lack of knowledge contributes to competitive power which can be overcome if involved individuals engage in the learning process towards a collaborative power approach. Therefore, strategies or action to address interprofessional power imbalances can contribute mutual transformation and change.

Nursing practice environment in Primary Health Care: a scoping review / Ambiente de la práctica de enfermería en Atención Primaria a la Salud: revisión de alcance (scoping review) / Ambiente da prática de enfermagem na Atenção Primária à Saúde: revisão scoping

ABSTRACT Objective: To examine the scientific evidence about the nursing practice environment in Primary Health Care. Methods: Three-step scoping review. 1) An initial research on CINAHL and MEDLINE. 2) A broader search using the same keywords and search terms in the remaining EBSCOHost platform databases. 3) Search the bibliographical references of the selected articles. The studies selected were from 2007 to 2018. Results: 19 articles were included, most reported findings of the nursing practice environment and results for clients, nurses, nurse managers and the efficiency of organizations, in Primary Health Care. Conclusion: Improving the environment of nursing practice has consequences on the quality of nursing care, with increased results for clients, nursing and Primary Health Care.

RESUMEN Objetivo: Examinar la evidencia científica acerca del ambiente de la práctica de enfermería en la Atención Primaria d a la Salud. Métodos: Revisión de alcance (scoping review) de la literatura en 3 etapas: 1) Una investigación inicial en la CINAHL y MEDLINE. 2) Una búsqueda más amplia utilizando las mismas palabras clave y términos de búsqueda en las bases de datos restantes de la plataforma EBSCOHost. 3) Buscar las referencias bibliográficas de los artículos seleccionados. Los estudios seleccionados han sido de 2007 a 2018. Resultados: Han sido inclusos 19 artículos, la mayoría relacionó hallazgos del ambiente de la práctica de enfermería y resultados para clientes, enfermeros, gerentes de enfermería y la eficiencia de las organizaciones, en Atención Primaria a la Salud. Conclusión: Mejorar el ambiente de la práctica de enfermería tiene consecuencias en la calidad de los cuidados de enfermería, con mayores resultados para los clientes, la enfermería y la Atención Primaria a la Salud.

RESUMO Objetivo: Examinar a evidência científica acerca do ambiente da prática de enfermagem na Atenção Primária à Saúde. Métodos: Revisão scoping da literatura, com 3 etapas: 1) uma pesquisa inicial na CINAHL e MEDLINE; 2) uma pesquisa mais ampliada, utilizando as mesmas palavras-chave e termos de pesquisa, nas bases de dados restantes da plataforma EBSCOHost; 3) pesquisa nas referências bibliográficas dos artigos selecionados. Os estudos selecionados foram do período entre 2007 e 2018. Resultados: Foram incluídos 19 artigos; a maioria relatou achados do ambiente da prática de enfermagem e resultados para os clientes, para os enfermeiros, para os enfermeiros gerentes e para a eficiência das organizações, na Atenção Primária à Saúde. Conclusão: Melhorar o ambiente da prática de enfermagem tem consequências na qualidade dos cuidados de enfermagem, com aumento de resultados para os clientes, para a enfermagem e para a Atenção Primária à Saúde.

Segurança e satisfação de pacientes com os cuidados de enfermeiros no perioperatório / Safety and satisfaction of patients with nurse's care in the perioperative / Seguridad y satisfación del paciente con los cuidados de enfermeros en el perioperatorio

Objetivo: investigar a segurança e a satisfação de pacientes e sua relação com os cuidados dos enfermeiros no perioperatório. Método: estudo multinível, transversal, correlacional, realizado com 105 enfermeiros da área cirúrgica e 150 pacientes operados em um hospital terciário espanhol. Para os enfermeiros foram coletadas as variáveis sociodemográficas, a percepção do ambiente de trabalho, o desgaste profissional e a satisfação no trabalho. Para os pacientes, a segurança de eventos adversos e nível de satisfação, por meio de registros e questionários. Utilizou-se análise multinível, univariada e multivariada. Resultados: satisfação no trabalho, compromisso profissional e participação em questões hospitalares foram preditores negativos para eventos adversos relacionados ao paciente, enquanto o cuidado do enfermeiro no pós-operatório foi um preditor positivo. Conclusão: observa-se aumento dos eventos adversos quando os enfermeiros têm insatisfação no trabalho, menor compromisso profissional e baixa disponibilidade para participar nos assuntos de sua unidade. Por outro lado, os eventos adversos diminuem quando os enfermeiros realizam os cuidados no pós-operatório. A satisfação foi boa e não houve associação com as características do cuidado dos enfermeiros. Recomenda-se melhorar esses preditores para aumentar a segurança de pacientes cirúrgicos.

Objective: to investigate the safety and satisfaction of patients and their relationship with nurse's care in the perioperative period. Method: cross-sectional, multi-level, correlational study with 105 nurses in the surgical area and 150 patients operated in a Spanish tertiary hospital. For the nurses the sociodemographic variables, the perception of the work environment, the professional burnout and the satisfaction in the work were collected. For patients, the safety of adverse events and level of satisfaction, through the application of questionnaires. Univariate and multivariate analysis were used. Results: job satisfaction, professional commitment, and participation in hospital issues were negative predictors for adverse events related to the patient, while postoperative nurse care was a positive predictor. Conclusion: there is an increase in adverse events when nurses are dissatisfied at work, less professional commitment and low availability to participate in the subjects of their unit. On the other hand, adverse events decrease when nurses perform the care in the postoperative period. Satisfaction was good and there was no association with the characteristics of nurses' attention. It is recommended to improve these predictors to increase the safety of surgical patients.

Objetivo: investigar la seguridad y la satisfacción de los pacientes y su relación con el cuidado de los enfermeros en el perioperatorio. Método: estudio multinivel, transversal, correlacional, realizado con 105 enfermeros del área quirúrgica y 150 pacientes operados en un hospital terciario español. Para los enfermeros fueron recolectadas las variables sociodemográficas, la percepción del ambiente de trabajo, el desgaste profesional y la satisfacción en el trabajo. Para los pacientes, la seguridad de eventos adversos y el nivel de satisfacción, mediante la aplicación de cuestionarios. Se utilizó análisis univariante y multivariante. Resultados: satisfacción en el trabajo, compromiso profesional y participación en cuestiones hospitalarias fueron predictores negativos para eventos adversos relacionados al paciente, mientras que el cuidado del enfermero en el postoperatorio fue un predictor positivo. Conclusión: se observa aumento de los eventos adversos cuando los enfermeros tienen insatisfacción en el trabajo, menor compromiso profesional y baja disponibilidad para participar en los asuntos de su unidad. Por otro lado, los eventos adversos disminuyen cuando los enfermeros realizan los cuidados en el postoperatorio. La satisfacción fue buena y no hubo asociación con las características de la atención de los enfermeros. Se recomienda mejorar estos predictores para aumentar la seguridad de los pacientes quirúrgicos.

Burnout e a organização do trabalho na Enfermagem / Burnout and work organization in Nursing

Introdução: A síndrome de burnout (SB) é um conjunto de sintomas que surgem da resposta a estressores interpessoais crônicos no trabalho e envolvem a percepção que a pessoa tem de si própria e do ambiente em que realiza seu trabalho. Objetivo: Identificar os fatores de risco psicossociais e da organização do trabalho preditores de sofrimento mental, bem como estimar a prevalência da SB em uma população de profissionais de Enfermagem de um hospital público do interior do Estado de São Paulo. Métodos: Pesquisa mista, combinando as abordagens quantitativa e qualitativa, desenvolvida em um hospital público universitário. Foram utilizados o Maslach Burnout Inventory-Human Services Survey (MBI-HSS), para estimar a prevalência de SB, e a análise de conteúdo em grupos focais (GFs), para identificar fatores psicossociais de risco no trabalho (FPRT). Resultados: A prevalência de SB na instituição estudada (5,7%) foi compatível com a literatura internacional. A análise das falas emergentes dos GFs revelou a existência de FPRT atuando como estressores na organização do trabalho. Conclusão: Esta pesquisa apontou ainda a necessidade de um olhar mais amplo sobre as causas da SB, sendo de grande importância a inclusão, nos trabalhos, do estudo da singularidade dos fatores psicossociais e da organização do trabalho por meio da voz dos profissionais que têm como foco de trabalho o cuidado ao ser humano.

Background: Burnout syndrome (BS) consists of a set of symptoms that appear in response to chronic interpersonal stressors at work and involve the perceptions individuals have of themselves and their work environment. Objectives: To identify psychosocial risk and work organization factors able to predict mental suffering, and to estimate the prevalence of BS in a sample of nursing professionals from a public hospital in the state of São Paulo, Brazil. Methods: Mixed methods research combining quantitative and qualitative approaches conducted at a public university hospital. Maslach Burnout Inventory-Human Services Survey (MBIHSS) was used to estimate the prevalence of BS. Thematic content analysis of narratives gathered in focus groups was performed to identify psychosocial risk factors at work (PRFW). Results: The prevalence of BS at the investigated institution (5.7%) is consistent with the rates reported in the international literature. Analysis of the narratives gathered in focus groups revealed stressors in the organization of work. Conclusion: The present study also points to the need for a broader look into the causes of BS, in which consideration of singular psychosocial risk and work organization factors from the perspective of workers devoted to proving care to human beings has paramount importance.

Estudo de risco de suicídio e transtorno mental comum em profissionais de um hospital geral no estado de São Paulo / Study of risk of suicide and common mental disorder in professionals of a general hospital in the state of São Paulo

A organização do trabalho passou por diversas modificações ao longo da história e as mudanças de paradigma nos processos laborais geraram mudanças significativas na construção da subjetividade do indivíduo e na dialética do sujeito com o mundo. Podese observar que as transformações no campo produtivo, ocasionadas por múltiplos fatores, como os processos de gestão, a organização do sistema econômico vigente e as reestruturações ocorridas com a globalização transmutaram o trabalho em mercadoria, impactando diretamente no processo de saúde-doença dos trabalhadores. A padronização e sistematização do processo de trabalho, proposto por diversos autores, a priori, adotado nos processos de produção industrial, passam a ser adotados pelas organizações de assistência à saúde, ocasionando arredamentos diversos no modo de produção deste setor, expondo os profissionais que ali executam suas atividades laborais a situações de fragilização e adoecimento. O debate em torno do processo de trabalho nas organizações dos serviços de saúde tem se mostrado extremamente importante, particularmente quando nos debruçamos sobre a micropolítica de organização do trabalho nessas instituições. Diante desta problematização, este estudo teve como objetivo estimar a prevalência de ideação suicida e de transtorno mental comum em trabalhadores de um hospital geral, buscando associação com categoria profissional, sexo, idade, escolaridade, estado civil, tempo de trabalho na instituição, tempo de trabalho na profissão. Trata-se de um estudo epidemiológico de delineamento transversal descritivo, de amostragem não probabilística, com amostra por quotas da população investigada. A presença das variáveis TMC e ideação suicida foram avaliadas a partir do Self Reporting Questionnaire (SRQ). Para a avaliação das possíveis variáveis associadas, os participantes responderam a um questionário sociodemográfico. Os resultados obtidos neste estudo evidenciaram a presença de TMC superior aos estudos correlacionados na literatura e aos índices apresentados na população geral; as queixas sobre o processo de trabalho, que se apresenta como propiciador de sofrimento atinge quase » desta população. O agrupamento dos itens da escala SRQ-20, que apresentou menor representatividade estatística, foi a ideação suicida, sendo considerado com relevância neste estudo por ser indicador de risco direto de vida. Apesar de haver limitações do estudo em estabelecer um nexo causal entre TMC e ideação suicida com os processos de trabalho, o alto índice de adoecimento evidenciado ressalta a necessidade da realização de medidas interventivas, pois independente se ocasionados pelo processo de trabalho, estes indivíduos expressam essa realidade no setor de atuação profissional. Diante disso, estabelecer alternativas que possibilitem a criação de novos meios de intervenção, estratégias que proporcionem melhorias dos ambientes de trabalho para promoção e proteção da saúde desses profissionais, podem contribuir para A organização do trabalho passou por diversas modificações ao longo da história e as mudanças de paradigma nos processos laborais geraram mudanças significativas na construção da subjetividade do indivíduo e na dialética do sujeito com o mundo. Podese observar que as transformações no campo produtivo, ocasionadas por múltiplos fatores, como os processos de gestão, a organização do sistema econômico vigente e as reestruturações ocorridas com a globalização transmutaram o trabalho em mercadoria, impactando diretamente no processo de saúde-doença dos trabalhadores. A padronização e sistematização do processo de trabalho, proposto por diversos autores, a priori, adotado nos processos de produção industrial, passam a ser adotados pelas organizações de assistência à saúde, ocasionando arredamentos diversos no modo de produção deste setor, expondo os profissionais que ali executam suas atividades laborais a situações de fragilização e adoecimento. O debate em torno do processo de trabalho nas organizações dos serviços de saúde tem se mostrado extremamente importante, particularmente quando nos debruçamos sobre a micropolítica de organização do trabalho nessas instituições. Diante desta problematização, este estudo teve como objetivo estimar a prevalência de ideação suicida e de transtorno mental comum em trabalhadores de um hospital geral, buscando associação com categoria profissional, sexo, idade, escolaridade, estado civil, tempo de trabalho na instituição, tempo de trabalho na profissão. Trata-se de um estudo epidemiológico de delineamento transversal descritivo, de amostragem não probabilística, com amostra por quotas da população investigada. A presença das variáveis TMC e ideação suicida foram avaliadas a partir do Self Reporting Questionnaire (SRQ). Para a avaliação das possíveis variáveis associadas, os participantes responderam a um questionário sociodemográfico. Os resultados obtidos neste estudo evidenciaram a presença de TMC superior aos estudos correlacionados na literatura e aos índices apresentados na população geral; as queixas sobre o processo de trabalho, que se apresenta como propiciador de sofrimento atinge quase » desta população. O agrupamento dos itens da escala SRQ-20, que apresentou menor representatividade estatística, foi a ideação suicida, sendo considerado com relevância neste estudo por ser indicador de risco direto de vida. Apesar de haver limitações do estudo em estabelecer um nexo causal entre TMC e ideação suicida com os processos de trabalho, o alto índice de adoecimento evidenciado ressalta a necessidade da realização de medidas interventivas, pois independente se ocasionados pelo processo de trabalho, estes indivíduos expressam essa realidade no setor de atuação profissional. Diante disso, estabelecer alternativas que possibilitem a criação de novos meios de intervenção, estratégias que proporcionem melhorias dos ambientes de trabalho para promoção e proteção da saúde desses profissionais, podem contribuir para o processo de saúde destes trabalhadores e a qualidade do ambiente de atuação profissional desses indivíduos

The organization of work has undergone several modifications throughout history, these paradigm changes in labor processes have generated significant changes in the construction of the subjectivity of the individual and in the dialectic of the subject with the world. It can be observed that the transformations in the productive field, caused by multiple factors, such as the management processes, the organization of the current economic system, the restructurings with globalization, transmute the work into merchandise, directly impacting the health-disease process of the workers. The standardization and systematization of the work process, proposed by several authors, a priori, adopted in the processes of industrial production, are now adopted by health care organizations, causing various drawbacks in the way of production of this sector, exposing the professionals that there they carry out their work activities to situations of embrittlement and illness. The debate about the work process in health service organizations has been extremely important, particularly when we look at the micropolitics of work organization in these institutions. In view of this problem, this study aimed to estimate the prevalence of suicidal ideation and common mental disorder in workers of a general hospital, seeking association with professional category, gender, age, schooling, marital status, working time in the institution, work in the profession. This is an epidemiological study with descriptive cross-sectional, non-probabilistic sampling, with a sample of the population investigated. The presence of TMC variables and suicidal ideation were assessed from the Self Reporting Questionnaire (SRQ). For the evaluation of possible associated variables, participants answered a sociodemographic questionnaire. The results obtained in this study evidenced the presence of MCT superior to the correlated studies in the literature and the indices presented in the general population; the complaints about the work process, where it presents itself as a propitiator of suffering reaches almost » of this population. The grouping of SRQ-20 items that presented less statistical representativeness was suicidal ideation, but was considered relevant in this study, since it is an indicator of direct risk of life. Although there are limitations of the study in establishing a causal nexus between CMD and suicidal ideation with work processes, the high rate of illness evidenced highlights the need for interventional measures, because if they are caused by the work process, these individuals express this reality in the professional sector. Therefore, establishing alternatives that allow the creation of new means of intervention, strategies that provide improvements in work environments for the promotion and protection of the health of these professionals, can contribute to the health process of these workers and the quality of the professional environment of these workers.

Configuração das práticas de saúde entre médicos e enfermeiros no ambiente hospitalar na perspectiva das relações de poder / Configuration of health practices among physicians and nurses in the hospital environment in the perspective of power relations

O ambiente hospitalar é símbolo do poder social da profissão médica, favorecendo a visibilidade desse profissional como ator central do cuidado. A crescente profissionalização administrativa dos hospitais requer que seus funcionários, inclusive médicos, se comprometam com atividades burocráticas, que, muitas vezes, são mediadas pelo enfermeiro. Dessa maneira, apesar da forte valorização do modelo médico-centrado na assistência, observa-se que os enfermeiros têm alcançado visibilidade pelas práticas gerenciais, o que pode gerar tensões nas relações profissionais. Essa nova conformação hospitalar reconfigura as relações de poder. O poder circula constantemente, de acordo com a composição de forças formadas a partir de conhecimentos e práticas pelo referencial Foucauldiano. Nas relações profissionais quem detém maior conhecimento assume uma posição privilegiada nas relações de poder. Com o objetivo de analisar como se configuram as relações de poder constituídas nos e pelos saberes e práticas cotidianas de médicos e enfermeiros no ambiente hospitalar, foi desenvolvida uma pesquisa qualitativa na perspectiva pós-estruturalista, com base no referencial teórico-metodológico do filósofo francês Michael Foucault. O cenário do estudo foi o Centro de Terapia Intensiva de um hospital filantrópico geral, de grande porte, localizado na cidade de Belo Horizonte, capital de Minas Gerais, Brasil. No Centro de Terapia Intensiva procedeu-se à observação do campo e a realização de entrevistas com roteiro semiestruturado a 08 médicos e 12 enfermeiros. A partir da análise dos discursos constituídos, foram identificadas três categorias empíricas principais: Identidade profissional: o reconhecimento de si na profissão; Disciplina: atitudes individualizantes ou necessidade coletiva? e Circularidade do poder: saber na constituição das práticas cotidianas. A avaliação dos dados permitiu refletir que a configuração das práticas de saúde entre médicos e enfermeiros no ambiente hospitalar perpassa questões socioeconômicas, históricas, culturais e de gênero. Tais questões influenciam a formação identitária do sujeito, o desejo pela visibilidade, sua aceitabilidade à disciplina e a busca da movimentação do poder pelo saber. Percebeu-se que as relações entre médicos e enfermeiros são eminentemente problemáticas, assim também como, tensão, disputa de poder, entre os próprios médicos, e ausência de unidade entre os enfermeiros, que estão alienados ao cuidado direto do paciente. Os discursos mostram que a equipe médica em geral, não possui intimidade com as normas institucionais, sendo, portanto, os enfermeiros os principais norteadores desse processo. Contudo, poucos enfermeiros deixaram evidente sua segurança quanto ao conhecimento técnico exigido pela profissão, principalmente no momento de comunicar alterações hemodinâmicas aos médicos, executar procedimentos invasivos ou até mesmo ao auxiliá-los. Este estudo possibilita incentivo a outras pesquisas que associadas a ele poderão contribuir para melhores práticas de saúde entre médicos e enfermeiros que atuam em unidades de terapia intensiva.(AU)

The hospital environment is a symbol of the social power of the medical profession, favoring the visibility of this professional as a central actor of care. The growing administrative professionalization of hospitals requires that their employees, including doctors, commit themselves to bureaucratic activities, which are often mediated by nurses. Thus, in spite of the strong valorization of the physician-centered model in care, it is observed that the nurses have achieved visibility by the managerial practices, which can generate tensions in the professional relations. This new hospital conformation reconfigures power relations. The power circulates constantly, according to the composition of forces formed from knowledge and practices by the Foucauldian referential. In professional relations, those who hold the greatest knowledge assume a privileged position in the relations of power. With the objective of analyzing how power relations are constituted in the knowledge and daily practices of physicians and nurses in the hospital environment, a qualitative research was developed in the poststructuralist perspective, based on the theoretical and methodological framework of the French philosopher Michael Foucault. The study scenario was the Intensive Care Center of a large general philanthropic hospital, located in the city of Belo Horizonte, capital of Minas Gerais, Brazil. In the Intensive Care Center, the field was observed and interviews were conducted with a semistructured script to 08 doctors and 12 nurses. From the analysis of the constituted discourses, three main empirical categories were identified: Professional identity: recognition of self in the profession, Discipline: individualizing attitudes or collective need? and Power: constitution knowledge of everyday practices. The evaluation of the data allowed us to reflect that the configuration of health practices among physicians and nurses in the hospital environment pervades socioeconomic, historical, cultural and gender issues. Such questions influence the subject's identity formation, the desire for visibility, its acceptability to discipline and the search for the movement of power through knowledge. It was noticed that the relationships between doctors and nurses are eminently problematic, as well as tension, power struggle among the doctors themselves, and lack of unity among the nurses, who are alienated to the direct care of the patient. The speeches show that the medical team in general, does not have intimacy with the institutional norms, being, therefore, the nurses the main guides of this process. However, few nurses have made their safety clear about the technical knowledge required by the profession, especially when communicating hemodynamic changes to physicians, performing invasive procedures or even assisting them. This study allows the encouragement of other research that associated with it may contribute to better health practices among physicians and nurses working in intensive care units.

Effect of the practice environment of nurses on job outcomes and safety climate / Efeito do ambiente da prática do enfermeiro nos resultados do trabalho e clima de segurança / Efecto del ambiente de la práctica del enfermero en los resultados del trabajo y clima de seguridad

ABSTRACT Objective: to propose and analyze a theoretical model to measure the effect of nurses' perceptions about the practice environment on safety climate, job satisfaction, intention to stay employed and in the profession, and burnout syndrome. Method: correlational study with probabilistic sample of 465 nurses. In the theoretical model, the dimensions of the nursing practice environment were considered as independent variables and job satisfaction, safety climate, intention to stay employed and in the profession, and burnout were considered the outcome variables. Structural Equation Modeling was the method used in the analysis. Results: small adjustments were made in the model and the dimensions of practice environment predicted job satisfaction (R2 = 43%), safety climate (R2 = 42%) and burnout (R2 = 36%), as well as the intention to stay in the job (R2 = 22%) and in the profession (R2 = 17%). Conclusion: the practice environment showed a strong impact on job satisfaction, safety climate and burnout, with a moderate impact on the intention to stay in the institution and in the profession. The findings can be used to manage care in health institutions, focusing on promoting nurse retention and improving the safety climate.

RESUMO Objetivo: propor e analisar um modelo teórico que mensura o efeito da percepção de enfermeiros quanto ao ambiente da prática no clima de segurança, na satisfação no trabalho, na intenção de permanecer tanto no emprego quanto na profissão e no burnout. Método: estudo correlacional com amostra probabilística de 465 enfermeiros. No modelo teórico, as dimensões do ambiente da prática foram consideradas variáveis independentes e satisfação no trabalho, clima de segurança, intenção de permanecer no trabalho e na profissão e burnout, variáveis de resultado. Para análise, utilizou-se o método de Modelagem de Equações Estruturais. Resultados: realizaram-se pequenos ajustes no modelo e as dimensões do ambiente da prática foram preditoras da satisfação no trabalho (R2 = 43%), do clima de segurança (R2 = 42%) e burnout (R2 = 36%), bem como da intenção de permanecer na instituição (R2 = 22%) e na profissão (R2 = 17%). Conclusão: o ambiente da prática mostrou forte impacto na satisfação no trabalho, clima de segurança e burnout, com moderado impacto na intenção em permanecer na instituição e na profissão. Os achados podem ser utilizados para o gerenciamento da assistência em instituições de saúde, com enfoque na promoção da retenção de enfermeiros e melhoria do clima de segurança.

RESUMEN Objetivo: proponer y analizar un modelo teórico que mida el efecto de la percepción de enfermeros sobre el ambiente de la práctica en el clima de seguridad, en la satisfacción en el trabajo, en la intención de permanecer tanto en el empleo cuanto en la profesión y en el burnout. Método: estudio correlacional con muestra probabilística de 465 enfermeros. En el modelo teórico, las dimensiones del ambiente de la práctica fueron consideradas variables independientes y satisfacción en el trabajo, clima de seguridad, intención de permanecer en el trabajo y en la profesión y burnout, variables de resultado. Para el análisis se utilizó el método de Modelaje de Ecuaciones Estructurales. Resultados: se realizaron pequeños ajustes en el modelo y las dimensiones del ambiente de la práctica fueron predictoras de la satisfacción en el trabajo (R2 = 43%), del clima de seguridad (R2 = 42%) y burnout (R2 = 36%), así como de la intención de permanecer en la institución (R2 = 22%) y en la profesión (R2 = 17%). Conclusión: el ambiente de la práctica mostró fuerte impacto en la satisfacción en el trabajo, clima de seguridad y burnout, con moderado impacto con la intención en permanecer en la institución y en la profesión. Los hallados pueden ser utilizados para el gerenciamiento de la asistencia en instituciones de salud, con enfoque en la promoción de la retención de enfermeros y mejoría del clima de seguridad.

Positive distraction and the rehabilitation hospitals of joão filgueiras lima.

OBJECTIVE: This article discusses the use of positive distraction, an evidence-based design approach, in rehabilitation hospitals in Brazil through the work of João Filgueiras Lima ("Lelé"). BACKGROUND: In many parts of the world architects may not formally incorporate theories of positive distraction and evidence-based design, but there are multiple international examples of health facility architects and designers that use nature, daylighting, art, and social interaction to enhance the healing experience. The work of the Brazilian architect João Filgueiras Lima is a particularly salient example. Lima has been a dominant figure in 20th and 21st century Brazilian architecture and the architect of several rehabilitation facilities. METHODS: First positive distraction is defined as it relates to nature and art, and in the context of rehabilitation hospitals. Second, rehabilitation facilities are defined. The discussion then focuses on awareness of evidence-based design in Latin America. Next, Brazilian healthcare architecture is discussed along with the history of the Brazilian Sarah rehabilitation hospitals designed by Lelé and Lelé's role in the history of Brazilian architecture. Last we look at Lelé's use of positive distraction. RESULTS: Despite Lelé's recognition in Brazil, his work has not gained much international exposure. Lelé played a critical role in the design of the Sarah facilities and served on the board of directors for the Technological Center of the Sarah Network (CTRS) in Brazil from 1992 to 2009. Based on our review of his work it was clear that Lelé used positive distraction as a tool for creating healing environments. CONCLUSIONS: In spite of the lack of formal integration of evidence-based design in healthcare architecture in Latin America, many of its basic tenets have been incorporated in Brazilian rehabilitation hospitals. Lelé's projects are a clear example of this phenomenon and demonstrate an alignment between research and practitioner objectives. The presence of nature, art, and natural light in his rehabilitation hospitals serves as a model for evidence-based design in facilities throughout the world and presents an opportunity to measure the benefits of positive distraction on rehabilitation patient outcomes.

Gestão do ambiente organizacional na expansão e desenvolvimento do mercado de serviços de saúde no Brasil / Internal environment management for expansion and development of the health care market in Brazil

Introdução: diante do aumento dos gastos com saúde, uma questão importante diz respeito às dificuldades para efetivação dos investimentos nas unidades hospitalares (UHs), com vistas a evitar a deterioração dos serviços. Em face da escassez de recursos para investimento, ainda maior entre as UHs da rede pública de saúde no país, vislumbra-se a busca de solução alternativa, melhorando a gerência do ambiente hospitalar. Objetivos: este estudo testa a associação entre a gerência do ambiente hospitalar e as seguintes funções de organização da acreditação hospitalar (AH): o treinamento; a educação do paciente e do familiar; a governabilidade e a gerência da informação. Métodos: a amostra de conveniência é composta de 33 relatórios da AH, concluídos entre 2004 e 2009. Para tratar o material empírico, foram usados o modelo de regressão múltipla e a análise fatorial, com vistas a avaliar a influência daquelas funções de organização na gerência do ambiente hospitalar. Resultados: os testes da hipótese revelaram associações positivas e significativas entre as funções organizacionais selecionadas, o tipo de propriedade da UH e a gerência do ambiente hospitalar. Conclusões: como contribuição teórica, este trabalho esclareceu os fundamentos econômicos das relações existentes entre funções organizacionais e ambiente hospitalar. Como contribuição metodológica, o modelo estatístico utilizou dados de relatórios da AH, uma fonte de dados inédita na pesquisa sobre economia da gestão. Como contribuição gerencial, identificou fatores que influenciam o desempenho da gerência do ambiente hospitalar, contribuindo para o compromisso de gestores e profissionais de saúde com a mudança na organização.

Introduction: Given the increased expenses on health care, it is important to overcome difficulties in effectively applying investments in hospital units in order to avoid quality degradation of care services. The search of an alternative solution relying on improved management of the organizational environment is crucial to tackle issues of scarce investment resources, especially in public hospitals. Objectives:This study tests the association of hospital environment management with the following functions related to hospital accreditation: training; patients’ and family members’ education; governability; and information man agement. Methods:The convenience sample comprises 33 hospital accreditation reports from 2004 through 2009. The empirical data was analyzed using multiple regression and factorial analysis, with a view to assessing the influence of the organizational function on the management of the hospital environment. Results:The hypothesis tests pointed to positive and significant correlations involving the selected organizational functions, the type of hospital ownership, and the management of the hospital environment. Conclusions:As a theoretical contribution, this paper sheds a light into the economical grounds of the associations between organizational functions and the hospital environment. As a methodological contribution, the statistical model relied on data collected from hospital accreditation reports, an original source of data in studies on management economics. As a managerial contribution, this paper identifies factors influencing the management performance within the hospital environment, supporting managers and health professionals to fulfill their commitment to organizational change.

Assessment of characteristics of capacity among breast cancer screening facilities.

Use of mammograms to detect presence of breast cancer is influenced by many factors, including ability to access mammography services. Access to services is often affected by the capacity of mammography facilities to serve women. We sought to describe the capacity of mammography facilities to conduct mammograms in a largely urban area of Texas. We used a 24-item survey to all mammography facilities in Texas Public Health Region 6/5 South. The survey contained questions across six domains: facility type, scheduling, staffing, mechanical capacity, cost/payment methods, and patient reminders. We received or completed 60 surveys (43%). Most of the facilities were open only Monday through Friday (61.7%) and were open only during typical business hours (51.7%). About 83% of the facilities had one or two machines. Most facilities had only one or two staff to conduct mammograms. The results of this survey indicate that the capacity of mammography facilities vary dramatically across many characteristics of capacity. As these indicators are tied to the ability of women to access necessary preventive services, it is important to determine how these characteristics are associated with mammography utilization.

Contextual factors influencing success or failure of emergency department interventions for cognitively impaired older people: a scoping and integrative review.

AIM: This paper is a report of a scoping review of research on cognitive impairment in older adults who visit Emergency Departments of acute care hospitals, followed by an integrative review that included a quality assessment to determine the effectiveness of interventions for this population. BACKGROUND: Being old and cognitively impaired in the Emergency Department--a fast-paced intervention system--is a complex phenomenon that challenges many healthcare professionals. The rise in the incidence and prevalence of dementia will have a large impact on healthcare systems. DATA SOURCES: MEDLINE, EMBASE, CINAHL, PsycInfo, AgeLine, Abstracts in Social Gerontology, the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials and Google Scholar between 1990 and 2008, for qualitative or quantitative studies reporting extractable data on delirium or dementia in non-institutionalized older people (65+ years) in the Emergency Department. REVIEW METHODS: Titles screened by a project researcher and checked against inclusion criteria by another researcher. Two reviewers completed independent data extraction and synthesis of included studies. Quality assessment occurred using the Critical Appraisal Skills Programme Tools. RESULTS: Fifteen studies met the inclusion criteria for integrative review. Analysis of these studies indicates that the prevalence of cognitive impairment is high and improvements are needed. Contextual details and relevant features of an appropriate intervention are poorly explained. CONCLUSION: Although the prevalence and incidence of cognitive impairment is recognized, appropriate interventions and programmatic responses remain elusive. Quality improvements require more thorough examination of emergency department context to identify modifiable influencing factors that are transferable across settings.

Green surgical practices for health care.

The objective of this study was to identify leading practices to promote environmentally friendly and efficient efforts in the provision of surgical health care. Health care is the second leading contributor to waste in the United States. Despite widespread enthusiasm for "going green" in the US economy, little substantive information is available to the medical community, to our knowledge. We explore safe and efficient strategies for hospitals and providers to protect the environment while delivering high-quality care. We performed a systematic review of the literature using relevant PubMed search terms and surveyed a panel of hospital managers and chief executive officers of health care organizations pursuing green initiatives. Recommendations were itemized and reviewed by a 7-member panel to generate a consensus agreement. We identified 43 published articles and used interview data from the panel. The following 5 green recommendations for surgical practices were identified: operating room waste reduction and segregation, reprocessing of single-use medical devices, environmentally preferable purchasing, energy consumption management, and pharmaceutical waste management. The medical community has a large opportunity to implement green practices in surgical units. These practices can provide significant benefits to the health care community and to the environment. Additional research and advocacy are needed to further explore green practices in health care.

Isolamento social, sociabilidades e redes sociais de cuidados / Social isolation, sociability and social care networks

Este trabalho examina, em caráter exploratório, experiências de isolamento social vividas por indivíduos portadores de hanseníase, internados na ex-colônia Tavares de Macedo, em Itaboraí, onde foram mantidas da década de 1930 até os dias de hoje, para problematizar noções sobre segregação e discriminação social presentes nesse meio. Para tanto, examina sociabilidades e redes sociais de cuidados estabelecidas na vida em comum nessa "ex-colônia de leprosos", quase sempre como alternativas às condições oferecidas pelos sistemas públicos de proteção social. Faz isso com base em narrativas de alguns desses sujeitos, vistos em suas diferenças - nas interseções das relações por sexos, classes, raças/etnias, gerações, e também por religiões e graus de escolaridade. Recorre à história oral, modo de oferecer novas interpretações qualitativas de processos histórico-sociais evidenciados nessas sociabilidades e redes, nem sempre visíveis como formas singulares de proteção social da vida em comum.

This exploratory work examines the social isolation experienced by individuals with leprosy admitted to the former colony Tavares de Macedo, Itaboraí, where they were kept from the 1930s until the present day, to question notions of segregation and social discrimination present in this environment. So it analyzes sociabilities and social care networks established in the common life in this "ex-leper colony," usually as alternatives to the conditions offered by the public systems of social protection. The work is based on stories of some of the subjects, seen in their differences - at intersection of gender relations, classes, races/ethnicities, generations and also by religions and educational backgrouns. It adopts the oral history, so as to offer new qualitative interpretations of social and historical processes shown in these networks and sociability, not always visible as unique forms of social protection of life in groups.

Nurses' ratings of their health and professional work environments.

Interactions between nursing work environments and nurses' health are of growing significance, given the aging work force, nursing shortage, and workplace health risks. This study examined relationships among nurses' ratings of health behaviors, health status, and professional work environments. Registered nurses (N = 3,132) from five multi-state settings completed an electronic survey. Participants' general health ratings were good, yet stress levels remained the one consistent predictor of poorer health ratings and work environment ratings in regression models. Additionally, more than half of the participants reported being overweight, only 50% met physical activity standards, more than two thirds reported a history of back or needlestick injuries, and 44% and 62% reported experiencing verbal abuse by colleagues and patients, respectively. Contrary to other studies, professional work environment as measured in this study did not predict nurses' health ratings. Further study of the impact of stress on long-term health outcomes and work force retention, as well as on worksite health strategies, is needed.

Supporting patient safety: examining communication within delivery suite teams through contrasting approaches to research observation.

OBJECTIVE: to explore the nature of intra- and interprofessional communication on delivery suites, with a particular focus on patient safety. DESIGN: longitudinal study using contrasting forms of observation: ethnographic methods alongside the highly structured Interaction Process Analysis (IPA) framework. SETTING: four contrasting delivery suites offering different models of care and serving different populations: two in the north of England and two in London. PARTICIPANTS: the multidisciplinary delivery suite teams and visiting professionals from related areas. KEY FINDINGS: the ethnographic observations and quantitative findings combine to highlight four principal areas relating to communication: communication underpinning collaboration; effects of workload pressures on communication practices; interprofessional communication; and the influence of architecture on communication. Contextual factors (e.g. case acuity, client throughput, model of care) underscore some inter site differences and attention is drawn to implications for safety. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: the use of complementary methods aided exploration of communication in the complex environment of the delivery suite. The findings reflect the complexity of communication patterns and the multiple influences on patterns and norms. Interprofessional tensions, workload pressures and the design of the environment can restrict communication, with implications for safety. As such, these findings have implications for policy in that safety solutions which focus efforts on standardising communication need to be located within wider strategies that also address structural and organisational networks and influences.

Interruptions and pediatric patient safety.

This study explored interruptions in pediatric nurses' work and the systems issues related to interruptions in nursing work environments. A total of 5,325 interruptions were observed in this study, providing information on sources, types, and causes of interruptions. The nursing work being performed when interrupted and the outcomes of these interruptions are described.

Human factors and error in perinatal care: the interplay between nurses, machines, and the work environment.

Perinatal nurses work with intricate systems requiring frequent interface with complex technology. This interplay is strongly influenced by the work environment and systems operations. The interplay among worker, technology, and the environment increases the risk of medical error, adverse patient outcomes, and in some instances, healthcare team member injury. Human factors engineering is an applied science that provides the study of the interface between people and machines. Human factors engineers design operations and systems that recognize the capacities and limitations of human beings and make it difficult for errors to occur. This article discusses the role of human factors research in healthcare design and the application of human factors engineering to perinatal settings. Recommendations are offered for the development of ultrasafe, high-reliability operations based on knowledge accrued through human factors research.

The development and pilot testing of an instrument to measure nurses' working environment: the Nursing Context Index.

BACKGROUND: Evidence shows that adopting a person-centered approach to nursing alters the work environment, reduces anxiety levels among nurses in the long term, promotes teamwork among staff, and increases job satisfaction. However, few studies have attempted to quantify the outcomes from the adoption of person-centered nursing. The lack of outcome measurement is in part influenced by the lack of a standardized instrument to measure person-centered nursing. AIMS: The aim of this study was to develop an instrument (the Nursing Context Index) to inform the development of person-centered nursing and outcomes arising. METHODS: The Nursing Context Index (NCI) was developed through three stages. Stage 1 involved a systematic literature review to identify the key characteristics that needed to be considered in the instrument. Stage 2 involved the identification and selection of items for inclusion in the instrument identified through focus group discussions. A 19-construct instrument was developed. Face validity and content validity were gauged. In Stage 3, a pilot study (n = 23) was conducted to test the instrument. Measures of internal consistency were ensured using Cronbach's alpha. Criterion-related validity of the instrument was ensured through comparison between factors contained in the instrument. RESULTS: Findings show that the NCI is an accurate representation of the factors influenced by a clinical setting's progression to person-centered nursing. The factors were deemed appropriate to the clinical settings, and possessed face and content validity. Initial statistical findings confirm the validity and usability of the NCI. IMPLICATIONS AND CONCLUSIONS: The process used for the development and testing of the instrument was found to be effective. The NCI was deemed to be an effective measure of factors influenced by the implementation of person-centered nursing and would help in redressing a scarcity of quantitative evidence to examine the benefits of nurses working in a person-centered manner.

Anxiety in the operating theatre: a study of frequency and environmental impact in patients having local, plexus or regional anaesthesia.

AIMS: To estimate the frequency of intraoperative anxiety, the influence of environmental factors on intraoperative anxiety and to study the relationship between intraoperative anxiety and generalised anxiety and depression. BACKGROUND: Previous research has documented that surgery is associated with increased stress and anxiety, which have an adverse effect on patient outcomes. Few studies have been conducted to obtain patients' perspectives about the influence of the operating theatre environment on anxiety. DESIGN: The study used a survey design including questionnaires. METHOD: Clinical variables were noted from the anaesthesia medical records. The sample (n = 119) comprised patients undergoing elective surgery and emergency operations within 24 hours of admission. Anxiety was assessed by the Jakobsen's questionnaire and the Hospital Anxiety and Depression scale. RESULTS: Twenty-three per cent felt anxious on arrival at the operating theatre, 35% were anxious at induction of anaesthesia, while 12% felt anxious after induction. At start of surgery 15% experienced anxiety and during surgery 9% were anxious. Continuous information reduced the experience of anxiety in 49% of the patients and the opportunity to ask questions during the intraoperative period reduced anxiety in 55%. The sight of technical equipment and surgical instruments was reported to increase anxiety in 9% and 6% of the sample, respectively. Patients with higher levels of general anxiety and depression also experienced significantly higher levels of anxiety in the intraoperative period. CONCLUSIONS: In this study patients experience highest level of anxiety at induction of anaesthetics. The operating theatre environments impact on patients' anxiety are in less degree influenced by the sight and hearing of the technical equipment and the surroundings. Continuous information and opportunity to ask questions reduces patients' anxiety. Results indicate that there is a significant positive relationship between generalised anxiety and depression prior to admission and anxiety experienced during the intraoperative period. RELEVANCE TO CLINICAL PRACTICE: Generalised anxiety and depression prior to surgery should be identified to implement nursing interventions to reduce anxiety in the operating theatre.