Health Professional Redeployment and Cross-Training in Response to the COVID-19 Pandemic.

The onset of the COVID-19 pandemic in March 2020 required hospitals to respond quickly and effectively to ensure the availability of healthcare professionals to care for patients. The Ottawa Hospital in Ottawa, ON, used a five-step process to ensure organizational readiness for redeployment of regulated health professionals as and when necessary: (1) define current scopes of practice; (2) obtain discipline-specific input; (3) develop strategies based on literature review and government dictates; (4) identify potential duties; and (5) ensure support for staff. With hospital management support, this plan was readily implemented. Results are discussed in terms of operational outcomes (e.g., number and type of deployments) and staff experience. Outcomes were positive and led to recommendations for improved organizational readiness.

Hemodialysis shake-up on the front lines of the Covid-19 pandemic: the Treviglio Hospital experience.

The new coronavirus disease (Covid-19) pandemic in Italy formally started on 21st February 2020, when a 38-years old man was established as the first Italian citizen with Covid-19 in Codogno, Lombardy region. In a few days, the deadly coronavirus swept beyond expectations across the city of Bergamo and its province, claiming thousands of lives and putting the hospital in Treviglio under considerable strain. Since designated Covid-dialysis hospitals to centrally manage infected hemodialysis patients were not set up in the epidemic areas, we arranged to treat all our patients. We describe the multiple strategies we had to implement fast to prevent/control Covid-19 infection and spread resources in our Dialysis Unit during the first surge of the pandemic in one of the worst-hit areas in Italy. The recommendations provided by existing guidelines and colleagues with significant experience in dealing with Covid-19 were combined with the practical judgement of our dialysis clinicians, nurses and nurse's aides.

Experiences managing pregnant hospital staff members using an active management policy-A qualitative study.

BACKGROUND AND OBJECTIVE: During pregnancy, absence from work increases significantly. Job adjustments have been shown to decrease absences; however, studies show only half of pregnant women who need job adjustments receive them. Little is known about the viewpoints of managers and possible challenges in the management of pregnant employees. The aim of this study was to investigate the experiences and considerations of managers in relation to managing pregnant hospital staff members and to describe the experiences of an active management policy for pregnant individuals. METHODS: A qualitative study based on five focus group interviews was conducted at five public hospitals in Zealand, Denmark with participation of 19 hospital managers, from 17 different wards, representing six different medical specialties. The interviews took place from February to May 2019. Thematic analysis was used to analyze the data. RESULTS: Four themes were identified: (1) The everyday management, (2) Managerial dilemmas, (3) Acknowledging the workplace culture, and (4) Dialogue as a means for the working relationship. The managers' experiences revolved around investing a lot of effort into the working relationship with pregnant staff members by adjusting job tasks and work schedules while balancing work tasks between all staff members. The dialogue was considered central in order to identify the needs of the individual staff member. CONCLUSIONS: Overall, management dialogue constituted a central tool in order to identify the needs of the individual staff member. A proactive and open approach increased the chances of a fruitful dialogue. The individual staff member, the influence of the workplace culture, and the everyday management of the workplace all shaped the experiences of the managers. The concept of an active management policy for pregnant individuals was perceived to entail useful elements, but also as replicating what managers already did.

A comparative analysis on human resources among the specialized ophthalmic medical institutions in China.

BACKGROUND: This study compares perspectives on specialized ophthalmic medical institutions, identifies the gaps in property and geographic offerings, and explores the ways that ophthalmic medical institutions can better allocate resources. The results of this research will increase patient's access to equitable and high-quality ophthalmic care in China. METHODS: The data for this research was gathered from the Survey of China National Eye Care Capacity and Resource for the year 2015. The paper specified the number, professional level of expertise, and educational background of ophthalmic health personnel. The authors of the paper analyzed and compared the differences in ophthalmic care in public vs. private and urban vs. rural regions in China. Descriptive statistics were used. RESULTS: Of the 395 specialized ophthalmic hospitals surveyed, 332 were private medical institutions (84%), and 63 were public (16%). Of the 26 607 ophthalmic personnel surveyed, working in specialized ophthalmic hospitals, 17 561 were in private hospitals (66%) and 9 046 were in public ones (34%). Furthermore, 22 578 of those personnel worked in urban ophthalmic institutions (85%) and 4 029 worked in rural ones (15%). As for regional differences, 14 090 personnel were located in eastern China (53%), 8 828 in central regions (33%), and 3 689 in the western regions (14%). CONCLUSIONS: Public ophthalmic medical institutions still face challenges in providing equitable and widespread care. The availability of well-staffed health centers varies significantly by region. These variations impact resource allocation and directly lead to inequalities and inaccessibility of health services in certain regions of China.

Understanding the role of Foundation doctors through a self-reported time-mapping pilot study.

INTRODUCTION: There is a reduction in Foundation trainee applications to speciality training and this is attributed to an administrative job role, with subsequent fears of burnout. This pilot study presents the findings of a real-time self-reporting tool to map a group of Foundation doctors' elective activities. Self-reporting is efficient, low cost to run and allows for repeated measures and scalability. It aimed to example how a time-map could be used by departments to address any work imbalances and improve both well-being and future workforce planning. METHOD: Foundation doctors', at a busy District General Hospital, were asked to contemporaneously report their work activities over an 'elective' day. Outcomes measures included the mean duration per task and the time of day these were performed. RESULTS: Nine Foundation doctors' returned 26 timesheet days. Foundation doctors' time was split between direct patient tasks (18.2%, 106.8 min per day), indirect patient tasks (72.9%, 428.6 min per day) and personal or non-patient activities. Indirect tasks were the most frequent reason for Foundation doctors leaving late. No clinical experience was recorded at all and only an average of 4% (23.4 min per day) of a Foundation doctors' time was spent in theatre. CONCLUSIONS: This particular cohort performed a high proportion of indirect tasks. These have been associated with burnout. Time-mapping is a low-cost, acceptable and seemingly scalable way to elucidate a clearer understanding of the type of activities Foundation doctors may perform. This methodology could be used to modernise the traditional Foundation doctor job description.

General surgical foundation doctor: optimisation of daily practice.

INTRODUCTION: The role of a foundation year 1 (FY1) doctor has evolved over the years. Many doctors report significant anxiety and stress during this period. In this Quality Improvement Project, we looked at the difficulties FY1s face in their working day and if these issues could be resolved by implementing some structural changes. METHODS: The project was conducted in three cycles, each lasting 5 days (Monday to Friday), over three consecutive weeks. Week 1 consisted of shadowing of Surgical FY1s on wards observing daily routine (arrival, lunch and departure time), communication and handovers. Following this a number of interventions were made to the structure of their daily practice to improve productivity and performance. These improvements were measured in week 2 (as the new model was scaffolded into place) and week 3 (strictly observed). RESULTS: There was no significant difference in number of tasks between week 1, 2 and 3. In week 1, there was no set times for lunch, all of the FY1s lunches were interrupted, there was no structure for handovers and 100% of FY1s stayed at work beyond there contracted hours. In week 2 and 3 there was significant improvement in the number of uninterrupted lunches, amount of time spent beyond contracted hours, number and quality of handovers. The qualitative results collected also suggested positive impact on the working lives of those involved. CONCLUSION: The implementation of structural changes improved the quality of FY1s working day and increased the efficiency of service delivered on the surgical ward.

Assessment of time management practice and associated factors among primary hospitals employees in north Gondar, northwest Ethiopia.

BACKGROUND: Time management practice can facilitate productivity and success, contributing to work effectiveness, maintaining balance and job satisfaction. Thus, this study aimed to assess time management practices and associated factors among employees of primary hospitals in north Gondar. METHODS: An Institutional based cross-sectional study among primary hospital employees in north Gondar was conducted from March to April 2018. A structured and pre-tested questionnaire was used to collect the data. Simple random sampling technique was utilized to select 422 employees. Bivariate and multivariate logistic regression model were done to identify factors associated with time management practice. Adjusted odds ratio (AOR) with a 95% confidence interval (CI) was ascertained to show the strength and direction of association. RESULT: In this study, the prevalence of time management practice was 56.4% (95%CI: 49.3, 61.7). Being satisfied with organizational policies (AOR = 2.16; 95%CI: 1.02-4.68), performance appraisals (AOR: 2.11; 95%CI: 1.32-4.66), compensation and benefits (AOR: 4.18; 95%CI: 2.18-7.99), and planning (AOR: 2.86; 95% CI: 1.42-5.75) were statistically significant factors associated with time management practice. CONCLUSION AND RECOMMENDATION: The overall time management practice among the primary hospital employees was low. Planning, organizational policy, compensation and benefit, performance appraisal, and residence were factors significantly associated with hospital employee's time management practice. Thus managers and employees need to carry out interventions on significant factors to improve the employees' time management practice.

[Orientation for emergency and law enforcement personnel in internal threat situations in hospitals : Are guidance and orientation systems needed for hospitals?] / Orientierung für Einsatzkräfte bei internen Gefahrenlagen im Krankenhaus : Brauchen wir Leit- und Orientierungssysteme für Krankenhäuser?

BACKGROUND: Emergency exit and escape routes in public buildings, such as schools, hospitals and administrative offices are controlled by legal rules and regulations. Thereby escape from the building is very well organized in cases of internal threats (e.g. fire, active shooter and hostage situations). Complex buildings with numerous rooms are a special challenge to emergency and law enforcement personnel. Without additional means of orientation a targeted localization of the incident is not possible in many cases. MATERIAL AND METHODS: An extended literature search for guidance and building orientation systems, which enable an intuitive orientation and guidance for emergency personnel was performed. RESULTS: Only three German systems were identified that enable orientation and reliable guidance of emergency personnel within buildings. All three systems, i.e. uniform orientation system schools (EOS), color guidance system (FLS) and the Gütersloh model (GM) were derived from shooting incidents in schools in 2009. Based on a systematic labeling of all rooms, stairways, exits and entrances, ad hoc orientation and guidance of law enforcement and emergency personnel is possible. CONCLUSION: For targeted localization of an internal incident there only seem to be three German systems worldwide that enable an intuitive and immediate orientation and guidance within buildings. An increasing threat of worldwide terrorism and the fact that hospitals are seen as crucial infrastructures for attacks by terrorists make the implementation of guidance and orientation systems in hospitals urgently necessary. This is the first review dealing with this topic.

Assessing the relation of the coded nursing care and nursing intensity data: Towards the exploitation of clinical data for administrative use and the design of nursing workload.

Patient-care data from the electronic health record systems are increasingly in demand for re-use in administration and resource planning. Nursing documentation with coded concepts is expected to produce more reliable data, fulfilling better requirements for re-use. The aim was to ascertain what kind of relation exist between coded nursing diagnoses, nursing interventions, and nursing intensity and to discuss the possibilities for re-using nursing data for workload design. We analysed the retrospective nursing records of 794 patients documented by the Finnish Care Classification and nursing intensity data assessed by the Oulu Patient Classification over a 15-day period in nine inpatient units at a university hospital. Using the generalised linear mixed model, the clear relationship between the number of coded nursing notes and nursing intensity levels were ascertained. The number of coded nursing notes increases when the nursing intensity increases. The outcomes construct a good basis for continuing elaboration of electronic health record data re-use.

Orientações para boas práticas em alimentação e nutrição hospitalar no enfrentamento da COVID-19 / Guidelines for good practices in hospital food and nutrition in coping with COVID-19

Baseado em informações oficiais já disponíveis, "Orientações para boas práticas em alimentação e nutrição hospitalar no enfrentamento da COVID-19" foi elaborado por um grupo de profissionais nutricionistas do Brasil, atuantes em diversas áreas (clínica, hospitalar, unidades de alimentação e nutrição, docência e pesquisa universitária, consultoria em gestão de qualidade e segurança de alimentos), com o objetivo de contribuir com as adaptações nos processos de trabalho de nutricionistas e gestores de unidades hospitalares. Apresenta orientações: quanto à higienização de ambientes e materiais específicos, quanto aos cuidados no transporte e distribuição de refeições, dicas também para profissionais de saúde que trabalham na área de isolamento, orientações para os pacientes hospitalizados e apresenta condutas de avaliação nutricional. O resultado do trabalho foi de reforçar a condutas adequadas e contribuir significativamente com a segurança alimentar e nutricional de pacientes e colaboradores

Based on official information already available, "Guidelines for good practices in food and hospital nutrition in coping with COVID-19" was prepared by a group of nutritionists from Brazil, working in several areas (clinic, hospital, food and nutrition units, teaching and university research, consultancy in quality management and food safety), in order to contribute to adaptations in the work processes of nutritionists and hospital unit managers. It presents guidelines: regarding the cleaning of specific environments and materials, regarding care in the transportation and distribution of meals, tips also for health professionals working in the isolation area, guidelines for hospitalized patients and presents nutritional assessment procedures. The result of the work was to reinforce adequate conduct and significantly contribute to the food and nutritional security of patients and employees

Should Nursing Institute Random Drug Screening?

The nursing profession should follow what other professions have already done by instituting random drug screening in health care facilities now.

[The Effects of Hospitals' Family Friendly Management on Married Female Nurses' Retention Intention: Focused on the Mediating Effects of Work-Family Interface].

PURPOSE: This study examined the effect of hospitals' family-friendly management on married female nurses' retention intention. The focus was the mediating effects of the work-family interface (work-family conflict, work-family enrichment and work-family balance). METHODS: This study was a cross-sectional study. The participants were 307 nurses working at five public and five private hospitals with more than 200 beds in Seoul. Data were collected using structured questionnaires from September 10 to September 17, 2018 and analyzed with SPSS 24.0. Data were analyzed using an independent t-test, a one-way ANOVA, Pearson's correlation coefficients, and multiple regression following the Baron and Kenny method and Sobel test for mediation. RESULTS: There were significant correlations among family-friendly management, the work-family interface, and retention intention. Work-family conflict showed a partial mediating effect on the relationship between family-friendly management and retention intention. Work-family enrichment showed a partial mediating effect on the relationship between family-friendly management and retention intention. Work-family balance showed a partial mediating effect on the relationship between family-friendly management and retention intention. CONCLUSION: These findings indicate that both hospitals' family-friendly management and nurses' work-family interface are important factors associated with nurses' retention intention. Therefore, hospitals should actively implement family-friendly management for nurses and establish strategies to enhance nurses' work-family interface for effective human resource management.

Quality and safety of the nurse practice environment: Implications for management commitment to a culture of safety.

BACKGROUND: The Philippines experiences several challenges pertaining to the quality of the practice environment (PE) and nursing quality safety (NQS) among nurses. Although there is already considerable empirical data on PE effects on NQS, there is still little overall information on the association between these variables. AIM: This survey study examined the contribution of nurses' perceptions of their PE on their perception of their PE's quality of safety among hospital nurses in the Philippines. This survey was conducted in two government hospitals and two private hospitals in the Philippines. PARTICIPANTS: A total of 374 nurses selected from two selected government hospitals and two private hospitals in the Philippines using a convenience sample technique. METHODS: Data were collected using a self-administered questionnaire focusing on the PE and NQS among nurses. RESULTS: The overall PE mean score of nurses is 3.07 (SD = 0.159) while the overall mean score of their NQS is 3.97 (SD = 0.702). NQS was higher in female nurses compared with male nurses (M = 2404 vs 4.16). Nurses assigned to emergency departments (F = 1.04, [df = 11], and P = .025) presented higher perceived NQS compared with those in other departments. CONCLUSION: Nurses report moderate PE and higher NQS. Sex and emergency room department are significantly associated with NQS. Health care services have an obligation to ensure strong PE, as an important factor in regard to nursing management and affecting the QNS.

Impact of scribes on emergency medicine doctors' productivity and patient throughput: multicentre randomised trial.

OBJECTIVES: To evaluate the changes in productivity when scribes were used by emergency physicians in emergency departments in Australia and assess the effect of scribes on throughput. DESIGN: Randomised, multicentre clinical trial. SETTING: Five emergency departments in Victoria used Australian trained scribes during their respective trial periods. Sites were broadly representative of Australian emergency departments: public (urban, tertiary, regional referral, paediatric) and private, not for profit. PARTICIPANTS: 88 physicians who were permanent, salaried employees working more than one shift a week and were either emergency consultants or senior registrars in their final year of training; 12 scribes trained at one site and rotated to each study site. INTERVENTIONS: Physicians worked their routine shifts and were randomly allocated a scribe for the duration of their shift. Each site required a minimum of 100 scribed and non-scribed shifts, from November 2015 to January 2018. MAIN OUTCOME MEASURES: Physicians' productivity (total patients, primary patients); patient throughput (door-to-doctor time, length of stay); physicians' productivity in emergency department regions. Self reported harms of scribes were analysed, and a cost-benefit analysis was done. RESULTS: Data were collected from 589 scribed shifts (5098 patients) and 3296 non-scribed shifts (23 838 patients). Scribes increased physicians' productivity from 1.13 (95% confidence interval 1.11 to 1.17) to 1.31 (1.25 to 1.38) patients per hour per doctor, representing a 15.9% gain. Primary consultations increased from 0.83 (0.81 to 0.85) to 1.04 (0.98 to 1.11) patients per hour per doctor, representing a 25.6% gain. No change was seen in door-to-doctor time. Median length of stay reduced from 192 (interquartile range 108-311) minutes to 173 (96-208) minutes, representing a 19 minute reduction (P<0.001). The greatest gains were achieved by placing scribes with senior doctors at triage, the least by using them in sub-acute/fast track regions. No significant harm involving scribes was reported. The cost-benefit analysis based on productivity and throughput gains showed a favourable financial position with use of scribes. CONCLUSIONS: Scribes improved emergency physicians' productivity, particularly during primary consultations, and decreased patients' length of stay. Further work should evaluate the role of the scribe in countries with health systems similar to Australia's. TRIAL REGISTRATION: ACTRN12615000607572 (pilot site); ACTRN12616000618459.

Health care risk managers' consensus on the management of inappropriate behaviors among hospital staff.

Medical errors are the third-leading cause of death in the United States. One of the problems is timely recognition and management of inappropriate health care worker behaviors that lead to intimidation and loss of staff focus, eventually leading to errors. The purpose of this qualitative modified Delphi study was to seek consensus among a panel of experts in hospital risk management practices on the practical methods for early detection of inappropriate behaviors among hospital staff, which may be used by hospital managers to considerably mitigate the risk of medical mishaps. High reliability theory guided the research process, utilizing the conceptual framework of the fair and just culture patient safety model. A single research question asked what level of consensus exists among hospital risk management experts as to the practical methods for early detection of inappropriate behavior among hospital staff, which managers may use to ultimately mitigate the risk of preventable medical mishaps. This study included nonprobability purposive sampling (n = 34) and three rounds of questionnaires. Consensus was reached on 8 factors: setting expectations, developing a culture of respect, holding staff accountable, enforcing a zero-tolerance policy, confidentiality of reporting, communicating expected behavior, open communication, and investigating inappropriate behaviors.

Role of strategic human resource management in crisis management in Australian greenfield hospital sites: a crisis management theory perspective.

Objective This study examined strategic human resource management (SHRM) activities in two case hospitals relative to their approach to greenfield site success. Methods A comparative case study analysis approach was used, with documents sourced from public, open-access sites. The theoretical framework of crisis management theory's (CMT) proactive management and open communication channels was used to examine the documents, which were annual reports addressing both hospitals' first year of performance, union publications and transcripts of relevant parliamentary inquiries. Results The hospital that effectively used CMT in its first 12 months was demonstratively more 'successful' than the hospital that reported to not have effectively used CMT. 'Success' in this project was articulated as the hospital's ability to consolidate operations, without ongoing negative media attention, after 12 months. Conclusion This study provided an identification of how the use of CMT in a hospital's greenfield stage can increase the hospital's chances of 'success'. What is known about the topic? Journal and media articles illustrated a gap in greenfield human resource management (HRM) regarding successful consolidation, especially the healthcare context. Although manufacturing firms are addressed in academic literature in a greenfield context, there is a lack of knowledge concerning successful greenfield HRM in a healthcare context. What does this paper add? This study is among the first to identify the role of CMT in successful greenfield site establishment by identifying its presence in management activities. What are the implications for practitioners? The findings of this study suggest a potential link between the implementation of CMT and greenfield site success. This could allow future greenfield healthcare sites to operate with less cost and risk. The lack of stakeholder participation in the present study limits the applicability of its findings. However, archival document analysis provides a strong foundation for future studies.

Classification of patients and nursing staff's sizing: contributions of a management technology. / Classificação de pacientes e dimensionamento de profissionais de enfermagem: contribuições de uma tecnologia de gestão.

OBJECTIVE: Applying PRAXIS® technology resources for patient classification and nursing professional sizing in university hospital inpatient unit. METHOD: Convergent Care Research following the design and instrumentation phases - defined the research theme and purpose, performed in a medical clinic hospital unit involving 633 participants; scrutiny - classification of patients during 30 days of June 2016, followed by sizing, analysis and interpretation of the results - elaborated with the support of the management theorization in hospital nursing. RESULTS: Amongst the total of 633 classifications made, 29.38% were patients in minimal care, 35.71% were intermediate care patients, 33.02% were highly dependent, 1.42% were semi-intensive and 0.47% were in intensive care. Two references were used to carry out the sizing; in both the available team showed to be in deficit. CONCLUSION: The classification of patients and the sizing of nursing professionals are directly related, they are indispensable for management in nursing and difficult to perform daily. Computerized technologies are useful for performing these activities.

[Between protocols and subject: quality of hospital care in a hematology service]. / Entre protocolos e sujeitos: qualidade do cuidado hospitalar em um serviço de hematologia.

The article presents partial results of a study at Hospital Edgar Santos, Universidade Federal da Bahia (HUPES), Brazil, analyzing the service's experience with improvement in quality of care within a context of hospital accreditation. The article focuses on the hematology service and specifically its quality of care and intersubjective processes. The study adopted a qualitative approach, using interviews and observation. From the theoretical point of view, the work of Campos, Cecílio, and Merhy acknowledge healthcare's complex nature and micropolitical and intersubjective dimension and the capacity of health professionals to produce meanings and practice creativity. To understand the health professionals' processes of psychosocial linkage and subjective mobilization, we drew on concepts from the French school of psychosociology (Enriquez) and Dejours' psychodynamics of work. The analysis was organized along three lines: psychosocial linkage and the imaginary of self-management; bonding and affect: singularity of the subject's care and clinical case; real work and the healthcare team. One of the main conclusions is the building of a self-management imaginary, expressed in shared projects, expectations, and some forms of interpreting and operating reality, based on affectively invested representations of autonomy and unity. Alongside technical elements such as protocols, the article highlights professional judgment, proper to the intersubjective dimension, fostering the singularity of care. In our view, the real work in the patient care scene is traversed by adjustments that demonstrate team cooperation.

No artigo, apresentamos parte dos resultados do estudo desenvolvido no Hospital Edgar Santos, da Universidade Federal da Bahia (HUPES), que analisou a experiência de melhoria da qualidade da assistência em um contexto de acreditação hospitalar. O artigo volta-se para o serviço de hematologia e tem seu foco na qualidade do cuidado e processos intersubjetivos. A investigação foi pautada na perspectiva qualitativa, empregando-se entrevistas e observação. Do ponto de vista teórico, os trabalhos de Campos, Cecílio e Merhy reconhecem a natureza complexa do cuidado em saúde, sua dimensão micropolítica e intersubjetiva, e a capacidade dos profissionais de produção de sentidos e de criatividade. Para compreender os processos de articulação psicossocial e de mobilização subjetiva dos profissionais empregamos conceitos da psicossociologia francesa de Enriquez e da psicodinâmica do trabalho de Dejours. A análise foi organizada em três eixos: articulação psicossocial e o imaginário de autogestão; vínculo e afeto: singularização do cuidado e clínica do sujeito; trabalho real e equipe de saúde. Destacamos como uma das principais conclusões a constituição de um imaginário de autogestão, expresso no compartilhamento de projetos, expectativas e algumas formas de interpretar e operar a realidade, que têm por base representações, afetivamente investidas, de autonomia e unidade. Ao lado de elementos técnicos, como protocolos, é realçado o julgamento profissional, próprio à dimensão intersubjetiva, permitindo a singularização do cuidado. Compreendemos que na cena assistencial o trabalho real é atravessado por ajustes que demonstram a cooperação entre os profissionais.

En este artículo presentamos parte de los resultados del estudio desarrollado en el Hospital Edgar Santos, de la Universidad Federal de Bahía (HUPES), que analizó la experiencia de mejora de la calidad de la asistencia en un contexto de acreditación hospitalaria. El artículo se dirige al servicio de hematología y centra su atención en la calidad del cuidado y procesos intersubjetivos. La investigación fue pautada desde la perspectiva cualitativa, empleando entrevistas y observación. Desde el punto de vista teórico, los trabajos de Campos, Cecílio y Merhy reconocen la naturaleza compleja del cuidado en salud, su dimensión micropolítica e intersubjetiva, y la capacidad de los profesionales para producir nuevos significados y ser creativos. Para comprender los procesos de articulación psicosocial y de movilización subjetiva de los profesionales empleamos conceptos de la psicosociología francesa de Enríquez y de la psicodinámica del trabajo de Dejours. El análisis se organizó en torno a tres ejes: articulación psicosocial e imaginario de autogestión; vínculo y afecto: singularización del cuidado y clínica del sujeto; trabajo real y equipo de salud. Destacamos como una de las principales conclusiones: la constitución de un imaginario de autogestión, traducido en compartir proyectos, expectativas y algunas formas de interpretar y manejar la realidad, que tienen como base representaciones, afectivamente invertidas, de autonomía y unidad. Junto a elementos técnicos, como los protocolos, se realza el juicio profesional, propio de la dimensión intersubjetiva, permitiendo la singularización del cuidado. Comprendemos que en la escena asistencial el trabajo real está cruzado por ajustes que demuestran la cooperación entre los profesionales.