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.

Using In Situ Simulations to Improve Pediatric Patient Safety in Emergency Departments.

PROBLEM: Given the complex interaction among patients, individual providers, health care teams, and the clinical environment, patient safety events with serious consequences are most likely to occur in intensive care units, operating rooms, and emergency departments (EDs). With low-frequency, high-risk events such as pediatric resuscitations, health care teams working in EDs may not have the clinical opportunity to identify deficiencies, review and reinforce knowledge and skills, and problem solve in authentic clinical conditions. Without creating opportunities to safely practice, hospitals run the risk of having health care teams and environments that are not prepared to provide optimal patient care. APPROACH: Researchers employed a case series design and used a train-the-trainer model for in situ simulation. They trained health care professionals (instructors) in 3 general, nonacademic EDs in the San Francisco Bay area of California to perform pediatric resuscitation in situ simulations in 2018-2019. In situ simulations occur in the clinical work environment with simulation participants (teams) who are health care professionals taking care of actual patients. OUTCOMES: Teams made up of physicians, nurses, and ED technicians were evaluated for clinical performance, teamwork, and communication during in situ simulations conducted by instructors at baseline, 6 months, and 12 months. Debriefing after the simulations identified multiple latent safety threats (i.e., unidentified potential safety hazards) that were previously unknown. Each ED's pediatric readiness-its ability to provide emergency care for children-was evaluated at baseline and 12 months. NEXT STEPS: The authors will continue to monitor and examine the impact and sustainability of the pediatric in situ simulation program on pediatric readiness scores and its possible translation to other high-risk clinical settings, as well as explore the relationship between in situ simulations and patient outcomes.

Landscape analysis of nutrition services at Primary Health Care Units (PHCUs) in four districts of Ethiopia.

BACKGROUND: Good nutrition and healthy growth during the first 1000days have lasting benefit throughout life. For this, equally important is the structural readiness of health facilities. However, structural readiness and nutrition services provision during the first 1000 days in Ethiopia is not well understood. The present study was part of a broader implementation research aimed at developing model nutrition districts by implementing evidence based, high impact and cost-effective package of nutrition interventions through the continuum of care. This study was aimed at assessing structural readiness of health facilities and the extent of nutrition service provision in the implementation districts. METHODS: This assessment was conducted in four districts of Ethiopia. We used mixed method; a quantitative study followed by qualitative exploration. The quantitative part of the study addressed two-dimensions, structural readiness and process of nutrition service delivery. The first dimension assessed attributes of context in which care is delivered by observing availability of essential logistics. The second dimension assessed the service provision through direct observation of care at different units of health facilities. For these dimensions, we conducted a total of 380 observations in 23 health centers and 33 health posts. The observations were conducted at the Integrated Management of Neonatal and Childhood Illnesses unit, immunization unit, Antenatal care unit and Postnatal care unit. The qualitative part included a total of 60 key informant interviews with key stakeholders and service providers. RESULT: We assessed structural readiness of 56 health facilities. Both quantitative and qualitative findings revealed poor structural readiness and gap in nutrition services provision. Health facilities lack essential logistics which was found to be more prominent at health posts compared to health centers. The process evaluation showed a critical missed opportunity for anthropometric assessment and preventive nutrition counselling at different contact points. This was particularly prominent at immunization unit (where only 16.4% of children had their weight measured and only 16.2% of mothers with children under six month of age were counselled about exclusive breastfeeding). Although 90.4% of pregnant women who came for antenatal care were prescribed iron and folic acid supplementation, only 57.7% were counselled about the benefit and 42.4% were counselled about the side effect. The qualitative findings showed major service provision bottlenecks including non-functionality of the existing district nutrition coordination body and technical committees, training gaps, staff shortage, high staff turnover resulting in work related burden, fatigue and poor motivation among service providers. CONCLUSION: We found a considerable poor structural readiness and gaps in delivering integrated nutrition services with a significant missed opportunity in nutrition screening and counselling. Ensuring availability of logistics and improving access to training might improve delivery of nutrition services. In addition, ensuring adequate human resource might reduce missed opportunity and enable providers to provide a thorough preventive counselling service.

Nursing practice environment in Primary Health Care: a scoping review.

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.

Development and Implementation of a Suicide Prevention Checklist to Create a Safe Environment.

BACKGROUND: An increasing number of patients are admitted to general hospitals for injuries sustained in suicide attempts and for assessment of their ongoing risk for suicide. However, clinical staff may lack knowledge and expertise in the provision of a safe environment for potentially suicidal patients. OBJECTIVE: In an effort to follow the Joint Commission's recommendations on the care of suicidal patients, a Suicide Prevention Interdisciplinary Task Force was created. The task force sought to design and implement a suicide checklist that would facilitate creation of a safe environment for potentially suicidal inpatients on nonpsychiatric units in a general hospital. METHODS: We describe the development and implementation of a Care of the Suicide and Self-Injury Patient Checklist and report on data derived from incident reports related to self-harm/suicide attempts over a 4-year period. We also report results of a Research Electronic Data Capture survey of nurses' feedback on the checklist. RESULTS: After implementation of the Care of the Suicide and Self-Injury Patient Checklist, a total of 47 incidents of patient self-injury were reported over 4 years on nonpsychiatric inpatient units at a large general hospital; only three sustained permanent or serious harm. The Research Electronic Data Capture survey revealed that 88% of responding nurses believed that the Care of the Suicide and Self-Injury Patient Checklist guided creation of a safe environment and 90% believed that it supported consistent practice. CONCLUSIONS: The Care of the Suicide and Self-Injury Patient Checklist contributed to the creation of a safe environment while caring for potentially suicidal patients on nonpsychiatric inpatient units and guided clinicians on the management of potentially self-injurious individuals.

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.

Paralelismo en los cuidados enfermeros entre Isabel Zendal y Florence Nightingale / Parallelism in nursing care between Isabel Zendal and Florence Nightingale

OBJETIVO PRINCIPAL: documentar el paralelismo en los cuidados enfermeros administrados por Isabel Zendal y Florence Nightingale durante su estancia en el Hospital de la Caridad y en Escutari. METODOLOGÍA: se realizó una revisión bibliográfica narrativa a través de fuentes secundarias y una investigación histórica mediante la observación documental y hermenéutica de las fuentes primarias. Para la localización y selección de las fuentes primarias se consultó el Arquivo da Deputación da Coruña y el Arquivo Histórico Municipal da Coruña. Para localizar las fuentes secundarias se utilizó el buscador Google académico y se consultaron las siguientes bases de datos: Cuiden, Scielo, y Dialnet. RESULTADOS-CONCLUSIONES: a pesar de la distancia en espacio y tiempo, el análisis de la bibliografía y de los documentos utilizados muestra muchas similitudes en cuanto a los cuidados ofrecidos por ambas enfermeras. Llama la atención el diferente reconocimiento que se le otorgó a cada una de ellas. Creemos que lo que determina esta diferencia son los distintos factores sociales, educativos y económicos de ambas

OBJECTIVE: our objective in this study has been to document the parallelism in the nursing care administered by Isabel Zendal and Florence Nightingale during their stay at the Hospital de la Caridad and in Escutari. METHODS: a narrative bibliographic review was carried out through secondary sources and a historical investigation through documentary and hermeneutic observation of the primary sources. To locate and choose the primary sources both the Provincial Council Archive and the Historical Municipal Archive of A Coruña were consulted. Both Academic Google and data basis such as Cuiden, Scielo and Dialnet were used to locate the secondary sources. RESULTS- CONCLUSIONS: in spite of the space and time distance, the bibliography and document analysis show many similarities regarding the attentions given by both nurses. However, the credit given to each one attracts the attention. We believe that they are the different social, educational and economic factors which determine that difference

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.

Estudio cualitativo sobre la influencia del entorno físico en los pacientes ingresados en una Unidad de Cuidados Paliativos tras su remodelación / Qualitative study on the influence of the physical environment in patients admitted to a Palliative Care Unit after its remodelling

OBJETIVO: El objetivo de esta investigación es profundizar en la influencia del entorno físico en la calidad de vida y experiencias de los pacientes de una Unidad de Cuidados Paliativos tras su remodelación. MÉTODO: Realizamos entrevistas semiestructuradas a 5 pacientes de la unidad a partir de un guión que incluía cinco dimensiones: vivencias en general, comunicación, calidad de vida, concepto de UCP y mundo emocional y espiritual. El análisis cualitativo de la información obtenida se realizó a través de un proceso de codificación mixta. RESULTADOS: Los pacientes dan una gran importancia a la privacidad e intimidad en las habitaciones individuales tanto a nivel personal como familiar. Los espacios comunes, la naturaleza y el arte favorecen las relaciones interpersonales, la vivencia emocional y espiritual y generan recuerdos positivos en los pacientes. A partir de lo expresado por los participantes, destacamos distintas categorías referentes al ambiente generado en la unidad y sus efectos sobre el bienestar físico y social de los pacientes en la unidad. CONCLUSIÓN: La humanización de las infraestructuras y de las estructuras materiales forma parte de la humanización de la asistencia sanitaria. El ambiente influye notablemente y se relaciona con el comportamiento de las personas. Es importante crear espacios que proporcionen un equilibrio entre intimidad, comodidad física y psicológica, y apertura para relacionarse y promover experiencias de conexión y vida

OBJECTIVE: The aim of this investigation is to study in depth the influence of the physical environment on the quality of life and experiences of patients of a Palliative Care Unit after its remodelling. METHODS: We conducted semi-structured interviews with 5 patients of the unit, using a guide that included five dimensions: experiences in general, communication, quality of life, Palliative Care Unit concept and emotional and spiritual world. We used a qualitative approach for data analysis through a process of mixed coding. RESULTS: The patients attached great importance to privacy and intimacy in single rooms both at a personal and a family level.common spaces, nature and art favour interpersonal relationships, emotional and spiritual experiences and generated positive memories in the PATIENTS: Considering the participants' answers, we highlight several categories related to the environment created in the unit and its effect on the patient's social and physical wellbeing. CONCLUSIONS: The humanization of infrastructures and material structures is part of the humanization of health care. Environment influences people's behaviour. It is important to create spaces that provide a balance between intimacy, physical and psychological comfort and to promote social relationships and experiences of connection and life

Effect of the practice environment of nurses on job outcomes and safety climate.

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.

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.

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.

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.

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.

Leading by walking around in long-term care and transitional care facilities.

Nursing staff in long-term care/transitional care (LTC/TC) facilities in the US work in unique environments that can be stressful and demanding. There is much in the literature that describes different leadership styles in nursing, but a limited amount on leadership in LTC/TC environments. This article explores the concept of leading by walking around (LBWA), also known as leadership by walking, to cultivate therapeutic work environments in LTC/TC facilities in the US. It defines therapeutic work environments and describes the specific environment of LTC/TC facilities. It also briefly describes the nursing hierarchy and nurse education in the US. Finally, it describes the cultivation of therapeutic work environments by using LBWA and includes two examples of the concept in action.

Toward a mediation model for nurses' well-being and psychological distress effects of quality of leadership and social support at work.

Given the lack of active nurses in industrialized countries throughout the world, in combination with demographic changes, it is of utmost importance to protect nurses' well-being and to prevent psychological distress, because of their strong association with premature occupational leave. The aim of this study was to investigate the effects of quality of leadership and social support at work on well-being and psychological distress of nurses and to determine whether nurses' overcommitment mediates the relationship between the abovementioned determinants and the outcomes. A cross-sectional survey design was used to gather our data. This study utilized part of the database of the Nurses' Early Exit Study. A total of 34,771 nurses (covering all nurse qualifications) working in hospitals, nursing homes, and home-care institutions in 8 European countries filled out a questionnaire (response rate = 51.4%). For all model variables (job satisfaction, satisfaction with salary, positive affectivity, personal burnout, negative affectivity, quality of leadership, social support from immediate supervisor, social support from near colleagues, and overcommitment), psychometrically sound, that is, valid and reliable measures were used. Outcomes from testing a structural equation mediation model indicated that, respectively, positive and negative influences of leadership quality and social support from supervisor and colleagues on nurses' well-being and psychological distress are partially mediated, that is, reduced, by nurses' overcommitment. Social work environment is highly important in relation to nurses' well-being and psychological distress.

Transmission of methicillin-resistant Staphylococcus aureus in long-term care facilities and their related healthcare networks.

BACKGROUND: Long-term care facilities (LTCF) are potential reservoirs for methicillin-resistant Staphylococcus aureus (MRSA), control of which may reduce MRSA transmission and infection elsewhere in the healthcare system. Whole-genome sequencing (WGS) has been used successfully to understand MRSA epidemiology and transmission in hospitals and has the potential to identify transmission between these and LTCF. METHODS: Two prospective observational studies of MRSA carriage were conducted in LTCF in England and Ireland. MRSA isolates were whole-genome sequenced and analyzed using established methods. Genomic data were available for MRSA isolated in the local healthcare systems (isolates submitted by hospitals and general practitioners). RESULTS: We sequenced a total of 181 MRSA isolates from the two study sites. The majority of MRSA were multilocus sequence type (ST)22. WGS identified one likely transmission event between residents in the English LTCF and three putative transmission events in the Irish LTCF. WGS also identified closely related isolates present in colonized Irish residents and their immediate environment. Based on phylogenetic reconstruction, closely related MRSA clades were identified between the LTCF and their healthcare referral network, together with putative MRSA acquisition by LTCF residents during hospital admission. CONCLUSIONS: These data confirm that MRSA is transmitted between residents of LTCF and is both acquired and transmitted to others in referral hospitals and beyond. Our data present compelling evidence for the importance of environmental contamination in MRSA transmission, reinforcing the importance of environmental cleaning. The use of WGS in this study highlights the need to consider infection control in hospitals and community healthcare facilities as a continuum.

Nurses' Perceptions of Pediatric Intensive Care Unit Environment and Work Experience After Transition to Single-Patient Rooms.

BACKGROUND: The architectural design of the pediatric intensive care unit may play a major role in optimizing the environment to promote patients' sleep while improving stress levels and the work experience of critical care nurses. OBJECTIVES: To examine changes in nurses' perceptions of the environment of a pediatric critical care unit for promotion of patients' sleep and the nurses' work experience after a transition from multipatient rooms to single-patient rooms. METHODS: A cross-sectional survey of nurses was conducted before and after the move to a new hospital building in which all rooms in the pediatric critical care unit were single-patient rooms. RESULTS: Nurses reported that compared with multipatient rooms, single-patient private rooms were more conducive to patients sleeping well at night and promoted a more normal sleep-wake cycle (P < .001). Monitors/alarms and staff conversations were the biggest factors that adversely influenced the environment for sleep promotion in both settings. Nurses were less annoyed by noise in single-patient rooms (33%) than in multipatient rooms (79%; P < .001) and reported improved exposure to sunlight. CONCLUSIONS: Use of single-patient rooms rather than multipatient rooms improved nurses' perceptions of the pediatric intensive care unit environment for promoting patients' sleep and the nurses' own work experience.