Challenges for the management of emergency care from the perspective of nurses/Desafios para a gerência do cuidado em emergência na perspectiva de enfermeiros

Headnote

Keywords

Nursing administration research; Nursing service, hospital; Nursing care; Management; Emergency nursing

Descritores

Pesquisa em administragäo de enfermagem; Serviço hospitalar de enfermagem; Cuidados de enfermagem; Gerencia; Enfermagem em emergência

Submetted

March 3, 2012

Accepted

February 21, 2013

Abstract

Objective: To analyze the challenges for the management of care in a hospital emergency department, based on the perspective of nurses.

Methods: A qualitative, descriptive and exploratory study, conducted from June to September 2009, through semi-structured interviews with 20 nurses in the Emergency Department of a university hospital in southern region of Brazil. Data were analyzed using thematic analysis.

Results: The main challenges of nursing in managing care in emergency units were: management of overcrowding, maintaining quality of care, and utilization of leadership as a management tool. The suggestions mentioned to overcome these were: reorganization of the health system to focus on emergencies, changes in the flow of patient care, and implementation of training on nursing management.

Conclusion: Such challenges and strategies represented a boost to the development of new practices through collaborative and coordinated work with the emergency care network.

Resumo

Objetivo: Analisar os desafios para a gerencia do cuidado em um serviço hospitalar de emergencia, com base na perspectiva de enfermeiros.

Métodos: Pesquisa qualitativa, do tipo descritiva e exploratória, realizada de junho a setembro/2009, por meio de entrevista semiestruturada com 20 enfermeiros do Serviço de Emergência de um Hospital Universitário da Regiäo Sul do Brasil. Os dados foram analisados mediante análise temática.

Resultados: Os principais desafíos dos enfermeiros na gerencia do cuidado em emergencia foram gerenciamento da superlotagao, manutengao da qualidade do cuidado e utilizagao da liderança como instrumento gerencial. As sugestöes citadas para superá-los foram reorganizagao do sistema de saúde para atençao às urgencias, alteragao no fluxo de atendimento dos pacientes e realizagao de capacitagao sobre o gerenciamento de enfermagem.

Conclusäo: Tais desafíos e estratégias representam um impulso para o desenvolvimento de novas práticas por intermédio de um trabalho colaborativo e articulado com a rede de atençao às urgencias.

Introduction

The organization of care and the management of care provided to patients in hospital emergency services are issues discussed in various countries, due to the epidemiological and demographic transition of the world's population. The longer life expectancy of the population and increased morbidity and mortality from cerebrovascular and coronary diseases, for example, are factors that have contributed to the increased rates of demand for care in those services, and encouraged the discussion about the need for adoption of new care models in order to provide more complex and prolonged care. (1,2) In Brazil, the National Policy for Care in Emergencies, established in 2006 and updated in 2011, states that the care for users with acute conditions must be provided at all ports of entry for services of the Unified Health System, enabling the resolution of integral problems or transfering those clients, responsibly, to a more complex service, within a hierarchical and regulated system, organized into regional networks of care for emergencies as links in a network of maintaining life in increasing levels of complexity and responsibility.(3)

However, emergency hospital services continue to be the place where unresolved or undiagnosed problems at other levels of care converge. For the largest parts of the population who do not have regular access to health care service, hospital emergency rooms are the main alternative of care for the most diverse situations, because in a common sense, these services gather resources that make them more resolute, namely consultations, medicine, nursing procedures, lab tests and hospitalizations.(4,5) As a consequence, it is observed that chaotic utilization, the overcrowding of emergency services, and the lack of hospital beds cause several difficulties of care, both for patients and the healthcare team.(2,4)

Specifically regarding the nurses' performance in care management for an emergency department, we highlight the need for a constant search for development of better strategies to enable them to overcome the challenges imposed by working in an environment characterized by the constant demand for care. Earlier studies have identified that management is an essential activity and predominant work of nurses in emergency services. It is up to these professionals to search for means to ensure the availability and quality of material and infrastructure resources for the team to operate for the care of patients with complex needs, visualizing not only the needs of the patient, but also reconciling organizational objectives and those of the nursing team, establishing interfaces with other hospital departments and the local health system, aimed at the production of comprehensive, effective and safe care.(5-8) Furthermore, informally, there are nurses who, many times, negotiate daily the resolution of internal and external problems of emergency work, which enables the proper functioning of the service.(2)

To achieve these objectives, the nurses in emer- gency units should combine control of time, theo- retical foundation, discernment, initiative, maturity, emotional stability and leadership ability, which re- quires the development of skills such as communi- cation, interpersonal relationship and decision mak- ing.(7) Leadership is a fundamental management tool for nursing work; because it coordinates the nursing work and mediation between the different profes- sionals of the health team, it can be learned and de- veloped, where there is interest and initiative.(9)

Based on the above, we point out the impor- tance of conducting a study about the challenges experienced by nurses in emergency care manage- ment, and their suggestions for addressing them and exercising a professional practice grounded in ethical, humanistic, and scientific principles guid- ing the practice of nursing. Thus, research questions were established: What are the challenges of nurses in care management of a hospital emergency depart- ment? What suggestions are proposed by them to overcome those challenges?

Thus, this study had as its objective to analyze the challenges for the care management in a hospi- tal emergency department, guided by the perspec- tive of nurses.

Methods

This was a qualitative, exploratory and descriptive study, whose data were collected in the emergency department of a university hospital located in the southern region of Brazil.

Data collection occurred between June and September of 2009, through semi-structured in- terviews with 20 of the 32 nurses who worked in the section. The guiding questions focused on the challenges faced in the care management of a hos- pital emergency department, and suggestions to overcome these. An intentional sample was defined, and involved the selection of subjects considered representative according to interest in the investi- gated issue and the study objectives. Thus, we in- cluded nurses who agreed to participate and had worked for more than six months in the emergency department. For the definition of this period, we considered six months as a long enough time for adaptation of the professional to the sector routines and teamwork, in this way, contributing more effec- tively to the investigation.

The interviews were recorded using an electron- ic audio device, totaling between ten to 50 minutes, and were then transcribed. The number of inter- views conducted was defined based on the criterion of data saturation, i.e., when the information ob- tained began to repeat itself, enabling the identifi- cation of convergences and the establishment of a linkage between the evidence.

For data analysis, the content analysis technique was used, of a thematic analysis type, which consists of three steps: pre-analysis, material exploration and data processing, inference and interpretation.(10) In the pre-analysis phase, by means of floating read- ing, the main ideas of the collected material were organized and systematized based on the criteria of exhaustiveness, representativeness, consistency and relevance. After that, we proceeded to the ex- ploration of the material in order to highlight the registry units, transforming raw data into nuclei of understanding of the text and the construction of empirical categories. In the final phase, we proceed- ed to the processing and interpretation of results. Through coordination between the empirical struc- tured material and the literature, three thematic cat- egories emerged that composed the theme: Chal- lenges in the management of care and suggestions for overcoming them.

The development of the study followed national and international standards of ethics in research in- volving humans.

Results

The results are presented in three categories: man- agement of overcrowding, maintaining quality of care, and use of leadership as a management tool.

Management of overcrowding

Management of overcrowding is a challenge for nurses, as they need to plan the implementation of care and to organize work, adapting to the condi- tions of care available, to the amount and severity of the patients' clinical symptoms, in order to achieve the best possible care, against a backdrop marked by constant demand for care, as evidenced in the following statement:

"[...] The management of overcrowding, the ex- cessive number of patients with our conditions [... ] I like to have the unit as organized as possible with- in the disorganization of emergency, people live and I live with it, always trying to minimize it, but it is a sector that in a little while gets 20, 60, 100 patients, and you're seeing things, one patient above the oth- er and so on [...]". (E1).

Among the reasons that cause overcrowding of emergency services, nurses highlighted the constant demand for care of low-risk patients, burdening the nursing staff and making the care of more ill patients difficult. In this way, some nurses demon- strated being critical in relation to the ignorance of people about the purpose of the department to handle actual emergencies and a lack of patience for those seeking primary health care:

"One of the main challenges is overcrowding, mainly due to the care of those patients that are not urgent" (E13).

"[... ] I have trouble understanding, why people cannot define that this is an emergency service, and they must avoid coming due to neck pain, ingrown toenails, and abdominal pain. This is a cultural issue of the people that do not work. Only that is not quite all, there are the people who no longer want to subject themselves and wait, because they come here and can do everything, like, x-ray, blood tests, and they don't need to run from one side to another [...]". (E15).

To avoid the overcrowding, the nurses suggested a reorganization of the entire healthcare system in order to receive less complex urgent care patients in the basic units and health centers.

"It is the entire network that has to change, not just in here. We cannot try to do a better job while the network does not change". (E10).

"[... ] the health system is poor, if we had a good service at the heath center unit, a lot of people would not come here". (E14). "It has to improve the health system as a whole, pri- mary care treating the less critical patients and we can work with more tranquility." (E20).

Maintaining the quality of care

Overcrowding poses a challenge to the mainte- nance of quality of care provided to patients in the emergency department. Many patients, after the first care and stabilization of their clinical condi- tion, stay in the emergency department and require attention that does not always correspond to the nursing team, according to the characteristics of the work unit, as reported by the respondent:

"Emergency care provides very good care, but the continuity of this is complicated. The right thing would be for the emergency department to give the first care and refer patients, but they end up staying, and we cannot provide adequate care" [...]. (E8).

The realization of care related to hygiene and comfort of patients who stay for observation is the principal difficulty faced by nurses and the nursing staff, considering the excessive number of patients and inadequate physical space of emergency ser- vice rooms. Accordingly, the quality of care pro- vided in observation rooms of emergency service concerns nurses:

"No matter whether we have sufficient material, if the unit is organized, if the number of techni- cians in the schedule is correct, they, at times, leave the patient's side. Yesterday, I had a patient in poor clinical condition with prescription for airway suc- tioning. I looked to the wall and did not have a suction cannister, so I looked for a cannister, tube, sleeve, and all the material and I said to the techni- cian: "Look at this patient's mouth," I showed her there was a crust. With the overcrowding, people forget to do what seems insignificant, but, what is essential". (E17).

With suggestions for seeking a higher quality of care in the emergency department, the nurses mentioned the need for change in the patient care flow and the expansion of the physical structure of the emergency service. Regarding the change in the flow of patient care, nurses highlighted the impor- tance of expediting the hospital admissions and re- lease of patients:

"What could be expedited is the issue of hospital- ization and discharge of the patients, this is something that depends a lot on the medical staff [...]" (E12).

"[... ] I would like, that here in emergency, the service was truly urgency and emergency, because 90% of patients who are in the observation room would be in inpatient units" (E15).

"Reducing the number of patients in the unit, but this doesn't depend on nursing, it depends on the patient flow from triage to the speed of discharge or transfer of the patient to hospital admission" (E19).

To streamline the flow of patient care, nurs- es recognized the need for participation and col- laboration of all professionals in the health team, especially the physicians. However, in one of the statements, there was a suggestion that patient admission should be managed by nurses because of their experience and management training re- ceived, which gives them a broader view in rela- tion to this issue:

"[... ] It would be very interesting if a nurse had the responsibility for the hospitalization of patients, not a physician and secretary. Nurses have a global view of this, experience and management training to make things go faster" (E12).

With regard to the enlargement of the physical structure of the emergency service, the study partic- ipants indicated, as a strategy, the need for a greater number of stretchers to accommodate patients.

"On the physical side, our biggest problem is the lack of stretchers [...]" (E9).

"There is a lack of better beds, because there are a lot of stretchers that are broken" (E13).

"[... ] The stretcher issue stresses me very much! It's a stress when the patient gets ill, is hypotensive and we don't have a stretcher or when we have to remove a patient from there to accommodate an- other patient" (E15).

Use of leadership as a management tool

To program and implement changes, in order to improve the care in the emergency department, leadership emerges as an important management tool for nurses. Practicing it is a challenge for them, in relation to the resistence of the nursing and health staff facing the proposition of new actions:

"A challenge that exists is the question itself of being more of a leader, because many people who are in here think that this is not right, but they say that it's always been like that, it doesn't make sense to do anything. I do not believe this, because if I come here, it is to work" (E8).

For this interviewee, many professionals, particular- ly those who have been at the institution a longer time, are reluctant to change, even when it can bring benefits to the unit and themselves as workers, which makes the performance of nurses as the leader of a nursing staff more difficult. Conscious of the challenges that involve leadership in the emergency department, the nurses mentioned as a suggestion the completion of a training course about nursing management.

"The ideal would be a course about people management with an expert, to come here and pass that knowledge on to us, for us to put it more into practice" (E3).

The realization of training focusing on nursing management is an interesting strategy, in view of the increasing importance of acquiring a manage- rial dimension in the work of the nurse in health services, and how quickly new knowledge has been produced in this area.

Discussion

This research provides subsidies for nurses, health professionals and managers of emergency services to reflect on their practices and invest in the develop- ment / refinement of strategies to improve the qual- ity of emergency care and the working conditions for health care staff.

This study presents as a limitation the results of the exclusive focus on the nurses. Managing care is a collective process, the implementation of the sugges- tions presented requires acting in combination with the nursing and health care staff, which leads to the recommendation for research with these profession- als in order to add new perspectives and opinions to the possibilities for solving the problem of over- crowding and contributing to the quality of care.

In the words of the nurses, overcrowding ap- pears as a characteristic incorporated into the work process in the emergency department. Accordingly, they mentioned the need to minimize and manage it, looking for conditions to provide adequate and humanized care to patients. This may be related to naturalization of the pressure of a humanized work- ing environment for health professionals and the lack of control over their practice, which makes the professional, often, intuitive.(2)

Overcrowding is linked to the concept of us- ers who seek care in emergency departments when there is an urgent need. Rather than waiting on health professionals, users seek care when present- ing health changes that they consider important. Actually, there is a mismatch between what users and health professionals think, regarding the pur- pose of the emergency department work.,,,, (11)

The difficulty of the healthcare team of patient acceptance, which is seen as a product of the failure of the network and inadequate for emergency care, may be faced by humanization policies, strategies of awareness and acceptance of emergency as the pos- sible and legitimate gateway into the current health- care system. Furthermore, it is important to discuss how to integrate within the network this type of patient to the other possible gateways and prepare to serve them, since the demands are generated by cultural factors and the deficiency of technological and social resources.(12)

Another aspect highlighted by the study par- ticipants was a mischaracterization of the mis- sion of the emergency service. The unit, which should have a transitory character, where the pa- tient would remain a short time, functions as an inpatient unit, due to the unavailability of beds in other hospital sectors. Therefore, meeting the basic human needs, such as sleep, rest, food and personal hygiene become compromised by exces- sive demand for treatment and due to the condi- tions of inadequate infrastructure for performing care activities. This result is convergent with the findings of previous studies in which structural conditions were described as factors that hindered quality care in emergency services.(7,13,14)

The retainment of patients after resolving their urgent needs was a common problem in emergency hospital services, which occurred due to the lack of an institutional culture with a view to optimizing the service regarding the management of vacancies, among other factors.(13) Consequently, healthcare professionals are faced with elevated workloads, in- adequate physical spaces, and with insufficient ma- terial resources and equipment, which along with compromising the quality of care delivered, causes suffering, dissatisfaction and conflict.(15,16)

The reorganization of the healthcare system for the care of urgencies of lower technological com- plexity was the suggestion of nurses to overcome the challenge of overcrowding. This suggestion is consistent with the principles governing the Uni- fied Health System and is already a reality in other settings. Fourteen years ago the region of Ribeiräo Preto began a process of organizing the flow of emergency patients that evolved into an intermu- nicipal referral, and enabled the organization and structuring of a regional health care network, hier- archical in attention to the emergency room, regu- lated through the implementation of Medical Reg- ulation and the Mobile Emergency Care Service.(17)

Inserted into this scenario, the Emergency Room of the Hospital das Clínicas of Ribeiräo Preto, with the support of clinical services linked to departments of the University of Säo Paulo and the Center for Studies of Emergencies, redefined its care and edu- cational mission, addressing overcrowding with a significant reduction in the number of consults and the occupancy rate in the unit.(17) This experience showed that through the joint efforts of professionals and health services and the articulation of the spheres of government, it is possible to overcome the dichot- omies that characterize attendances to the emergency room in Brazil.

Similarly, American studies(18,19) emphasize that the search for quality of care in emergency services should be planned at the regional level, through an agency to coordinate the standardization of care and referrals. In the specific field of services, we suggest the development of triage protocols for faster care and to increase the number of beds in intensive care units in order to transfer the most severely ill patients.

Regarding the role of a nurse, it was observed that this professional cannot develop sequenced work due to excessive demand and the constant requests, both by nursing staff, patients, and other professionals, which clearly demonstrates insuffi- ciency of these professionals and the lack of plan- ning in the performance of their role.(13) These char- acteristics can justify the fact that nurses consider it a challenge to exercise leadership in the emergency department. Leadership in nursing, as well as being a complex social phenomenon, is a fundamental in- strument for care management that requires nurses' commitment to the quest for continuous improve- ment of their skills and potential. For an effective exercise of leadership, it is important that the nurse be responsible, committed to the work of maintain- ing effective communication with the nursing team.

The challenges surrounding the management of care in emergency are collective and need to be conceptualized and discussed in the institutional and political context in which they exist. Therefore, it is important that the nurse glimpse the care of nursing as a social entrepreneurial practice, seeking to mobilize and integrate the different systems in a functionally differentiated network perspective, in- creasing and multiplying individual competencies and local resources aimed at creating an integrated plan and individualized care for the development of social policies, capable of understanding the com- plexity of factors involving human beings in their real and concrete context.(21)

Specifically in relation to their performance in the emergency department, the nurses suggested that greater participation in the nursing manage- ment of hospitalization and hospital beds could contribute to management of overcrowding in emergency units. Similarly, in the international context, the hiring of nurses and the expansion of their professional roles through advanced nursing practice, ranging from the performance of triage with risk classification to the clinical care provid- ed to cases of minor technological complexity, have contributed to the reduction of healthcare costs, improving quality of care and reduction of waiting time for care.(6)

Therefore, the challenges presented by nurses who manage the emergency care reinforced the need for being a creative, critical, and reflective profes- sional to suggest actions related to the organization and structuring of the unit and of the healthcare system for emergency care. The need for advance- ments in the organization of the healthcare system is undisputed, so that attention to urgent care can be performed in other ports of entry. However, the system will only be improved from the moment each service and health worker recognizes and as- sumes its share of co-responsibility in the pursuit of changes pointing to better resolution of the health needs of the population.

More studies are needed that focus on the par- ticipation and integration of hospital emergency services in an urgent care network, exploring the in- terfaces established with fixed and mobile pre-hos- pital service components with emergencies, and identifying those aspects that require improvement and discussion.

Conclusion

The main challenges that nurses were found to face in the management of care in a emergency hospi- tal service were the management of overcrowding, maintaining the quality of care, and use of leader- ship as a management tool. As suggestions for over- coming these, nurses indicated the need for health- care system reorganization to focus on emergencies, changes in the flow of patient care, expansion of the physical structure of the unit, and conducting training on nursing management.

Acknowledgements

Coordenaçâo de Aperfeiço amento de Pessoal de Nível Superior (CAPES) for the Master's education grant, to the Conselho Nacional de Desenvolvi- mento Científico e Tecnológico (CNPq; process # 478895/2008-9) for the productivity in research grant.

Collaborations

Santos JLG; Lima MADS; Pestana AL; Garlet ER and Erdmann AL declare that they contributed to the conception and design, analysis and interpreta- tion of data, drafting the article, critically reviewing it for intellectual content, and final approval of the version to be published.

References

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