ORIGINAL ARTICLES

The nurse technician in nursing care systematization: a phenomenological research

Pétala Tuani Candido de Oliveira Salvador¹, Kisna Yasmin Andrade Alves¹, Cláudia Cristiane Filgueira Martins Rodrigues¹, Yole Matias Silveira de Assis¹, Viviane Euzébia Pereira Santos¹

¹Federal University of Rio Grande do Norte

ABSTRACT
Aim: To understand the ideals of nursing students about the participation of the technician in the Systematization of Nursing Care (SNC), based on the theoretical framework by Alfred Schutz.
Method: This is a research using the comprehensive phenomenological method of Alfred Schutz.
Results: Data was collected by focus group with eight academic nursing students from a public university in Rio Grande do Norte.
Discussion: the analysis of the speeches allowed to reveal the typical ideals of participants from two perspectives - the reasons for and reasons-because the nursing technicians should attend the SNC.
Conclusion: the typical ideal is drawn delineating the investigated action - the nursing technician should participate in the SNC - along with their reasons-for and their reasons-because; also elucidating the typical nursing student puppet who believes in consolidation of SNC through teamwork.
Descritpors: Paciente Care Planning; Nursing Process; Students, Nursing.

INTRODUCTION

The Systematization of Nursing Care (SNC) is currently recognized as an essential tool for the consolidation of nursing as a profession of solid scientific basis. In other words, it seizes, increasingly, the absence of SNC leads to the execution of a merely do it means that without the systematization the nursing care turns out to be like a mere protocol without knowing why they are doing, compromising the quality of care and devaluing the craft⁽¹⁾.

To justify this assertion, literature highlights numerous benefits provided by a systematic nursing: valuing care as the essence of the profession, changing the way of thinking in pursuit of care quality^(1.2-3); the ability to raise the excellence of care quality, individualizing the care⁽⁴⁾; always looking for improvement, to develop the knowledge, and favoring an effective and efficient practice, which gives credibility to the work⁽⁵⁾.

In contrast to the recognition of such benefits both the current state of the art as the biographical situation of embossed study's authors understand that the SNC still faces multiple challenges (professional unpreparedness, poor labor resources, work overload), and one of the foundations to overcome these obstacles, admittedly, it is the solidification of teamwork.

This is stated from the fact that nursing is a profession composed of heterogeneous classes that should foster a unifying working process, with the common scope to meet / assist the user in a resolute and qualified way. In this context, it is emphatic that the SNC " ] will only be an effective practice if it is discussed and defended by its own professional category"^(6:406), ie, if result from a joint process including all nursing professionals.

It is in this perspective that highlights the essential role of nursing technicians (NT) in the SNC effective panorama. This, according to Decree No. 94,406/87, which regulates Law No. 7,498 of June 25, 1986 - the Law of Professional Practice of Nursing - is a professional component of nursing staff, with the prerequisites for exercising their profession, to hold a NT diploma or certificate, issued in accordance with the rules and be registered with the competent body⁽⁷⁾.

The nursing technician performs auxiliary activities, technical secondary level, assigned to the nursing staff, and under Article 10 of this Decree, shall assist the nurse in planning, programming, guidance and in the supervision of nursing care activities; in providing direct nursing care to patients in a serious condition;  and in the prevention and control of communicable diseases in epidemiological surveillance programs; prevention and systematic control of hospital infections and prevention and systematic control of physical damage that may be caused to patients during health care; perform service activities, except those specific to nurses; and integrate the health team⁽⁷⁾.

The nursing technician is, therefore, a unique component of the team, who must legally help nurses in their care activities and planning.

In addition to their qualitative relevance to the profession, and the enhancement of their quantitative representation: the NT represents the class with the largest number of professionals in the field of nursing on a national level. According to the Federal Council of Nursing (COFEN), 2011, there were 750,205 NTs in Brazil, a value corresponding to 40,41% of all professionals in the field⁽⁸⁾.

Contradicting this NT relevance scenario concerning the healthcare practices of the profession, and therefore the solidification of SNC, there are references in literature, which conclude that the participation of nursing technicians in the SNC requires clarification. There are questions and doubts about the skills needed to participate in the SNC and about the possible contributions of NTs in the different phases of the nursing process, which may result from various factors (lack of knowledge, poor training process, the category underestimation) that require research.

Thus, in view of the need to better understand how the different actors within the nursing profession allow for the participation of the NT in SNC, and taking into consideration the fact that the training process plays an important role in forming the thoughts and ideas of future professionals, the following survey question was asked: how do nursing students typify the participation of NTs in the SNC?

The purpose is to understand the typical ideal of nursing students about the participation of NTs in the SNC, within Alfred Schutz’s theoretical framework.

METHOD

This is an excerpt of the results obtained from the  ambiance with the field and the master's thesis study tool entitled "Typical understanding of the ideal of nursing technicians about the systematization of nursing care", held in August 2013 by the Nursing Postgraduate Program at the Federal University of Rio Grande do Norte (UFRN).

The study is an investigation using the phenomenological method of understanding by Alfred Schutz, which is based on the cognitive reality incorporated into the subjective process of human experiences.

Adopting Schutz’s method means weaving an investigation that revolves around the social actor, under which he/she relates to others, and of action projects that they formulate, that can only be understood by the motivations of the subjects^(9-11).

This research is based on three basic concepts of social phenomenology of Schutz: the reasons-for; the reasons-because; and typification. The understanding of these pillars resulted in the investigated action: NTs should participate in the SNC.

In this context, on the premise that it is necessary to understand the perceptions of subjects from their own meanings, so that they can interpret their behavior, Schutz developed the concepts of reasons-for and reasons-because. These are members of the so-called motivational contexts: “[...] contexto motivacional es, por definición, el contexto de significado dentro del cual se encuentra una determinada acción en virtud de su status como proyecto o acto de un determinado actor”^(9:116-117).

While the reasons-for are essentially subjective, which include the targets to be achieved and having a dedicated time-frame for the future, the reasons-because are more objective. They are shown in the events already completed, having a dedicated temporal direction in the past, and can be understood in retrospect^(9-10).

For the investigator, to understand the motivations of the subjects, Schutz teaches that it is necessary to seize the typical ideal "regarding the investigation of the reality of everyday life, what will enable the understanding of a social phenomenon by the researcher is the systematization of its typical traits"^(11:43).

The ideal-typical concept of Schutz is intrinsically related to what he calls the world of contemporary: one in which the other “[…] coexiste conmigo y es simultáneo con mi duración. No obstante, aun viviendo con él, no vivo a través de él como cuestión de experiencia directa”^(9:172).

The contemporary is thus someone who is known to coexist in the world but not experiencing immediately, so that the knowledge we have of the contemporary is inferential and discursive, ie, it starts from the construction of "ideal types" or "typification".

For this, we used the focus group, which is a quick, low-cost technique for evaluation and data collection and qualitative information. It allows to identify feelings, attitudes and ideas of the participants about a particular subject or activity⁽¹²⁾.

The focus group entitled "What I think about the SNC" took place in September 2012 at the Nursing Department of the UFRN. As inclusion criteria, participants had to have a scholarship of scientific initiation and be enrolled from the first semester of the third year of nursing. Twelve students were invited via e-mail, eight of whom attended the meeting. All were female.

In order to understand some of the academic biographical situations, was applied at the beginning of the meeting, a questionnaire composed of closed questions and divided into two areas: socio-demographic and academic data.

The study follows the ethical and legal principles governing scientific research in humans, recommended in Resolution No. 196/96 of the National Health Council, updated by Resolution No. 466/2012, preserving the voluntary nature of the participants and the anonymity of the parties and was approved by the Embodied Opinion of the Ethics Committee in Research of UFRN, No. 98.424 of 31 August 2012, CAAE No 05906912.0.0000.5537.

With the agreement of the participants, the focus group was recorded and photographed, with the cooperation of a reporter, who wrote down what could not be captured by the recordings (facial and body expressions, among others), and another collaborator responsible for the photographic record and support.

The transcription was performed by the researcher, after hearing the recordings repeatedly, and had as main support the records made by the rapporteur of the group. We used Microsoft Word 2010 to carry out the transcript of the meeting, and Microsoft Excel 2010 to synthesize the results via a spreadsheet.

The texts were grouped by subject; each identified by letters AE (Academic Nursing), followed by a sequence number from one to eight (AE1, AE2, so on, until AE8).

So we proceeded with the organization of the transcripts from multiple readings, which enabled, from the Alfred Schutz framework, unveil the typical ideal of academic nursing students about the participation of NTs in the SNC, elucidating the reasons-for and reasons-because of the investigated action - if the NT should participate in the SNC - revealed from the analysis of participants' speech.

RESULTS

The meeting lasted 125 minutes, with the collaboration of eight academic nursing students, from 19-24 years old. They attended either the first semester of the third year (3; 37%), the second semester of the third year (2; 26%) or the first semester of the fourth year (3, 37%).

The academic age profile differed from other studies that also investigated nursing students in similar course periods, in what appeared to be predominantly 21-32 year olds⁽¹³⁾ and 17-30 year olds⁽¹⁴⁾. These surveys also included the participation of male students. These studies, however, had a larger sample, which could explain the diversity found.

When asked about their first contact with the SNC in their academic training, the participants unanimously answered that it occurred in the 2nd semester of the second year of the course, via the discipline of Semiology and Semiotechnique of Nursing. This shows that this subject promotes the articulation of theoretical and practical aspects of the profession, teaching nursing techniques allied to knowledge about the SNC.

After the evidence of the biographical situation of the study participants, followed up with research via the focus group, with the guiding question: "How do you visualize the participation of the NT in the SNC?".

In seeking the interpretation of the typical ideal of academic nursing students regarding the participation of NTs in the SNC, recognized the importance of understanding the experience of these individuals and their motivations, which enabled the understanding of the phenomenon investigated and contributed to the elucidation of important mechanisms that translate into opportunities for practical improvements for the nursing profession.

DISCUSSION
 
The analysis of the academic speeches allowed, thus, for an understanding of the typical ideal of academic nursing students about participation of NTs in the SNC. This was outlined in the action highlighted in the speech of subject: NTs should participate in the SNC. Below are elucidated the reasons-for and the reasons-because such action is defended. Finally, it describes the typical doll of this academic students, who advocate a SNC incorporating the NT for its effectiveness.

Reasons-for NT participate in the SNC
Academic nursing students believe that the NT is a key element for the SNC to be effective, being an actor of fundamental importance to the success of care.

They visualize this aspect from the finding that the SNC requires cohesive care by everyone involved, not working as a "theoretical recipe" that planning and execution are independent and fragmented stages, but as a continuous process of care, whereby planning, implementation and evaluation are interdependent factors that interact daily:

]sometimes only the technician who listens to what the patient says, some very important information that he does not tell the nurse about. In this case, it may be important to change completely, it may be crucial to fully change their care plan for that patient. (AE1)

The vision of the students agree with the perception of a study conducted in Mato Grosso do Sul, which concluded positively with the participation of assistants and technicians in the SNC alongside nurses, emphasizing the importance of team integration in care planning, as a motivating factor of quality care⁽¹⁵⁾.

In this context, the interviewees believe that the NT plays a fundamental part in almost all stages of the nursing process: determinants for a proper history, NTs are the closest actors of patients; their perceptions and proximity to the patient should be seen as important in choosing the best diagnosis by nurses (who must recognize the auxiliary role of NTs in planning their assistance), since they are in daily contact with patients and therefore can identify relevant information about care. They are the main protagonists in implementing nursing care, and because they are essential elements to the process, they should be heard and participate effectively in the nursing assessment.

Therefore, only the formulation of diagnosis and planning is seen as a private activity of nurses, but that has it’s planning and implementation influenced and, sometimes, determined by integration of the NT in the SNC.

This understanding is consistent with the rules of COFEN (Resolution No. 358, 2009): the nurse has the responsibility of leadership in the implementation and evaluation of the nursing process, and privately, is responsible for the diagnosis and the prescription of actions or interventions to be carried out⁽¹⁶⁾.

Visualizes thus that the students typify the participation of the NT in SNC more embracing and reflective when compared to a study in 2012, which states that in the operationalization of the SNC, the nursing staff can assist nurses in the collection of data and the implementation of care established by it⁽¹⁷⁾.

It is emphasized that this last vision, overtaken by academic nursing components of this study, translates into a significant gap of understanding that needs to be overcome. The NT's role should not be restricted to that of a mere executor of the prescription given by nurses, neglecting the assignment legally supported of participation in the planning, programming, counseling and supervising the assistance activities.

In other words, it is understood that the consolidation of a systematic, humanistic and qualified practice requires understanding that it is the result of teamwork, where the components act in unison so that the SNC becomes effective in search of better nursing care.

Reasons-because the NT participates in the SNC
The reason-because that leads academics to believe in and advocate for the participation of NTs is their education. They advocate that a SNC will only be effective when it is the result of teamwork.

It is worth highlighting that the reflections of the participants were enriched by a collective realization: actions by them were defended - that the NT should participate in the SNC - is not being experienced by the current nursing process.

The participants understand that such a limitation is the result of a complex process that involves, interdependently, the dichotomy between thinking and doing, characteristic, respectively, of the nurse's work and the NT’s.; the NT's ignorance about the SNC; the disinterest of the NT; underestimation of their role and the existence of conflicts in the nursing team.

In reflecting on the ever-present gap regarding the participation of NTs in the SNC, it is evident that there is still a cartesian dissociation of the care process, which reflects the historical path of the professional legalization of nursing, as, since it was institutionalized as a profession in the mid-nineteenth century, it has been characterized by dividing the exercise through the consolidation of various forms of auxiliary work, fitting to the nurse teaching activities, supervision and administration and for the auxiliary most of the care activities⁽¹⁸⁾.

Worryingly, it is evident that there is still a dichotomy between top-level professional planning assistance and other technical level that perform the assistance, with or without communication between both levels. As a result of this fact, we are witnessing an alarming extent, the fact that it "is subtended that nurses in this context cannot gain the respect and trust required [...]”^(15:299).

It's just that they do, but do not know why they are doing. (AE1)

However, this lack of interest may come from the idea that they already have, that they are trained to do and not to think. So, I do not need to think because I'm just going to do. (AE3)

So, I think they do the technique by technique itself, even without knowing what they are doing. (E4).

They should be a nurse's partner and not just someone who cannot think, but can only do. (AE6).

Meanwhile, rescuing the TN as a key member of the SNC means, according to the conception by Schutz, affirming the profession as an action, in contrast to the reductionist view of conduct: “[...] lo distintivo entre acción y conducta es que la acción es la ejecución de un acto proyetado”^(9:90).

Overcoming single conduct means learning nursing not as spontaneous practice, free of planning and scientific. Seize it as action is reflected in the defense of a profession of solid scientific basis, an aspect that still needs to be solidified.

Therefore, according to the academic study, it is necessary to overcome a difficulty still experienced: the poor training of NTs regarding the SNC.

I think so: the technician is crucial for the success of SNC, only they do not have, I think they do not know what is SNC, because I, for example, did the technical course and I did not know that had it, did not know what, I did not know anything, that had all these areas prior to the nurse develop their activity, understand? (E4).

In fact, I think the technician is greatly underestimated since their training . If they are so important, it is an individual so important in SNC, so why not educate them from the training? (AE6).

It is understandable, therefore, that the recognition of the NT as an actor essential to the SNC is the first step from which it is understood that the nursing training at all levels should be based on the SNC founded on teamwork.

Typical Ideal of nursing academics about NTs participating in the SNC
Figure 1 summarizes the typical ideal spoken about in the speeches of the students, in what matches the action "the NT should participate in the SNC".

Figure 1 - Typical ideal of nursing academics about the action "the NT should participate in the SNC". Natal, 2013.

Source: own elaboration, 2015.

The typical action elucidated by the participants is that the NT should participate in the SNC: to contribute to the quality of patient history; help nurses in planning their care, by helping them in choosing the best nursing diagnoses; effectively implement the SNC; participate in the evaluation of the assistance provided and consolidate the real effectiveness of the SNC, that results from teamwork.

The academics believe in and advocate for the participation of NTs in the SNC because their education tells them that the SNC can only work as a result of teamwork. Their initial contact with the subject took place in the 2nd semester of the second year through subject Semiology and Semiotechnique of Nursing .

The typical nursing academic is therefore a critical and reflective subject, with a comprehensive and integral vision of the nursing working process. They believe that the SNC will only be effective when resulting from teamwork that integrates the NT, and recognizing that, many challenges are posed to that the advocated action be built, which are founded on the fragmentation of care and the poor training process of the NT with regard to the SNC.

CONCLUSION

The objective of this study has been achieved: to understand the typical ideal of nursing academics about the participation of NTs in the SNC. The student, a critical and reflective individual, argues that the NT should participate in the SNC,  because his training was defending such issues and believes that the action advocated is essential for the SNC,  really effective and qualified, which is guided in the care cohesion.

Alfred Schutz’s framework was essential to the enrichment of heavy discussions, including the investigation of the ideal types of subjects is a fundamental aspect when it is necessary to investigate a subjective and complex phenomenon - such as the actual effectiveness of the SNC - involving multiple actors that need to be heard and understood in its essence, that is to plot improvement paths for nursing.

It is also noteworthy that the woven reflections are influenced by the environment in which they were encouraged, especially by the formation process of the investigated participants, which constitute the limit of the study. It is imperative for a broader concern that the views of other individuals are studied in other environments and at other levels of education.

The study has as impact it's contribution to that cohesive care be continually sought and provided, recognizing the key role of all components of the nursing team, integrating thinking and doing as elements of a single care process and building a SNC resulting from a qualified teamwork.

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All authors participated in the phases of this publication in one or more of the following steps, in According to the recommendations of the International Committee of Medical Journal Editors (ICMJE, 2013): (a) substantial involvement in the planning or preparation of the manuscript or in the collection, analysis or interpretation of data; (b) preparation of the manuscript or conducting critical revision of intellectual content; (c) approval of the versión submitted of this manuscript. All authors declare for the appropriate purposes that the responsibilities related to all aspects of the manuscript submitted to OBJN are yours. They ensure that issues related to the accuracy or integrity of any part of the article were properly investigated and resolved. Therefore, they exempt the OBJN of any participation whatsoever in any imbroglios concerning the content under consideration. All authors declare that they have no conflict of interest of financial or personal nature concerning this manuscript which may influence the writing and/or interpretation of the findings. This statement has been digitally signed by all authors as recommended by the ICMJE, whose model is available in http://www.objnursing.uff.br/normas/DUDE_eng_13-06-2013.pdf

Received: 04/23/2015
Revised: 01/25/2016
Approved: 02/02/2016