Analysis of the process of implementing the patient care service with COVID-19
Odilon Adolfo White1, Claudia Mara Melo Tavares1
1 Federal Fluminense University
Abstract
The COVID-19 pandemic has demanded enormous effort from hospital managers, challenging them to act and think about care flows in a timely manner while adopting safe care strategies. Objective: To analyze the planning and implementation process of a patient care service with COVID-19 in a university hospital, through the experience of daily management. Method: This is a systematic experience report on the care implementation and treatment flow process in a university hospital of people affected by COVID-19. The experience was recorded in a field diary, and the narratives were submitted to content analysis. Results: the analysis of the narratives lead to the organization of data in the following categories: need for professional safety, training, empathy and participatory management. Conclusion: It is important to use work processes and Continuing Health Education as tools for guiding care to COVID-19 patients. Clinical reasoning, interdisciplinary work and decision-making in a participatory manner allowed the proper care implementation, despite the team's fear of the challenges caused by the pandemic.
Keywords: Pandemic; Professional Practice Management; Permanent Education.
INTRODUCTION
The COVID-19 pandemic is a challenge to health services, requiring high complexity care, new work models and permanent education processes for health personnel.
At the present moment, it is important to understand the reality that health professionals are experiencing, due to the demands for comprehensive and multidisciplinary care to people affected by COVID-19. Professionals are invited to reflect on the limitations and complexity of the provision of care, placing them before two phenomena already experienced historically in the health area – the fear of death and infection. Facing a pandemic of great proportion requires comprehensive health policies, in addition to a robust hospital structure and an integrated Public Health network, which enable quick and adequate decision-making for the control and spread of the virus (1).
COVID-19 infection can result in serious illness, including intensive care unit hospitalization and death. According to a report dated 21/08/2020, in the State of Rio de Janeiro, there were 207,036 confirmed cases, and 15,202 deaths. In Brazil, there are already 3,532,330 cases, with 113,358 deaths due to COVID-19, with a 53.9% mortality rate (2).
The COVID-19 pandemic has resulted in an unprecedented demand for health services, especially in the high complexity hospital network for critical care. There is emphasis on nursing and physiotherapy care, which requires enormous effort from hospital managers, challenging them to act in the face of the application of scientific principles involving professional mobilization, administrative, social and emotional competence, through the reorganization flows/processes and conducts of care, description and attainment of materials, safety measures, training, agreement and emotional work with the multidisciplinary team.
It is necessary to highlight that in this new emergency care context, nursing workers will be exposed to the risk of infection due to prolonged and frequent exposure to potentially contaminated patients, and more intense workdays and complex work tasks (1).
With the beginning of this pandemic, one of the main concerns presented by professionals is related to how care should be performed to patients who are suspected or confirmed to have contracted the disease. This first contact still generates doubts and apprehensions, mainly due to the recurrent changes in the care flow (3).
The pandemic causes an extra challenge to the mental health of doctors, nurses and nursing technicians. Under greater pressure, these professionals tend to neglect their own mental health in the tireless and constant fight against COVID-19, which may lead to the emergence of stress and anxiety related disorders(3).
In this context, the work of the nursing manager becomes even more challenging, it is their responsibility to ensure quality patient care, but also to ensure conditions so that the whole team can work safely.
Given the numerous challenges posed by the pandemic scenario experienced today, considering the global emergence of the theme and the role of the manager, the present study seeks to answer the following question: What aspects related to management are involved in the process of implementing care to people affected by COVID-19 in a university hospital?
Thus, the aim of this study is to report the daily experience of hospital care management, during the period of planning and implementation of actions for the care of people affected by COVID-19 in a university hospital.
METHODOLOGY
This is an analysis of the experience regarding the care implementation process for people affected by COVID-19 in a university hospital. Based on the systematization of the experience, narratives were constructed based on what was experienced by a nursing manager regarding the need to review processes and protocols to serve this clientele, aimed at necessary adaptations to ensure care to suspected or confirmed users and their complications, as well as safety for health professionals involved in the direct and indirect care process.
The Systematization of Experience is a qualitative research modality, oriented to the production of meanings, through critical and self-critical analysis, to record achievements , failures, difficulties and possibilities of improvement in a reasoned way (4). It aids in the construction and explanation of the knowledge produced in a given experience by one or different subjects, through the analysis and valorization of actions (5).
The study scenario was a university hospital, located in the city of Niterói, State of Rio de Janeiro. This hospital is part of the referenced program for the treatment of diseases previously classified as medium and high complexity, as well as, in principle, a reference for the treatment of people affected by COVID-19.
The narratives were made through daily reports about what had been experienced in the routines and decisions made by the manager and were sent by instant messages, via the WhatsApp application, to the author's advisor, during the first two weeks of the COVID-19 Pandemic in Brazil and later categorized.
Based on the categorizations identified through the analyzed reports, the steps proposed by the content analysis technique were followed for the development of the research: pre-analysis, exploration of the material, treatment of results, inference and interpretation(6). The initial ideas presented by the theoretical framework were systematized and indicators were established for the interpretation of the information collected. An overall reading of the chosen material was carried out for the analysis, floating reading, choice of documents (definition of the corpus analysis; hypotheses formulation and objectives from the initial reading of the data; formulation of indicators in order to interpret the collected material).
The absence of submission of the project to the Research Ethics Committee for the issuance of a Consolidated Opinion was not necessary because it was a self-report experience, thus an unnecessary step.
RESULTS
Need for Professional Safety
Nursing as a profession involves different types of risks - chemical, biological, physical and emotional, dealing every day with situations that involve threats to their existential condition and that of their families. The working conditions and salary of nurses and the nursing team are chronically unsatisfactory and although there is an idealistic and romanticized notion about the profession, it is a professional category that is socially undervalued. This contextual and macro-structural starting point caused a lot of insecurity in the beginning of the work with patients affected by COVID-19.
Every day a new moment, but with very similar situations... with each information about a professional who comes to me and reports that he has flu-like symptoms, I see in their eyes the concern that he has been contaminated by COVID -19.
The number of COVID-19 cases is increasing and people close to us already have disease-related complications. We keep asking ourselves, who's next. Professionals are increasingly afraid of becoming infected.
It was observed that despite the professionals´ insecurity caused by the severity of the pandemic, when they perceive that the manager is concerned about their safety, they tend to work practice greater self-confidence and tranquility.
I follow it closely, the work dynamics of the nursing professionals and the CCIH who are performing the scheduled collection of the SWAB of the upper airways of symptomatic professionals, through the drive-thru system and I observe them, with regard to the guidelines for the importance of maintaining social isolation, until the results come out. I see the worry on the faces of the professionals being tested and I put myself next to them.
The permanent education sector of the hospital was in high demand during this period, with an emphases on the knowledge required for staff and patient safety.
The main demands were training related to the proper use of PPE, because all of them are very anxious about providing nursing care due to COVID-19, and the Permanent Education and Hospital Infection departments are in high demand.
The Permanent Education Nurse, the medical and nursing CCIH team and the Epidemiological Surveillance team are responsible for this training, always helping nurse coordinators regarding safety actions.
It is not possible to do a job of this magnitude, focused on only a single professional category, all workers of the hospital institution need to be considered for the training and continuing education processes.
Together with Permanent Education, internal actions were activated to promote training, considering the profile and possibilities of patients and their investigative/diagnostic needs for COVID-19, among them, hand hygiene before and after procedures, attire and unattire, SWAB collection technique - which will diagnose the patient or professional.
Empathy as an instrument for the humanization of management
Empathy is a fundamental condition which leads teams in times of crisis, in a humanistic perspective. The use of empathy helps the manager to understand the behavior of their team, make more assertive decisions, and consider the objective and subjective dimensions that influence professional practice.
I notice that the ICU team is very dissatisfied with the structural work conditions regarding the care of patients affected by COVID-19. I will take the demands of the team to the CCIH, request the presence of the doctor and nurse for possible clarification, in order to minimize doubts and improve the work process in the ICU.
I stand in front of the group, listen, analyze and ask for prudence in the face of the situation we are experiencing at the moment. I commit to answering questions and I advise on the strategy of internal records so that we have better inputs and can increase the safety of our professionals. I tell them that I am there to cooperate in whatever it takes and they reinforce the issue of lack of communication.
When the nursing team is included in the work process in an empathic way, using institutional protocols appropriately, it results in a safer professional practice, bringing less risk to its health and the patient."
I start the day with the information that one of our emergency department nursing technicians tested positive for COVID-19 and that he would be under observation at HUAP due to complications arising from the disease. Even though it is a public holiday, I go to monitor the progress, give support, make myself available and observe how the team feels regarding the team member. I found very balanced, focused health teams and support staff on duty conducting the work process well and quickly. The employee was included in the complete protocol (Respiratory isolation, blood collection, chest computed tomography (CT) and admission to the DIP).
This is not only perceived in the practice of patient care, but also in management. The fact that the manager, attending the various services managed by him and allowing him to actively listen to the possible weaknesses in the construction of flows, protocols and routes, calls him to reflect and allows the exchange of experiences, enabling confidence and the feeling of interest so that the process becomes increasingly appropriate, minimizing damage to frontline workers, as well as for users, in addition to the possibility of viewing the fronts that this manager needs to adopt in order to produce structural or protocol improvements.
I visited the critical care departments (emergency and ICU), to learn about the demands and difficulties that may arise, because we are in the developmental phase of a very dynamic work process and sometimes doubts arise.
Being present and making a commitment to closely monitor the work process of the health team, causes managers to expose themselves to the risks of COVID-19 infection, but these are conditions inherent to their work.
The emotional overload is difficult for everyone, but for me also, I'm no different. I realize that I need to show confidence, I need to be calm and control of the situation and after all, I need to support, listen ... but I am tired and concerned about our evolution, about what is still to come, based on the projection of the peak of COVID-19.
Visualizing the hospital macro is important in this process, so that it can be followed up in all sectors of the hospital universe, without distinction, in a unified way, aiming at conducts directed and referenced by institutional determinations and also with the proactive and effective participation of patients, who must show their interests, their needs and be respected, within a minimally adequate logic for a hospital environment.
Being a participant represents a power of speech, a space, an achievement. The voice cannot be prevented, because in it, they may contain essential elements for change or remanagement of actions that we do not know about. For me to act, I need to know how to do, for me to do, I need to know and for me to know, I need to participate.
I expose the team to the need, the intention and the importance of developing shared management close to the frontline, where the most diverse opinions will be considered, valued and discussed, thus resulting in consolidated strategies, but not in stone. Depending on the position I hold, I need to make quick decisions alone, because the whole process is very dynamic. However, I will try my best to share thoughts and ideas without affecting the institutional mission, that are guided by ethical principles.
A shared, participatory management process promotes integration and greater participation from professionals, it makes them feel part of and co-authors of the action. The participation of the team of workers who make up the health care unit enables process improvement, professional valorization, active listening and recognition of rights.
Today was light, at least for my management, although we received information regarding the very high infection of COVID-19, above average, of the patient who is hospitalized in the ICU ...the nursing professionals were more present in terms of precaution and aware of the importance of following the protocols and CCIH guidelines.
I perceive an ethical and social commitment on the part of many professionals, who even living in distant municipalities, even over 60 years of age, associated with comorbidities are present for their work activities and are making themselves available to collaborate, because they recognize their current importance in the face of the situation we are going through.
DISCUSSION
Institutions are not prepared to contextualize health problems, considering their complexity. They follow the norms, protocols and routines, often without the needs of the person being considered. And then, when we come across an unexpected situation, which is out of our control and that even seems insignificant such as a virus, we are perplexed, reflective, analyzing the interdependence that we have in an institution and the existing micro-powers and its ability to generate power/impotence in our daily way of acting.
Emergency departments are environments where health professionals are constantly exposed to risks, both physical and psychological, because it is a service in which care is permeated by pressure, and a place whose workers routinely deal with patients at imminent risk of death (7) .
It is important to highlight that the conception about the occupational risks that permeates nursing work is fundamental to understand the relationship between the health-disease process of the worker and, from this, to develop measures that seek to improve working conditions, thus aiming to promote health and prevent injuries, as well as the control and reduction/elimination of risks and health problems of nursing staff(8).
It is important to mention that the services must ensure adequate working conditions, and provide alternative professionals capable of multidisciplinary health work, even in risk contexts. A proper institutional climate promotes good work team relations. Social recognition is also a fundamental issue and can be demonstrated by adequate salary.
In the context of the COVID19 epidemic, permanent health education emerges with great strength and need, and should be mediated by an action plan which is well adjusted to the needs of the moment, contemplating the technical aspects, but also the emotional and relational aspects, present in daily work in this moment of pandemic.
Nurses can provide different ways of knowing and doing by performing care and education practices in a more refined model to the needs and context of PHE actions (10).
PHE has become a possibility for nurses to improve professional skills, qualifying their actions in the face of the complexity involved in their work (11).
However, PHS requires teamwork. It is necessary to think about the psychosocial dimensions of care, which can be identified and considered by the nursing team and developed in an integrated way with physiotherapy, psychology and social work services. It would be very important and necessary to integrate community members as volunteers, emotional and social supporters.
In this context, empathy is the ability to understand the needs, feelings and problems of others, putting oneself in the other´s place and responding satisfactorily to their emotional reactions. The applicability of tools that allow the production of relationships involved in the professional-user encounter through the practice of active listening, the demonstration of interest, the construction of bonds of trust, are the tools that make it possible to capture the singularities of users, enhancing this relationship. Empathy is a process by which an individual can see beyond external behavior and correctly perceive the inner experience of another person (12).
This is not only in the practice of patient care this is perceived, but also in management. The fact that the manager comes to the various services managed by him and allows him to actively listen to possible weaknesses regarding the flow constructions, protocols and routes, calls him to reflect and enables the exchange of experiences, permitting confidence and the feeling of interest so that the process becomes even more adequate, minimizing harm to workers at the top, the front, as well as to users, in addition to the possibility of visualizing the fronts that this manager needs to adopt to produce improvements, whether structural or related to protocol.
Empathy can be incorporated as an instrument capable of improving the interaction between the manager, professionals and users, contributing to the effectiveness, efficiency and satisfaction in health production. The leader needs to be able to feel and understand the views of all the members who make up the team. Using empathy as a management tool means taking into account the feelings of employees, together with other factors, in the process of making intelligent decisions and making the work environment a place with healthy and productive people (13).
Seeing the hospital macro is important in the face of this process, so that it can be followed up in all sectors of the hospital universe, without distinction, in a unified way, aiming at conducts directed and referenced by institutional determinations and also with the proactive and effective participation of patients, who must expose their interests, their needs and be respected, within a minimally adequate logic for a hospital environment.
The nursing manager must gather personal qualities and adequate work tools, act democratically, be able to stimulate communication and value the team's knowledge, act with a sense of fairness to demand greater results (14).
Participatory management, linked to the care model, forms spaces for listening, exchanging information, planning, decisions, commitments and co-responsibility for work processes and their results. In these spaces, desires, affections, interests and powers are expressed, capable of producing more autonomous subjects and more committed to collective interests(15).
The integrated work of the PHE Team and the Hospital Infection Control Commission was fundamental for care effectiveness, because together they nurtured and strengthened, through professional training, the work process in the front line to treat people affected by COVID-19.
Being present and making a commitment to closely monitor the work process of the health team, causes managers to expose themselves to the risks of contamination by COVID-19, but these are conditions inherent to their work.
CONCLUSION
Based on the study conducted we conclude that the process of planning and implementation of a patient care service exposed to COVID -19 requires meticulous multidisciplinary work, review of care protocols - integrating different professional actors - from team safety, linked work between hospital infection committees, permanent education, management, among others.
It can be concluded that the management mode adopted and described in this study provided humanized and empathic health care, with greater safety for nursing workers and the client, expanding the participation of the multidisciplinary health team, promoting greater interaction.
The COVID-19 pandemic imposed reviews of processes, protocols and routes established in the university hospital, causing the nurse manager, together with the team of managers, to understand the fragility to which the nursing service was exposed, and then to review, create and recreate guidelines for an effective, identifiable and applicable work process.
To increase the safety of the health team who provides care to people affected by COVID-19, it was important to use the Nursing Work Process as a tool for orienting care. Clinical reasoning and diagnostic decision-making, promoted satisfactory results and interventions, leading to improved teamwork. The integrated work of the Permanent Health Education Team and the Hospital Infection Control Commission was fundamental for us to achieve the effective care, strengthen the training process of frontline professionals and the imperative actions in relation to the COVID-19 pandemic.
This study contributes to the review of nursing practice, emphasizing the value of multidisciplinary teamwork and the use of empathy in the management process. The importance of continuing education in service and the description of training stages and preparation of protocols is evidenced, aiming at the safe work of the team and nursing education. The strategy implemented in this study to obtain data and describe results through everyday narratives, can contribute to the development of new nursing research, where the urgency of innovation for decision making is necessary.
REFERENCE
1. Gallasch CH, Cunha ML, Pereira LAS, Silva-Junior JS. Prevenção relacionada à exposição ocupacional: COVID-19. Rev Enferm UERJ [Internet]. 2020 [cited 2020 jul. 24];28: (e49596). Available from: https://www.e-publicacoes.uerj.br/index.php/enfermagemuerj/article/view/49596/33146 doi: 10.12957/reuerj.2020.49596
2. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Boletim Epidemiológico (11). Doença pelo Coronavírus 2019 (COVID 19). COE-COVID19 [Internet]. 2020 abr. [cited 2020 jul 24]. Available from: https://www.saude.gov.br/images/pdf/2020/April/17/COVID---ATUALIZACAO-DE-VIGILANCIA-EPIDEMIOLOGICA.pdf
3. Rodrigues NH, Silva LGA. Gestão da pandemia Coronavírus em um hospital: relato de experiência profissional. J Nurs Health [Internet]. 2020 [cited 2020 jul 24];10(n.esp.)e20104004: 1-9. Available from: https://periodicos.ufpel.edu.br/ojs2/index.php/enfermagem/article/view/18530
doi: HTTPS://DOI.ORG/10.15210/JONAH.V10I4.18530
4. Upegui AAS. El artículo sistematización de experiencias: construcción de sentido desde una perspectiva crítica. Rev Virtual Univ Católica Norte.[Internet] 2010 [cited 2020 abr 18];29: 1-7. Available from: http://www.redalyc.org/articulo.oa?id=194214466001
5. Souza JF. Sistematización: un instrumento pedagógico en los proyectos de desarrollo sustentable. Rev Inter Magisterio. Educación y Pedagogía [Internet]. 2008 [cited 2020 abr 03]; 23: 9-13. Available from: http://centroderecursos.alboan.org/ebooks/0000/0713/6_SOU_SIS.pdf
6. Bardin L. Análise de conteúdo. São Paulo: Edições 70; 2011.
7. Angelim RCM, Rocha GSA. Produção científica acerca das condições de trabalho da enfermagem em serviços de urgência e emergência. J res: fundam care [Internet]. 2016 [cited 2020 abr 26]; 8:3845-3859. Available from: http://www.seer.unirio.br/index.php/cuidadofundamental/article/download/4473/pdf_1800 doi: 10.9789/2175-5361.2016.v8i1.3845-3859
8. Souza NVDO, Pires AS, Gonçalves FGA, Cunha LS, Shoji S, Ribeiro LV, Tavares KFA. Riscos ocupacionais relacionados ao trabalho de enfermagem em uma unidade ambulatorial especializada. Rev Enferm UERJ [Internet]. 2012 [cited 2020 abr 30]; 20(esp.1):609-14. Available from:https://www.e-publicacoes.uerj.br/index.php/enfermagemuerj/article/view/5873
9. Mendes ACG, Araújo Junior JLAC, Furtado BMASM, Duarte PO,Silva ALA, Miranda GMD. Condições e motivações para o trabalho de enfermeiros e médicos em serviços de emergência de alta complexidade. Rev Bras Enferm [Internet]. 2013 [cited 2020 abr 30]; 66(2): 161-66. Available from: http://www.scielo.br/pdf/reben/v66n2/02.pdf doi: http://dx.doi.org/10.1590/S0034-71672013000200002
10. Flores GE, Oliveira DLL, Zocche DAA. Educação permanente no contexto hospitalar: a experiência que ressignifica o cuidado em enfermagem. Trab Educ Saúde [Internet]. 2016 [cited 2020 maio 18];14(2):487-504. Available from: https://www.scielo.br/scielo.php?script=sci_arttext&pid=S1981-77462016000200487
doi: https://doi.org/10.1590/1981-7746-sip00118
11. Paim CC, Ilha S, Backes DS. Educação permanente em saúde em unidade de terapia intensiva: percepção de enfermeiros. Rev Pesqui Cuid Fundam [Internet]. 2015 [cited 2020 maio 14]; 7(1): 2001-2010. Available from: http://www.seer.unirio.br/index.php/cuidadofundamental/article/view/3586/pdf_1443 doi:10.9789/2175-5361.2015.v7i1.2001-2010
12. Waidman MA, Stefanelli MC, Jouclas VMG. O caminhar com a teoria de Joice Travelbee na prática de enfermagem psiquiátrica – desvelando uma experiência. Cogitare Enferm [Internet]. 1998 [cited 2020 maio 02]; 3, 1, 7-12. Available from: https://revistas.ufpr.br/cogitare/article/view/44245 doi: http://dx.doi.org/10.5380/ce.v3i1.44245
13. Coelho AS. A empatia como instrumento de gestão. Intervozes: trabalho, saúde, cultura [Internet] 2018 [cited 2020 maio 02]; 3(2): 20-40. Available from: https://www.fmpfase.edu.br/Intervozes/Content/pdf/Artigo/03_02/ARTIGOAempatia.pdf
14. Lanzoni GMM, Magalhães ALP, Costa VT, Erdmann AL, Andrade SR, Meirelles BHS. Tornando-se gerente de enfermagem na imbricada e complexa fronteira das dimensões assistencial e gerencial. Rev Eletr Enf [Internet]. 2015 [cited 2020 maio 02]; 17(2): 322-232. Available from: http://dx.doi.org/10.5216/ree.v17i2.29570 doi: https://doi.org/10.5216/ree.v17i2.29570
15. Deus AD, Melo EM. Avaliação de uma experiência de gestão hospitalar participativa no âmbito do SUS: produção de saúde, sujeitos e coletivos. Saúde debate [Internet]. 2015 [cited 2020 maio 17] 39(106):601-615. Available from: https://doi.org/10.1590/0103-110420151060003003
Received: 07/12/2020
Revised: 07/22/2020
Approved: 08/22/2020