- by Hewison, Alistair
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However, coordination and integration of administration and care, leadership, communication, interaction, decision-making and cooperation were identified as essential characteristics of nursing care management. The application of this concept in nursing care management is an emerging need for the development of an administration model related to care.
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Assuming that management and administration are synonyms and mean action, thinking and decision, they can be understood as the art of obtaining results that can be defined, predicted, analyzed and evaluated. Therefore, management and administration can be treated as scientific and rational fields, from which analyses and cause and effect relationships can be extracted.
At the same time, they are exposed to unpredictability and human interactions, which gives them an intuitive, emotional and spontaneous dimension. Health care management is defined as the provision of health technologies, taking into account the unique needs of people at different times in their lives, aiming at offering well-being, safety and autonomy.
It manifests in six dimensions: individual, family, professional, organizational, systemic and societarian. In nursing, care management is applied to the coordination of the management and service dimensions of the nursing work process. When nurses act in the management dimension, they develop actions directed toward work organization and human resources, whose goal is to enable proper conditions for the delivery of care to patients and nursing team performance.
by Hewison, Alistair
The target of the care dimension, in its turn, is the needs of health care, which must be met fully. Therefore, two complementary dimensions can be identified in the nursing work process: the management dimension, whose subjects are work organization and nursing human resources; and the care dimension, whose focus of intervention is the care needs of patients. However, when nurses carry out the management dimension, they often encounter dilemmas, doubts, conflicts, misunderstandings and contradictions, because they have to deal with administrative duties that are not well-coordinated with care actions.
This generates conflicts, frustration and dissatisfaction about professional identity, mainly as it relates to know-how about care, given that management actions usually focus on administrative and bureaucratic activities to meet institutional demands. A study focused on the theoretical elaboration of nursing care management in the hospital context corroborated this, supporting the idea that nurses have conceptual difficulties with nursing care management actions and revealing a dialectical relationship between management and care expertise.
This dialectic consists of an entanglement involving knowledge about management and care, through the existence of an interface separating these two objects in nursing practice, so that know-how has a technical and technological dimension, and involves personal and scientific knowledge, technical skills, and management and care competencies.
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Taking this into consideration, it is known that this problem is not an exclusive concern of the recent context of nursing practice. Other initiatives oriented to solving the conceptual and practical dichotomy of nursing care management have preceded the present study. Such research has presented important contributions regarding reflections on nursing care management as they foster new investigations.
However, inconsistencies persists between care management concepts and their application by nurses.
Thus, it is considered relevant to analyze the concept of nursing care management in the hospital context to broaden the discussion, strengthen the foundations of nursing science, and potentialize the applicability of the concept. To achieve that, the authors proposed to analyze the concept of nursing care management in the hospital context to make it clearer and contribute to this subject. Concept analysis is a method that requires a careful process of examination of the basic elements of a concept, helping point out similarities and differences by splitting the concept under discussion into simpler elements to make it easier to determine its internal structure.
Walker and Avant 8 simplified the concept analysis procedure suggested by Wilson, which consisted of 11 steps, by reducing it to eight. The new version consisted of the following stages: 1 selection of the concept; 2 determination of the purpose of the analysis; 3 identification of the uses of the concept; 4 determination of its attributes; 5 identification of a model case of the concept; 6 identification of contrary cases; 7 identification of antecedents and consequences; and 8 definition of empirical references.
Following the method, the authors chose to use the concept analysis framework by Walker and Avant, 8 by means of the stages: selection of the concept; determination of the purpose of the analysis; identification of the uses of the concept; determination of its attributes; identification of a model case of the concept; identification of antecedents and consequences and definition of empirical references. Since the construction of the concept of care management in the hospital context required the clarificarion of the phenomenon in question, the authors chose not to use the identification of contrary cases, which is employed to reinforce the decision on the definition of attributes.
After the choice of the method, an integrative review was carried out about nursing care management in the hospital setting. The selected texts were submitted to a second screening based on the following inclusion criteria: complete papers whose titles had the terms management or administration oriented to nursing care in the hospital context, available free of charge in the searched databases, in English, Portuguese or Spanish, published in the past five years.
This screening process was performed to make it easier to spot the studies related to the topic in the hospital context. Data extraction was performed by one researcher from December 27, to January 15, Database surveys were carried out by using one keyword and two descriptors: 1: care management, 2: nursing, and 3: hospital, respectively, in Portuguese, English and Spanish. In LILACS, 1, publications were selected by crossing the first and second items, by crossing the first and third items, and by crossing all the items.
Inclusion criteria were subsequently applied; duplicate papers were excluded. The abstracts were then read, and the remaining material consisted of 13, 4 and 3 papers for each search combination, totaling 20 studies obtained from this database. In BDENF, 82 papers were selected by crossing the first and second items, by crossing the first and third items, and 63 from the combination of the three items.
After application of the incusion criteria and exclusion of duplicates, 6 studies remained for analysis.
A Case Review: Integrating Lewinâs Theory with Leanâs System Approach for Change
After a careful reading of the full texts, 4 papers were chosen for inclusion in the final sample of the review. The survey in SciELO provided the following results: papers were obtained by crossing the first and second items, by crossing the first and third items, and 66 in the search that included all the items. After exclusion of duplicate studies, application of the inclusion criteria, and meticulous reading of the manuscripts, 3 publications were chosen. Figure 1 depicts the paper selection process. After collection of the scientific production about the subject, exhibited in chart 1 , the full papers were read thoroughly to determine the defining attributes, the identification of precedents and consequences, and the empirical references of the concept of nursing care management.
To identify the concept, attributes, antecedents and consequences in the studies, the following questions were created to guide the work: What is the definition of nursing care management or administration in the hospital context? What are the specificities that the concept under analysis presents?
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What events contribute to the existence of the concept under analysis? What are the results of the application of the concept under analysis? To identify the model case and the empirical references, the guiding questions were: What model case in nursing care management demonstrates all the attributes of the concept definition? How can this concept be measured? Careful reading of each paper allowed the identification of the words related to antecedents, attributes, consequences and empirical references of nursing care management.
During the review process, words that referred to antecedents were highlighted in yellow, those related to attributes in blue, and those associated with empirical references in red. Finally, the terms used more times in the papers were selected. The data are shown in a chart, and analyzed according to the literature. Most original investigations oriented to nursing care management in the hospital context focus on the way that nurses perform management and care actions in their practice. It was noticed that care management is construed as a complementary subprocess in the nursing work process, but that it is necessary to recognize care as the target to be administered in health services.
It was shown that in these places nursing management practices are oriented mainly toward providing material resources and determing the size of work teams, in an activity separate from care to patients and the fulfillment of user needs. Although studies have shown that nursing management practice is focused on bureaucratic administrative activities that bear little relationship to care, the analyzed papers presented coordination and integration as essential characteristics of care management, as well as leadership, teamwork, communication, and coordination and cooperation among nursing teams and with other healthcare professionals and users.
Coordination of management actions and the care process provides nurses with possibilities to reunite with care, and consequently contributes to increased satisfaction levels and decreased work stress. The literature survey allowed identification of coordination and integration of management and care, and the practices of leadership, interaction, communication, decision-making and cooperation, as fundamental attributes in nursing care management.
The interactive relationship between nurses and users stands out as an important element in care management dynamics, because it allows exchanging information and establishing trust and bonds, contributing to the realization of actions to promote and recover user health.
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The model case is an example of use of the concept and presents all its attributes. It can be found in the literature and based on real-life events or created by the concept analyst. The case is described below. A nurse integrating the multi-professional team in a pediatric unit came across the case of a teenager with a diagnosis of chronic kidney disease; she had been submitted to a kidney transplant six months previous, having the father as the donor.
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After the kidney transplant, the teenager was readmitted to the hospital several times because of recurrent urinary infections, a problem that was always permeated by the family issues and the precarious socioeconomic conditions she lived in. After the surgery, the father won custody of her. He was unnemployed and both were living on governament benefits. In this scenario, chief nurses assume the position of leader of the nursing team and carry out nursing care management, emphasizing integrated and humanized care, centered on user needs.
They use relational technologies and interact with patients and their families by welcoming them and creating bonds, assuming that they will help establish affection and trust, which are essential to care management. The nursing process systematizes this care by identifying patient needs, outlining nursing diagnoses, planning and executing nursing prescriptions, implementing interventions oriented to comprehensive care, and evaluating the care provided.
From this perspective, nurses coordinate and communicate with the members of nursing teams and other health professionals in this case, a nephrologist, social worker, nutritionist, psychologist and pharmacist through interprofessional discussion of the case and establishing interactive and cooperative relationships, sharing and negotiating responsabilities and decision-making, in the search for alternatives to improve the quality of life of patients.
Interprofessional interaction allows nurses to participate in the design of the singular therapeutic projects of patients; the goals are improvement of patient clinical condition, reinsertion in families, and hospital discharge. To achieve care comprehensiveness, nurses, together with interprofessional hospital teams and relatives, enables cotinuity of care at home through coordination and interaction with the Family Health Strategy or home care services.