Systematization of nursing care : challenges and features to nurses in the care management

Objective: To analyze the advantages and challenges of nurses in instrumental assistance management by Systematization of Nursing Assistance (SNA). Methods: This is a qualitative study, based on the framework of dialectical hermeneutics. The sample consisted of 32 nurses from three hospitals in a city in southern Minas Gerais. We used the Focus Group with the guiding question: "What are the facilities and the challenges for the implementation of the SNA in the management of assistance?". After the interviews, the speeches were transcribed verbatim. Content analysis of the data allowed to extract the category Facilities and challenges for SAE in the daily work of nurses. Results: The results showed facilitators and challenging points, in which participants consider the SNA a facilitator in planning and organization of care, however, there are internal issues in the institutions that serve as barriers to nurses in its implementation. Conclusion: However, the successful implementation of the SNA happens through a mutual development.


INTRODUCTION
Since past decades in different health services, especially in hospitals, nursing management has assumed crucial importance in linking the various professionals of the healthcare team and the organization of nursing work for those who seek these services.
It is understood that the hospital organization is one of the most complex health care services due to the coexistence of numerous assistance and administrative processes, and fragmentation of assistance decision processes with the presence of a multidisciplinary team with a high degree of autonomy.Thus, it uses technology intensively and extensively, and may constitute itself into a space for teaching and learning and also a field of scientific production 1 .
In this context, nurses experience a challenge in building and compilation of knowledge on which is based its management and assistance practice.The development of nursing work process is part of this challenge, to realize the proposal of promoting, maintaining or restoring the health status of the patient.Thus, the Systematization of Nursing Assistance (SNA) is to add and shape the planning, execution, control and evaluation of the actions of direct and indirect patient care 2 .
It is noteworthy that there are different ways of systematizing nursing care, among which we can mention the care plans, protocols, standardization of procedures and the nursing process.These are different ways to develop care, in other words, various methods can be used to solve a real situation at a given time in order to achieve positive outcomes for patient health.These modes of action are not mutually exclusive and have different natures 3 .
As a result, it is understood that nursing management and assistance are key functions in daily nurse, aiming for excellence in the quality of health care offered to the patient, the family and the community with intervention in the health-disease process.
From this premise, SNA is located as an instrument of the assistance process of the nurse, which can help to ensure the quality of care, since it includes a range of tools that include communication, interaction and articulation of management and assistance dimensions 4 .
Accordingly, in an attempt to facilitate the operation of SNA, nursing staff often, initially, decides for piecemeal work.But this systematized work is still incipient with assistance practice, being more present in the ideal scenario, guided by the management and assistance models based more on management theories than on the actual making of everyday life in the hospital setting.
The nurse in the hospital environment develops numerous tasks with high demands and responsibilities which depending on how they are systematized and his knowledge of management tools able to assist him, may impair the quality of care.Thus, this study presents the following questions: What are the facilities and the challenges of the nurse in hospital management?Can the SNA help nurses in the management of care?What are the facilitator mechanisms used by the nurse to the implementation of the SNA?What are the challenges and limitations that pervade nurses' everyday-work in face of the implementation of the SNA?
Carrying out this study is justified in order to contribute to the reflection of nurses about the need to implement the SNA as a strategy for care management, achieving autonomy and space in an attempt to break the dichotomy between what is recommended and what is achieved in daily nursing, contributing to the planning and organization of the management and assistance practice.With that, this research aims to analyze the facilities and challenges of the nurse in the management of assistance instrumentalized by SNA.

METHOD
This is an exploratory study, with qualitative approach, grounded in the theoretical and methodological framework of dialectical hermeneutics, considered an empirical research method, which reveals a belief in the process of moving that exists permanently in society as well as in the historic building and in the ability of transformation and overcoming contradictions through praxis 5 .
The field work of research was developed at the place where the nurses are working, and consisting of three hospitals in a city in southern of Minas Gerais, such as public teaching hospital, public general hospital and private one.The total of 85 nurses of those institutions were invited to participate in the research, and the selection was made through invitation letter, telephone and e-mail.
Given this opportunity, it was presented the research objectives, the importance of their adherence to the realization of this research, the assurance of anonymity, seeking to reduce concern of any future exposure.
It is important to emphasize that the reaction of these participants was partial, appearing in the days and hours scheduled by agreement of the nurses invited, only those who accepted to participate in this research.
To collect empirical material, we chose the focus group technique using digital recorders to record the speeches of the participants.In developing work together with focus groups, 32 of 85 nurses invited comprised the sample, since according to the Dimension of Nurses in each hospital, it was performed six meetings, of these a focus group with four nurses occurred in private hospital in December 2012, two focus groups occurred at the public hospital in January 2013, and of these two groups, both were made up of seven nurses, and three focus groups occurred in public teaching hospital in February 2013, the first group consisted of five nurses, the second of four nurses and the third of five nurses.It is noteworthy that each focus group was held in the very hospital required, where the groups were performed consecutively and were arranged according to periods of work, i.e., shifts of morning, afternoon and evening as well as the availability of each nurse to participate in focus groups.
It is clear to emphasize that participants belonging to each focus group were identified by the letter N for nurse, and received a sequential numbering in Arabic numerals, thus guaranteeing the anonymity of speeches.Thus were referenced from N1 to N32.
For data analysis we used the content analysis technique proposed by Minayo 7 , comprising three basic phases: preanalysis, exploration of material and treatment results.Preanalysis is considered the organizational phase of the study, with the first step in organizing the data collected in the focus groups conducted with study participants, preceding the transcription of DVRs, respecting the speeches in full.
The material exploration phase is the analysis itself, it is an ample moment of the study, since it requires a movement of coming and going of speeches in order to explore in depth the available material.
The phase called treatment of the results allows researchers to propose inferences and perform subsequent interpretations foreshadowed in the theoretical framework, glimpsing new fronts, serving as a basis for further analysis, alluded by reading the material for new theoretical dimensions held by the Hermeneutic-Dialectic Method.

RESULTS AND DISCUSSION
To better emphasize the understanding of the empirical category of the study, the characterization of the participants was held, stressing that all nurses are responsible for units of small, medium and large complexity sectors.Among these, the female sex was predominant, aged between 20-40 years old.Thus, data showed professionals with some type of Lato Sensu Postgraduation and only one nurse owned Stricto Sensu Postgraduation.The length of service ranged from one year to 25 years in the profession; of these 10 nurses were graduated from public institutions and 22 by private institutions.
Related to the 32 nurses who participated in the study, 10 were nursing technicians before completing the Nursing Graduation; two nurses had more than 20 years since graduation; seven more than 10 years since graduation, and the other 23 had from one to 10 years since graduation.Thus, two categories have emerged from the qualitative data: "Facilities for SNA in the daily work of nurses" and "Challenges for SNA in the daily work of nurses".

Facilities for SNA in the daily work of nurses
Given the technological evolution, the constant exchange of information and demands of health institutions in an effort to maximize resources, reduce costs and improve quality of care, it has been increasingly demanded the improvement of nursing services, planning and operationalizing care, reinforcing the undeniable need to adopt and consolidate the SNA 8,9 .
Improving on the excellence of the quality of nursing care has conformed a need to change practice and the role of the nurse in order to bring a new feature to his performance 10 .Thus, despite failing to implement the SNA in the daily work, the nurse is aware that it directs the planning and organization of care activities and functions of members of the nursing staff, which is observed in the following speech: [...] with the systematization you become more independent because it is deployed, it has a protocol of systematization, I guess that it leaves you freer to do something else by the patient and not having the systematization, not having this protocol [...] you depend on the doctor, you get more tied... (N06).
Thus, the nurse also gets committed to involve the whole nursing staff, always showing the importance of systematic care for awareness and active participation of managers.However, despite difficulties related to the implementation of the SNA under managerial point of view, there is an appreciation by nurses regarding the need to systematize care, working as a motivational factor and a concern not only in dedicating themselves to implementation of activities in the health care guarantee, as well as in the benefits that the systematization can offer to the customer and to the nurses 9 .

[...] I think it is necessary because it is a tool to qualify the nursing work. (N03). [...] there is no way to work without systematization, because you do it automatically, anything you do with the patient is inside the systematization [...] (N06).
[...] we think that the systematization will improve further, we have a lot to improve, but when we implement just a little bit, we see that we can get satisfactory results.(N20).
However, it is notable emphasize in this study that nurses, for not having SAE implemented, end up performing their actions in accordance with the priorities of their work process.

[...] we work according to priority of gravity, it is a very dynamic sector, we do not have systematization, we accept outpatients and we accept more severe patients, logically we prioritize to the most serious, and we [...] attend according to the severity level. (N03).
It is observed in health facilities, especially in the hospital, where there is a large contingent of nurses, that there is a constant effort to offer quality care in nursing using the SNA tool, which should facilitate the process of nurses' work, as well generate positive results not only for the organization, but also to meet the needs of clients and their families.However, care and nursing services management involve complex actions, requiring knowledge in the acquisition of new tools which is a major factor in defining the practice of professional 11 .

Challenges for SNA in the daily work of nurses
SNE has been implemented for decades in Brazil, with the Theory of Basic Human Needs 12 .However, only after the Systematization of nursing care: challenges and facilities Soares MI, Resck ZMR, Terra FS, Camelo SHH legalization it has been required within the Brazilian health institutions.Nevertheless, today, we can still observe that this resolution alone does not provide all the necessary support for its implementation, since many factors trigger practical difficulties in the implementation process of this assistance tool 9 .
[...] I noticed many times that it was a legal requirement that had to be fulfilled [...] (N04).
I think we' have always done it, now that the word is at the pinnacle, it is systematization, we have always done it, but we have never named it as systematization [...] we have always this done since long before, before hearing about systematization [...] (N15).
We can do something, we already do much, but we do not put these things on paper, [...] and you cannot prove you did it... the proof that you did it, that you wrote it, nothing.We do not know how to put it; we do not know how to prove [...] we made everything.(N18).
These notes bring up one of the major problems highlighted in this research: the failure of the nurse records in relation to SNA.It was realized that the lack of recording, i.e. not putting on paper, makes SNA to become informal, hindering its implementation.Therefore, the unsatisfactory completion of the nursing record makes SNA incomplete and inoperative, revealing a contradiction between what is said and what is practiced 4 .
Thus, it was realized by the nurses' testimonies a difficulty to systematize the assistance correctly: So I believe we have an informal systematization which often is not written or described, but we have a labor organization, especially when we are on duty... so... we have actions to perform [...] (N01).

[...] the systematization of care here [...] from what I see [...] is very informal, it is done automatically, but with no record of anything [...] So I think we need to have a formalization, because everything that is informal gets like this, one throwing to another. I think when the institution intends to do something, it has to formalize it [...] so it is a process that we can do... but from the moment it was not put on paper, ah! [...] There is no use, it does not work. (N06). [...] it is not a written, formalized systematization, but it is already a routine, a sequence of work that comes out of a structured way. (N11).
For nurses participating in the study, little or no systematic recording of SNA may result, on the one hand, in the absence of visibility and professional recognition; on the other hand, which is perhaps more serious, in the absence or difficulty in evaluating their practice 13 .Thus, the lack of a protocol, print and/or paper is evidenced as a hindrance in daily nurse.

.] (N15).
Added to that, the greater the number of demands affected of the patient, the greater the need of planning assistance, since the systematization of actions aimed at planning and organizing, the validity and efficiency of care provided 14 .This can be seen in the testimony of nurses:

[...] we have returns to be received, so we get on duty and we define what the priorities are. So of these priorities we see if there is any patient who requires some special care [...] if we have any pending [...] we take it as a priority to be resolved... in our routine work, we systematized by priorities that must be made [...] (N01). [...] I think this is what is missing now [...] a little more than we having this opportunity to provide for the patient a better quality of care, which is the systematization [...] (N15).
The SNA is planning actions, which are based on the development of goals and outcomes, as well as a plan of care designed to assist the patient in resolving the identified problems and achieve the identified goals and expected outcomes 14 .This is referenced by the nurses participating in the study:

will be done and I watch side by side with the technicians, going up to the bedrooms [...] acting alongside them. (N30).
Thus, implementing SNA is currently regarded as a challenge, especially with regard to management of care, since a complex, multifaceted and multidimensional reality requires from nurses commitment and creativity in developing and implementing innovative and participatory strategies and to maintain favorable conditions for the adoption process of SNA, involving political and economic issues for hospital accreditation 12 .This fact is referenced by nurses, since even not having the structured SNA, they create a means of implementing this instrument, but in a piecemeal way: [...] there is a great assistance demand and it is one nurse per sector, then they even try, it is not that systematization as it is on paper, but it is adapted to our reality [...] (N23).

[...] we still do not have systematization [...] to speak the truth, we have a checklist, which raises issues and our evolution, but it is a very poor thing [...] (N27).
Professionals point to the lack of training as one of the limitations for the implementation and execution of the SNA, and the lack of knowledge from nurses the main reason for the lack of commitment in some health institutions and the absence in others, while this ignorance generates disinterest and lack of adherence to care method 15 .

[...] before you act, you already expect return, which is what the systematization assures us, if we perform well, our return will be quicker [...] (N01). [...] we are pretty excited to deploy the systematization of nursing... (N32).
It is noteworthy that during the course of SNA, many nurses are faced with several critical factors in its implementation, requiring its adjustment to the reality of the moment and the health institution, since many have administrative and welfare problems, especially in public organizations, considered as barriers in improving quality of care 9 .
With this, it is regarded the knowledge of nurses, as well as the training of the nursing staff for implementing the SNA within the institution itself.This because nurses are trained in different schools and taught differently.In addition, it is needed to enable nurses in relation to the specificities of this methodology in the institutional context 12 .This fact was confirmed by the testimony of the nurse N07:

[...] because systemization is made in five stages, I do not remember the five, because it is been a while, [laughs ...] it is divided into five phases, implementation, data collection, I do not remember the order, then you have to study where you are going wrong to try to improve [...].
Another issue pointed out by one of the nurses related to non-operationalization of SNA was the lack of an environment for information about changing shifts: [...] I think the first fault here, we do not have an environment where the shift change happens, I think the shift change needs to be held in a private room, a place for this, where you are calm, you have peace [...] (N27).
However, despite the physical structure in the literature is underreported for the operationalization of SNA, its analysis is essential when the idea is to deploy it.An example of this fact is that the existence of a private room for exchange of information about the attendance can mean a space for professionals to express themselves freely, helping to define the nursing actions that will be put into practice by SNA 12 .
However, the time factor also represents one of the fundamental features of an organization and its management contributes to improvements in individual and collective performances in productivity.Thus it arises the need of shaping tools in nursing actions according to each institution by entering facilitator software on progress of activities, trying to overcome these limitations 16 .
In addressing the SNA through the electronic medical record, it is understood that nursing records permeate all stages and should be noted in the patient's record complete information about the history, physical examination, nursing diagnoses, the prescription of assistance and the evolution/ nursing assessment 17 .
However, it should be added that, apart from the advantages of electronic medical records for the SNA, the nurse still realizes that it brings many obstacles in the registry of nursing activities.However, it is realized that, in practice, the SNA is still far from being properly implemented in its entirety, since the systematic making of records, which is essential for its consolidation, is still not a routine work in nursing in many institutions 17 .
[...] documented, actually, we do not have, there is the nursing report, to speak that it is ours, of the nurses, we write what we do, every day [...] (N18).
[...] we have many problems with the electronic medical record.It is an issue of prescription quantities, that sometimes we have to be aware [...] (N28).
[...] to record on paper is hard, then to execute is more, because it is the assistance itself.On the paper it is not done properly.(N30).
Therefore, it is believed in the viability of the electronic nursing record as a tool for organizing the work of nurses and their staff, including documentation of all phases of SNA, however, it is necessary, first, that the nurses commune of this statement to then make it a utopia or a concrete proposal in healthcare practice 17 .

Systematization of nursing care: challenges and facilities
Soares MI, Resck ZMR, Terra FS, Camelo SHH It is perceived that nurses still face many obstacles related to nursing records that impair effective realization of SNA.
[...] sometimes there are people who think that nursing report is not even a document, I have seen doctors who have never read it.(N15).
[...] the issue of nursing report, there was a time it was kind of bad... there were a lot of repeated information, some put things that were not so important, left out those that mattered, we managed to fix this, it is not perfect, but vastly improved.(N26).
Thus, it is important to question how the nursing staff perceives their records for the realization of SNA, which will only be an effective practice if it is discussed and defended by the very professional category 17 .This fact greatly complicates communication among nurses, which is seized by the nurse N09:

[...] even on paper records the employee does not write properly, one way or another it is poor, it has five little lines there all night, it does nothing.
It is noteworthy that the activities of nurses are divided by shift work and communication between teams of different shifts occurs, in hospital reality, through the occurrence book, which often replaces the shift change, and also, most of the time, the patients' records and other legal forms of information and communication 17 .For nurses in the study, recording the attendance in the book of complications is essential for professional support.
I think that the book is important for you to make a shift change, because it will be there anyway, you are registering there [...] in my duty, people think I write too much in those shift changes books, but many of the things that happens in day to day life, I record on that book.If it is to be only complication in that book, if it will serve to someone one day, I do not know, but it is recorded there, it is.(N12).

I like to record everything, sometimes my record is huge, I think it' is the support you have there, I like to write down almost everything, I enjoy writing quite a lot. (N31).
It is observed by the speeches of the nurses that there is the awareness of the importance of nursing records as a legal support, which COFEN, from the Resolution Nº 308/2009 establishes the SNA as one of their private activities, which must occur in every institution of public or private health care.This duty is recognized in its legitimacy and importance, despite not being performed by some of the nurses interviewed 17,18 .
[...] you end up losing yourself with so much paper and it is very bureaucratic, you have many books, too much bureaucracy, we try to get some things out, but there is no other way, you fill book by book and the patient?It is too bureaucratic, you cannot handle it...So it is, there are many books, there is a lot of bureaucracy.(N18).
Given these not systematized notes, it is imperative that nurses take ownership of the management tools to transform the care process, that when considering that managing the care is, among other things, arranging care, they are building a relationship between the SNA and the very management of care 4 .

CONCLUSION
The hospitals have specific characteristics with regard to the facilities and challenges for the operationalization of the SNA, which should be analyzed by the nurses, in order to implement this assistance tool with real knowledge of the situation and possible goals to be achieved.
The flow of testimonials seized lead to envision scenarios of everyday life of nurses in which a fragmentation still occurs in their work process, where this work for so many reasons does not accomplish SNA in a systematic and individualized way.
Thus, it is clear to emphasize that in the reality of the hospitals surveyed, through focus groups, several situations were pointed oud in which sometimes the professional fails to exercise its actions on account of which it is imposed in the face of global changes and transformations.
In this sense, making an articulation of the results, one can notice that there are more challenges than facilities that pervades the nurses' every day in face of operation of SNA, such as the correctly implementation of SNA, the lack of forms, protocols, scarcity nurses, which creates a lack of time, lack of knowledge, i.e., not professional training, lack of an environment for the shifts change as well as incomplete nursing records.
However, all participants recognize the importance of SNA for an individualized and quality care; however, these barriers cited leaves the nurse hands tied, not having the necessary support to implement it.Thus, by the discourses of nurses it is notorious to emphasize that they have been struggling to implement the SNA in the institution of action.
However, the successful operation of SNA takes place by means of a mutual development in which people are valued by the organization at the extent that they effectively contribute to its development as well as organizations are valued by people in the extend that they offer concrete conditions for their growth.
Finally, it is noteworthy that there is no point in using the SNA as cake recipe, but it should be adjusted according to the circumstances of each institution, verifying the number of professionals proportional to the number of beds in the hospital, contemplating resistance by some nurses who refuse to SNA as legal support profession, breaking the taboo that this instrument came to score and invigorate the professional autonomy.
, we do not have a record like that... we just observe, then we see if there are results or not, it is more direct, it does not have the script itself.(N07).