Ensino da sistematização da assistência de enfermagem aos técnicos de enfermagem Teaching the systematization of nursing care to nursing technicians

Objective: To understand the typical ideal of nursing staff about the systematization of nursing care (SAE) in the light of the Alfred Schutz's theoretical framework. Methods: This is a phenomenological investigation. The study was approved by the Research Ethics Committee of UFRN (Federal University of Rio Grande do Norte). The data were collected by focus group in February 2013, according to experiential pedagogy humanescent with thirteen nursing staff of a university hospital of Rio Grande do Norte. Results: The analysis of discourse, from posters and written descriptions allowed to reveal the typical ideal of participants from four axes: typifying the concept of SAE; benefits of SAE, which resulted in the reasons to believe in the positive-that working tool; problems experienced, revealing the world of everyday life of nursing professionals, and possibilities of improvement. Conclusion: It was concluded that the nursing technician believes in the benefits of SAE.


INTRODUCTION
Systematization presupposes the organization of dynamically interrelated elements, i.e. a sequence of steps to achieve a goal.Based on this concept, the systematization of nursing care (SNC) must be understood not only as a way of performing, but also as a way of thinking about health care practice 1 .
Consequently, the SNC is known as a tool that qualifies nursing care -and contributes to its recognition-and it is legally defended as an essential mechanism to organize nursing work in terms of methods, personnel and instruments 2 .
Likewise, the SNC is understood as the primary way to be followed to consider this profession as a social action, compared to the reductionist view of conduct, according to Alfred Schutz' concepts, the theoretical framework of the present study: "[...] lo distintivo entre acción y conducta es que la acción es la ejecución de un acto proyetado" (what distinguishes action from conduct is that action is the execution of a planned act) 3:90 .
Overcoming the simple conduct means to understand nursing not as a spontaneous practice, without planning and scientificity, aiming at the practical actions that include the entire nursing team.Thus, it means stating the relevance of nursing.
To achieve this, the clinical power of nursing must be reaffirmed, finally overcoming the dichotomy that characterizes its professional practices, a reflection of the historical edification of this profession: on the one hand, those or that who plan(s); and, on the other hand, those who execute, provoking a problematic division of the care process.
Therefore, what is defended is that Nursing Technicians (NT) should be integrated into the SNC.According to Decree 94,406/87 which regulates Law 7,498 from June 25 th 1986 -the Law of Professional Exercise of Nursing -NT are professionals comprising the nursing team 4 .
They are a unique component of this team, supporting nurses in their health care and planning activities.Moreover, the NT represent the group with the largest number of nursing professionals in Brazil.According to data from the Conselho Federal de Enfermagem (COFEN -Federal Nursing Council), in 2011, there were 750,205 NT in this country, corresponding to 40.41% of all nursing professionals 5 .
However, despite the unquestionable relevance of this professional category in the edification of nursing support, it should be emphasized that the participation of these professionals in the SNC remains as an obscure field.
In this context, it should be noted that Article 10 of the Law of Professional Exercise of Nursing describes that "Nursing Technicians, having a technical secondary education level, perform supporting activities and are responsible for: 1) helping Nurses: a) in the planning, scheduling, guidance and supervision of Nursing support activities" 4 .
Thus, the participation of the NT is foreseen in the nursing support planning, an essential aspect to consolidate the SNC.However, the inclusion of the NT in this process has not been observed in practice yet.
In the meantime, based on the observation that it is essential to include the NT in the discussion about the SNC, the phenomenon under study appears: the typical ideal of the NT for the SNC, as it is understood that this is the way to reveal the meanings they attribute to this work tool and how the teaching provided to the NT is connected to the SNC.
Thus, based on the assumption that it is essential to reveal subjective human experiences to understand a phenomenon better, seeking to systematize the typical ideal of the individuals investigated 3 , as well as understanding and defending the crucial integration of all professional categories comprising the area of nursing for the real implementation of the SNC, the following questions arose: What is the typical ideal of the NT for the SNC? Would the teaching provided to the NT be including the theme of the SNC?
Thus, the objective of the present study was to understand the typical ideal of the NT for the SNC in the light of Alfred Schutz' theoretical framework.

METHODS
The present study originated from the results of the Master's dissertation entitled "Understanding the Typical Ideal of Nursing Assistants for the Systematization of Nursing Care", conducted through the Postgraduate Nursing Program of the Universidade Federal do Rio Grande do Norte (UFRN -Rio Grande do Norte Federal University).
A comprehensive phenomenological investigation was performed, using Alfred Schutz' theoretical framework 3,6 .Alfred Schutz' comprehensive sociological phenomenology is founded on the cognitive reality incorporated into the processes of subjective human experiences 3 .
In this sense, it is observed that investigating the typical ideal of the NT for the SNC, following Alfred Schutz' comprehensive approach, is founded on the idea that the NT bring their biographical situation, which must be revealed to understand what meanings are attributed to this work tool, contributing to the inclusion of this professional category in the debate about the SNC.
The typical ideal was the key concept that guided this study and it is understood as the way through which individuals interpret their own attitudes and the attitudes of others, according to their stories and relevance, helping these individuals to find themselves in the social world and to maintain their relationships with others and with cultural objects 3 .
To outline the typical ideal, the biographical situation of the individuals investigated must be revealed.This is understood as the consolidation of all previous experiences they had, organized according to their "storage of knowledge at hand", determining the way each actor thinks and acts in their social space 7 , which influences and is influenced by the motivations of individuals, including their reasons-for and reasons-why.
The reasons-for are essentially subjective, constituting the goals to be achieved, having a temporal structure geared towards the future, and forming a subjective category of action.

Teaching systematization of nursing care
Salvador PTCO, Santos VEP, Barros AG, Alves KYA, Lima KYN In contrast, the reasons-why are regulated by objectivity, which is evidenced in events that have already occurred, thus having a temporal structure directed towards the past; they can be understood retrospectively, i.e. one is not aware of them during action 3 .
Data collection was conducted on February 15 th 2013, in a previously prepared room on the 4 th floor underground of the Hospital Universitário Onofre Lopes (HUOL -Onofre Lopes University Hospital), totaling 101 minutes.The focus group technique was used in this study.This focus group, entitled "What do I think about the SNC?", was held according to the a Pedagogia Vivencial Humanescente (PVH -Humanescent Experiential Pedagogy): an educational process that promotes, in the sphere of teaching, learning through imagination, valuing previous knowledge, the path and rhythm of development of each individual, and promoting reflection and creativity 8 .
Consequently, the proposal was to use the "create-speakwrite" triad to encourage participants' expression of perceptions of the guiding question: 1) to create a poster based on the following key question: "What is systematization of nursing care for you?"; 2) to speak about their representations, sharing ideas and opinions; and 3) to write a description of the scenario built in a research tool that contributed to the analysis of speech of the NT.
A total of 13 nursing technicians (NT) collaborated with this study, all of whom worked at the HUOL, in the city of Natal, Rio Grande do Norte state, Northeastern Brazil.This university hospital only has the SNC implemented in some of its sectors, although planning to fully implement it.Participants who met the inclusion criterion -to work at the HUOL, performing direct care with patients -were included in this study.The study sample was defined according to the ideal number of individuals that must comprise the focus group, guaranteeing the effective participation of all 9 .
Aiming to identify study subjects, a questionnaire was applied to participants at the beginning of the meeting.This questionnaire included closed questions and it was divided into two parts: sociodemographic and professional data.
This research project followed the ethical and legal principles of human research recommended by Resolution 196/1996, of the Brazilian Health Council, and it was approved by the Research Ethics Committee's Official Opinion number 98,424 from August 31 st 2012, CAAE 05906912.0.0000.5537.
Aiming to reveal the phenomenon, data analysis was performed by Zeferino 7 from the proposal of guiding principles of a research method based on Schutz' own work.

RESULTS AND DISCUSSION
A total of 12 nursing technicians collaborated with this study, having the following biographical situation: 12 women (92.3%) and one man; age ranging between 23 and 53 years, mainly in the 31-to-35-year age group (4; 30.7%); and a family income of up to two minimum wages in the majority of cases (9; 69.2%).
The predominance of females has also been reported in other studies that included NT as research subjects 10,11 , revealing that the presence of women in nursing is historical.The age group ranging from 31 to 35 years was emphasized by another study 10 , showing that NT may already have a previous nursing career, especially as nursing assistants, seeking professional improvement.
The search for professional development is also revealed by two NT enrolled in undergraduate nursing courses, an aspect that has already been discussed in the literature, emphasizing the fact that such individuals seek this as a way to achieve personal and professional growth and to acquire knowledge 12 .Financial improvement can also be a contributing factor, as the majority of NT receive only two minimum wages per month.
Differently from other studies that revealed that the NT had completed their technical course more than ten years before 10,13 , the present study showed a period varying from four months to two years since the completion of this course, of which 11 NT (84.6%) had concluded it two years before.
Therefore, the biographical situation of the NT revealed that they had graduated two years before on average, at the time when COFEN's Resolutions 272/2002 and 358/2009 had already been published, defending the implementation of the SNC in the context of nursing teams.
However, the NT revealed that they had never had contact with this theme, whether academically or professionally, and they were even unaware of the term "SNC", unlike other studies that sought to investigate NT's perception of SNC and showed that these professionals had at least had the slightest contact with such theme 10,13,14 .Similarly, however, other studies emphasized that there was no such contact in technical courses in nursing, nor were there any discussions about the SNC in the academic environment of the NT 10,11 .
This is an alarming problem, as we understand that, "while knowledge about the methodology is restricted to the practice of nurses, it is unlikely that the other nursing team categories will contribute with their acknowledgement" 11:926 , thus resulting in the misrepresentation of the nursing technical category with regard to the SNC.
However, it should be emphasized that, despite the lack of studies on this theme, some researchers have already attempted to focus on the unique importance of investigating and defending the key relationship between NT and the SNC 10,11,[13][14][15] .
A study conducted in the cities of Ribeirão Preto, SP and Brasília, DF, including interviews with nurses from several institutions, identified that 88.8% of nurses responded positively to the participation of nursing assistants and technicians in the SNC, showing the relevance of integration in the nursing team when planning health care as this is a factor that promotes the quality of such care 15 .
Among study respondents, nursing assistants and technicians can participate in the following ways: performing activities inherent in data collection (55.5%), limiting their performance to activities prescribed by nurses (33.3%), using Teaching systematization of nursing care Salvador PTCO, Santos VEP, Barros AG, Alves KYA, Lima KYN specific tools developed by nurses (11.1%), and following patients' progress and/or evaluating health care (11.1%) 15 .
In contrast, in the perspective of nursing assistants and technicians, a study interviewed 77 representatives of these categories who worked at a university hospital in the state of São Paulo and showed that 75% of professionals who reported participating in the SNC could not identify the stage in which they were in.They mentioned performing the following activities in the SNC: providing care, promoting comfort, following norms, checking nursing prescriptions, admitting patients, collecting information and providing emotional support and guidance 10 .
Therefore, the relevant gap found in the participation of NT in the SNC should be emphasized.The result of this distressing problem is, "[...] the possibility of performing care disconnected from planning, contradicting the SNC's benchmark" 11:926 .Consequently, the traditional Cartesian view of labor division remains and the participation of NT in the SNC continues to be unclear, lacking in-depth studies.
Although unaware of this theme, the NT typified what the SNC would be, emphasizing a more subjective side of this systematization, in addition to the scientific concepts, a side which is in fact implicit in its practice.Schutz 3,6 understands that every social actor, not only scientists, typifies the world to understand it and these typifications are constructed from the social situation -the biographical situation -where individuals are in the social reality and from the acquisition of concepts already formed in their world-routine life.
In this way, based on their biographical situation, the NT typified the concept of the SNC as follows: as the system that comprises nursing; as the means to deal with patients; as the way to provide equal quality care; as systematic care; as norms and techniques inherent in this profession, including both theory and practice; and as a professional learning process.
The typifications from the NT revealed that they were unanimous when considering the SNC to be positive: To be honest, I never understood this, but I think that it's a study, that everything is working in an equal way, like, that all rights are the same in health, that health professionals provide a good service and that, one day, it'll be as good as it's planned in theory (NT10) In general, the scientific concept appeared in their descriptions, when they understood the SNC to be an organizational method for this profession, the planning of care that would benefit from the knowledge of such professionals:

[...] for us in the nursing area, it [the SNC] begins when you take the course, where you'll find out everything, how it works, what there is, what you'll discover, what you'll learn, what you'll work with (NT1)
Thus, although recognizing that they do not know what exactly the SNC is, through their representations and speech constructed through group interaction in the focus group, which was facilitated with the use of projective techniques, the NT idealized it as something positive that could bring benefits that translated into the reasons-for SNC consolidation.

Reasons-for SNC consolidation: idealized benefits
Based on the fact that the reasons-for refer to the state of things to be established, the project to be conducted and the will to do so 3 , the NT reflected on these reasons whose aim is to value the SNC.Thus, the reasons-for the SNC consolidation translated into the following benefits provided by such tool: to promote humanescent care with love, affection and dedication; to be characterized by respect for user individuality; to qualify and organize care; to foster union among professionals; to be based on health care planning; to be focused on user needs following a holistic view; to seek the theory-practice combination; and to strengthen the professional-user bond.
Among research participants, the possibility of valuing humanescent care should be emphasized, which was represented by the presence of flowers in almost all posters: [...] health care and everything else depend on the system to get there, for this broken seed to come and get better [.

..] (NT9).
The understanding that the SNC organizes care, broadening the perspective of professionals who begin to focus on the actual needs of users, was also emphasized, translating into the knowledge that care begins to be guided by clinical reasoning through the SNC: We shouldn't only focus on the disease, but also on the needs of patients.We got to pay attention to certain events, the reason why something happened, say, a pressure ulcer: why did it open?What should we do?Why should we do it?How to do it?(NT7).
This perspective has been clarified in other studies that included the NT as their research subjects, understanding that the SNC increases professionals' knowledge about patient conditions, improving and directing the service being provided, qualifying health care 11,13,14 : For me, systematization of health care means to plant well to reap better (NT12) However, at the same time that they recognized the benefits of the SNC, the NT reflected on the problems encountered in their professional practice that hinder its implementation -the difficulties found in their world-routine life: Adequate health care is the ideal, but we know that the environment for this care usually prevents us from performing this task with caution (NT7).

World-routine life: problems encountered
The world-routine life represents the space where men are situated with their daily problems in inter-subjectivity with others, not being the natural world exclusively, but also the social, historical and cultural world 3,6 .This is the space where the origins of the experiences of individuals are reflected and, in this sense, it represents the micro-space of the present investigation, the possibility of visualizing aspects that hinder the implementation of the SNC.
While results were being shared, the NT reflected deeply on the problems experienced in their professional practice, when the following stood out: lack of professionals and material resources; poor management; lack of acknowledgement by professionals, exposed to unsuitable working conditions; lack of humanization of professionals; work overload exposure to double and triple work shifts; and professional relationships.
With regard to the lack of recognition from professionals, several NT reports included unsuitable working conditions, which cause them to forget to care for themselves.A study which analyzed the relationship among work, health and the living conditions of nursing professionals found that they are exposed to inadequate working environments, in the material and subjective senses, and that they are submitted to poor working conditions, with insufficient time for rest and leisure, thus increasing the chances of falling ill and affecting their ability to care for themselves 16 .
Researchers understand the importance of health professionals having adequate working conditions, enabling them the opportunity to care for themselves.If caregivers are able to do this, they will have better living conditions and better conditions to care for others and help them to have a balanced life and to seek self-knowledge and self-care 17 .

Typical actions towards consolidating the SNC: requirements for improvement
In view of the reflections, the problems encountered in the world-routine life of nursing and, in contrast, on the reasons-for the implementation of the SNC, the typical action was designed, i.e. actions that must be performed to implement the SNC: professionals have to be united; multi-professional work must be implemented; professionals need to feel love and be responsible and sensible in their actions; ideas must be renewed; and the institutions in charge have to be more active.
To achieve this, professionals must fight to fulfill their wishes, contributing to the improvement in their professional practice: [...] while there is life, there is hope, so we are always fighting for better work conditions and for people to really be sensitive to patients (NT13).
Additionally, the NT understand that such achievements are only possible through a process of improvement:

[...] it's through education that we can learn this [...] much can be improved through studying and we would have better systematization for all (NT3).
Moreover, it is essential to integrate the NT into the process of consolidation of the SNC, revealing the urgent need to include this theme in the curriculum of technical nursing courses, explaining the roles and responsibilities of each nursing team member 10,11 .
Therefore, the typical NT are critical and thoughtful, with a biographical situation that allows them to believe in the positive aspects of the SNC, despite having an academic background that did not emphasize its essential theoretical aspects.They defend the idea that the benefits of the SNC surpass the difficulties encountered in the world-routine of nursing and that they want to experience the change towards nursing for knowledge, tracing a path that the team can follow, aiming to achieve qualified, holistic and goal-oriented health care.

FINAL CONSIDERATIONS
The discussions held, which were benefited by the use of Schutz' theoretical framework and the establishment of the focus group regulated by the Humanescent Existential Pedagogy, contribute to the emphasis on the relevance of debating the key interface of the NT to fully implement the SNC, which must be founded on an educational process integrated with this systematization.
It should be noted that the results shown represent a specific reality, influenced by the NT's curriculum, an aspect that restricts the study.In this perspective, it is suggested that there should be reflections in each micro-space of nursing.
Thus, contributions are expected to be made for the area of nursing to be increasingly consolidated.To achieve this, it must be understood that the historical dichotomy that causes thinking and executing to be further apart has to be overcome, considering the NT to be key professionals for the SNC.
Consequently, the process of qualification of the NT needs to be reviewed, definitely including the theme of the SNC in their curriculum.In addition, these discussions must also be incorporated into the qualification of nurses, as the SNC should be the result of a process that integrates all categories of nursing professionals.