Nursing work in pediatric emergency from the perspective of the companion

Objective: To analyze nursing staff working process in caring for children in an emergency from the caretaker's perspective. Methods: Qualitative study developed through semistructured interview with 20 companions of children assisted in a pediatric emergency unit of a hospital in Rio de Janeiro, participants from Programa SOS Emergência. Thematic Analysis was used for data processing. Results: Nursing work process has the agility in saving lives, the humanization in care through conversation and explaining the procedures to the child and its companion as the ideological base. The nursing work suffers influence of material and physical resources available in the hospital and the disruption of the health care network. Conclusion: To complement nursing work process started in the pediatric emergency, care advising and restructuring assistance network for children in all Health Unique System levels are necessary.


INTRODUCTION
In recent decades, the pediatric public hospital emergencies lived periods of overcrowding, since the demand was greater than the service offering 1 .This happened because in these places were met situations that do not constitute health emergencies and could have been resolved in less complex places, such as primary care.The high proportion of children with health problems that can be solved at the primary level and which fills hospitals bring repercussions to the work process of the nursing staff.
In pediatric emergencies, the focus of attention is primarily the children, but not exclusively, since they are entitled to a companion, who should also be targeted for assistance 2 .In these places, the work process of the nursing staff must be centered on care practice, educational and management of the health service 3 , as well as the need to take care of children in emergency situations and their companions.
In this sense, the work process in health occurs at the time of the professional-user meeting, being therefore a work alive in act.That is, it is the meeting of the companions and the children attended in the pediatric emergency hospital with health professionals.In addition, the worker process in health also involves configuring a complex network with the elements relating to the subject (needs, desires, interests), with social networks (production mode, mechanisms of ideological modeling) and with the own health services management (public policies, financing, management strategies) 4 .
Taking care of the pediatric clientele requires from the professional, technical and subjective caring that involves the uniqueness, individuality and the way the child expresses his feelings and emotions 5 .Thus, when it is in risk of death situation in an emergency room, a nursing care plan is needed, covering the care required and indispensable to sustain life as well as promote attention to the companion 6 .
The lack of humanized relationship between health professionals, specifically nurses, concerning the child and the companion can change the work process of the nursing staff in order to bring negative impact on the child's clinical recovery, prolonging the period of stay in the hospital, accentuating their weaknesses and compromising the assistance provided 2 .
In an attempt to improve the efficaciousness in hospital emergency services, the Federal Government created in 2011, the Network Assistance of Urgencies and Emergencies ("RUE") within the SUS, which found reinforcement for its implementation with the Programa SOS Emergência in 2012 6 .
The creation and implementation of new public policies in the reorganization of urgent and emergency services, from the perspective of network services, reflect directly on practice, in the process of work and nursing care 7 .
The area of knowledge of nursing management where is located the work process of the nursing staff, has been studied by the nurse's perspective, focused on care in the teaching-learning process, in the training of nursing professionals through health education, on the quality of care, focusing on process and product 8 .Other studies have addressed primarily the management of hospital services of assistance to adults, and did not give visibility to the work process of nursing in pediatric emergency through the escort of the child, who is also a user of the health service 2,9,10 .
Internationally, the studies have shown that the focus was on family and health professionals with greater concern in emergency care in primary health and home care of children, in order to avoid unnecessary emergency calls 11,12 .
Through the invisibility of work process of nursing in the pediatric emergency department, considering the companion's perspective, and also in the context of new public policies of reorganization of the attention networks of emergency, the production of this study is justified.The question that guided this investigation was: What are the perceptions of the companion about the work of the nursing staff in the care of children in an emergency?Thus, it aimed to analyze the working process of the nursing staff in the care of children on the accompanying perspective.

METHODS
This is a descriptive-exploratory study with a qualitative approach, developed in the pediatric ward of a General Hospital located in the State of Rio de Janeiro, which has pediatric emergency department with eight beds.The children's access to the Pediatric Emergency Department is referenced by the Regional Emergency Coordination ("CER"), which was created and implemented through the Programa SOS Emergência.Direct access to the hospital is guaranteed only for children transported in ambulances of the Mobile Emergency Service ("SAMU") and the Mayday Group ("GSE"), of the Military Fire Brigade of the State of Rio de Janeiro, with diagnosis of trauma.
In Rio de Janeiro, the implementation of "RUE" was given through the Regional Emergency Coordination ("CER"), located near the large general hospitals.It is a 24-hour service that covers the cases of less complexity, leaving the hospital freed up for the trauma and surgical cases.These services are part of the healthcare network of the local population.In 2015, there were five "CER" to assist the people, distributed in different geographical locations 7 .
The sample consisted of 20 children's companions who were in the Pediatric Ward.Inclusion criteria were: companion with more than 18 years old who remained with the children in the emergency department and then forwarded to the pediatric nursing, and who agreed to participate.Exclusion criteria were: children's companions transferred from other hospitals and remained not admitted to the pediatric ward, after the emergency care.
The data were generated in September 2014 from semistructured interviews guided by a form containing 11 questions

Nursing work in pediatric emergency
Neves FG, Moraes JRMM, Morais RCM, Souza TV, Ciuffo LL, Oliveira ICS related to the characterization of the participants, the reason of child's attendance in the emergence and even questions about the work of the nursing staff in the emergency pediatric sector.The construction of this instrument was based on the work process Merhy 4 .All the interviews were conducted by first author, had an average duration of 20 minutes and were recorded in full in MP3.
The companions who met the inclusion criteria were invited to participate in the research and clarified about its objectives.Interviews were conducted in the afternoon hours, after the completion of medical visits and nursing because it is considered a quieter time in the pediatric ward 3 .There was no refusal on participation and none of the companions, during data collection or after, expressed the desire to abandon the study.The number of participants was defined during the fieldwork, when the organization of the depositions made possible the identification of data saturation, that is, the existence of recurrence of ideas, practices and worldviews 13 .
All participants signed a Consent Form.In order to ensure the confidentiality and privacy, it was used the word "Companion" (Companion 1, Companion 2, Companion 3, etc.) to identify the participants, as the order of conducting the interviews.The study was approved by the Research Ethics Committee of Secretaria Municipal de Saúde e Defesa Civil in the Municipality of Rio de Janeiro, under the number 2017A/13.
The empirical data generated in the interviews was analyzed by the method of thematic analysis 14 , following the three steps proposed, being: pre-analysis, which consisted of floating reading and constitution of the textual corpus; exploration of the material with the transformation of raw data into thematic categories; processing and interpretation of results.

RESULTS
From the perspective of the companions, sought to describe the nursing work process to children in emergency situations in a public hospital, to be presented in two thematic units, namely: nursing care: agility and efficiency; and the management of health services: material resources and physical structure.
About the 20 participants of the study, all possessed bonds of consanguinity and resided in the same household of the child, 18 of these escorts were mothers and two, grandmothers.The companions were aged between 20 and 60 years.Attendance reasons at the pediatric emergency room were due to respiratory diseases, trauma, acute abdomen, skin disorders and neurological disease.

Nursing care: agility and efficiency
The evaluation of companions about nursing care to children in emergency situations revealed that the treatment was carried out quickly and efficiently, demonstrating competence of nursing professionals.

Agility and resolution (Companion 17).
From the speech of the companions it was evidenced that the nursing service was quick, cautious and decisive in the pediatric emergency department.These characteristics attributed to the nursing staff contribute to saving lives.
Participants also emphasized the skills of nurses and nursing technicians who work in the pediatric emergency room, the scenario of the study: I think that having professionals who can work well because they are taking care of lives and it is a very big responsibility.We deliver our children in their hands.(Companion 1).

Professionals who are trained to perform a good service (Companion 18).
In this perspective, the lines have expressed that the needs and interests of companions and children were provided by a competent nursing staff, which works well, is capable and transmits responsibility in care for the child in emergency situation:

Because they explained to me how he (child) was, if he had gotten better or not. (Companion 6).
Because even though my son is not full of units like the others, they would always know if he was okay and if he needed something.

They treated my granddaughter with a lot of patience and as for me, I have no complaints. They were very polite and friendly (Companion 16).
In general, the companions reported a satisfactory interpersonal relationship in which the nursing staff were friendly, helpful and patient.
From the speeches of the participants of this study have been shown the production methods of nursing care, which is socially patterned having as ideological basis how quickly the child's care in emergency situation is, coupled with care, attention and humanization.

Management of health services: material resources and physical structure
In this analytic category are presented the lines of the companions referring to the physical structure and material resources that are related to the management of the health service.

The chairs we slept are bad and uncomfortable (Companion 3).
The structure of the hospital is very bad, the beds and baby cribs are old and, in some, the grid does not raise

[...] (Companion 4 and Companion 6).
Relating to the material resources, specifically when it comes to durable goods, chairs intended for the accommodation of the participants in the study were described as bad and uncomfortable for the companions, not corresponding to the individual requirements of comfort for sleep.These participants also talked about baby cribs and beds for children, explaining that they did not work properly, because the protection grid did not work, which could compromise the safety of the child.
Still with regard to material resources, the necessary equipment for nursing care to children in emergency situations were also pointed out by the participants of the study.

[...] The system sometimes does not work and we have to wait for the team to find out one that works (Companion 2).
For my son, thankgoodness, there was no lack of anything, but I saw that for one child it was missing a device (monitor), I think that the one they had was obsolete (Companion 4).

[...] The equipment operates [...] (Companion 8).
The companions mentioned devices and monitoring equipment of the child and that assist the nursing care, in an ambiguous way.For Companion 2, there is a system, however, not always working and nursing spent time looking for an equipment that was suitable for use.Companion 4 pointed out the lack of equipment and mentioned that the device that was available for use was old.And Companion 8 presented an ambiguous speech to the previous ones because the equipment functioned in his opinion.
As for the physical structure, study participants evaluated the hygiene emergency sector and also the physical space of the place:

For being a very big hospital, I found the structure good [...] (Companion 11).
In my opinion, the emergency is clean and cute, with everything in its proper place (Companion 5).

For me, the place was small and with lack of privacy because the beds are very close [...] (Companion 18).
Regarding to the physical structure of the hospital, there was no uniformity in the statements.Companions 3 and 18 pointed the structure as poor and dirty environment, while Companions 5, 11 and 17 mentioned that the structure is good, organized, clean and with good indoor lighting.

DISCUSSION
In the context of pediatric emergency, nursing professionals are essential in the management and work process.Thus, the nurse, as a leader for the nursing staff 3 and clinical knowledge holder should be responsible for the users of the service stream according to acceptance and risk classification.The reorganization of pediatric emergency care, following established protocols and prioritizing the care of severe cases, can contribute to reducing the risk of death and increasing life expectancy 10 .
In Brazil, it is not mandatory that the nurses who work in emergency sectors are experts or trained in the area.However, the professional should provide assistance within the ethical precepts of its profession, with quality and commitment in improving the care provided to the child and to user interests.In the work process, the nurse and its team must be competent, trained, skilled, thus improving its practice, since the work in imminent risk of death situation requires a fast, interactive, complementary and multi-professional care 15 .
Different from the Brazilian reality, in the United States it is mandatory that the nurse do the two-year course of training before developing their practice in pediatric emergency healthcare.Only then, this professional can work in this sector.In that country, there are still several teams of nurses working in pediatric emergency, dividing the assistance in areas such as: cardiopulmonary resuscitation, venous access, among others 16 .
The nursing staff is permanent and constant in pediatric emergency services.These professionals are responsible for maintaining the standard in customer service, manage risk, and ensure quality 16 .Based on the lines of the respondents, it was identified that the ideology of the work process is focused on the agility of care, attention and the ability of nurses to provide humanized care, which does not necessarily require devoting more time to the child, or having ideal working conditions.Being enough just to know how to say direct words of comfort and safety, give real attention to the person, talk to them, and let them express their feelings 4,17 .
The humanization in the work process of nursing also manifests through effective communication, which is suitable when occurs individualized, whenever the professionals relate with the companions in an affectionate, loving and respectful way, and developing sensitive listening.So, it establishes

Nursing work in pediatric emergency
Neves FG, Moraes JRMM, Morais RCM, Souza TV, Ciuffo LL, Oliveira ICS a relationship of help, trust and creates a link between the professionals, children and companions, which facilitates the process of care.Thus, communication is a way to make the emergency care less traumatic 2 .
Thereby, the model of care and management in health is still predominantly centered in the cure, and should not, in this sense, exclude the opportunity to work the aspects related to prevention.There is a greater appreciation of the disease, with the need to search for emergency care, which for many decades overcrowded hospitals.It was necessary to invest in specific public policies, like Humaniza SUS, Rede de Urgência e Emergência and SOS Emergência to ensure access to hospitals in truly emergency cases.Despite advances and investments in primary healthcare, the preventive model is still emerging in Brazil [6][7][8] .
The management of health services is inherent in the work process of the nursing staff.Aspects such as hospital infrastructure and furniture interfere in assistance provided.The maintenance of durable goods, as well as adapting to the profile of clients served, is the responsibility of managers in health and nurses.It is up to this professional managing emergency units and identifying deficiencies in access, efficiency and quality care, as well as discuss, negotiate and decide on the allocation of financial resources of the hospital 11,12 .
Still referring to the structure and physical resources in the pediatric emergency department, it must provide a safe environment for the child, their companion and for the healthcare professional.In this way, it aims to be a risk-free service without increasing the vulnerability situation to which the child is already exposed to 17 .The child safety maintenance increases when the nursing staff receives constant training.Thus, it is able to predict possible threats arising from the risks related to patient safety, such as mistakes with the medicines administration, misuse and/or lack of equipment, human resources, with regard to lack of technical skill, as well as inefficient communication between different health professionals and companions 18 .
In an attempt to minimize the risks in patient safety, nursing staff should receive training through simulations of caution to the user.This mode presents the advantage of identifying latent threats in patient safety and gaps in the knowledge of professionals, as well as reinforce positive work behaviors in team 19 .
For the companions interviewed in this study, the child's safety is guaranteed with the use of appropriate furniture, such as beds and baby cribs with grids that operate and avoid the risk of falling.In addition, availability, functionality and adequate number of monitors and devices for healthcare were also identified as inherent in the working process of the nursing staff in childcare in emergency situation 4,20 .
The beds and baby cribs, as well as monitors, must be in adequate number and size and in perfect condition for use, ensuring comfort, privacy and recovery with safety.The provision of this furniture and material should be a facilitating instrument of the work process, interpersonal relations between user and staff in a welcoming, resolute and humanized way 20 .
Technological resources, such as the monitors to assist in the care of the child must be working in proper amount to the number of beds.The unpredictability of material resources and equipment for nursing care, as well as hinder the action planning, sometimes expose the user to the improvisation and risks and the employee, to embarrassing situations.The Brazilian law that regulates the operation of hospitals in articles 50 to 55 determines that emergency units must have suitable equipment and materials to the complexity of the service needed to meet the demand, and should be properly regulated according to that institution 20,21 .
In the unit, it must be included written instructions relating to the use of equipment and materials, preventive and corrective maintenance on equipment and an operational reserve, according to the manufacturer or engineering service of the institution 21 .
The work environment should also be a safe place so that health professionals can provide quickly and effectively assistance.In pediatric emergencies, natural and artificial lighting are extremely important, both of them, when well designed, may result in soothing and welcoming stimuli for children and their companions, meeting part of the need for biological and psychological well-being.A healthy work sector for the nursing staff should also be well lit, since the care developed by these professionals is sometimes tiring and involves physical effort.A good lighting prevents fatigue and unnecessary visual effort 22 .
It is important to remember that when users choose the health services where they want to be served, they do it based on the geographic area, resolution, quality, agility, access, provided care and by the information available on their network.Thus, the network takes an important role in the manifestation of needs, desires and interests, as well as in the mode of production and ideological modeling mechanisms of the individuals who constitute it 4 .
Individuals entered in the social network of child's companions met in the pediatric emergency can also be co-responsible for breaking with the ideological model of assistance only on the part of professionals and managers 4 .SUS users must be active and engaged in building a better health system, through social control and supervisory activities.The children's companions, as users, must have active and representative voice in the National Health Council, in the hospital ombudsman, and in the encounter with the health professionals, strengthening the network 17 .In this way, professional managers and users can search for a health production model to be accrued in efficaciousness in the assistance 4 .

CONCLUSION
The nursing work process in the pediatric emergency room has as ideological basis the premise of saving lives; the humanization through conversation, explaining the procedure to the child and the companion.

Nursing work in pediatric emergency
Neves FG, Moraes JRMM, Morais RCM, Souza TV, Ciuffo LL, Oliveira ICS To analyze the work process of the nursing staff in the care of children in emergency situation, it was highlighted the difficulties for implementation nursing actions due to the scarcity of material resources and problems related to the furniture, which affects directly in the care of nursing as part of the work process.
As for the physical structure of the hospital, there was no uniformity in the lines because some companions classified it as insecure and dirty environment, while others stated that the structure was good, clean and organized.Referring to the furniture and hospital equipment, it must ensure the development of appropriate assistance for the maintenance of the child's safety and also for the safety of nursing professionals during their work.
The implication for health assistance practice evident in this study is the need to strengthen the hospital emergency, which should also be an area of childcare orientation, with evaluation of their growth and development, and for the implementation of homecare, after the emergency attention.It is necessary that the companions are oriented on the functioning of the network of health care; which situations of urgency may have recourse to help in Family Clinics and Emergency Units ("UPAs") and when to resort to hospitals and Mobile Emergency Service ("SAMU").The guidelines and referrals within the healthcare network of "SUS" are essential for the proper functioning health system and avoid overcrowding of emergency hospitals.
Limitations of the study are related to the fact that this has been developed with a small number of participants in a unique hospital, which is member of the public policy of the Programa SOS Emergência.