A cultura hospitalar na gestão do cuidado integral à criança com doença crônica e a prática do enfermeiro

Abstract

Based on the principle of integrality, care management requires a culture of integration between services and interaction among professionals in the levels of complexity of the Health Care Network, associated to the reorganization of the work processes of professionals. A demographic and epidemiological transition is experienced in the healthcare of the child due to the prevalence of the chronic disease. This new standard of health and disease imposes an extended care model, consistent with the proposal of the Unified Health System. In this child healthcare management, the insertion of the nurse as coordinator of the nursing team or as care manager is of fundamental importance. The objective of this study is to analyze the influence of hospital culture on the organization of care management for children with chronic disease or health condition in a pediatric unit of a general university hospital and the nurse´s role. This is a descriptive and analytical study of a qualitative approach, based on the principles of institutional ethnography as a theoretical and methodological reference. The research site is a unit of pediatrics of a university general hospital in a capital of northeastern Brazil. The study population included the professionals of this specialized unit with a total of 20 of them including nurse, psychologist, nutritionist, physiotherapist, pharmacist, social worker, and physician. The data collection instruments used were the participant observation technique, the field diary, the documentary analysis and the semi-structured interview carried out from May to August 2017. The information collected were analyzed followed the Bardin content analysis technique, helped by the Scientific Software Atlas version 8.0, emerging the following categories: institutional culture of the management of the care of a pediatric unit; visit as a management mechanism of care; nurses' performance in child care management; potentialities and weaknesses in care management. The results analyzed showed a culture of care management under the influence of the hegemonic care model, fragmentation of attention and care, although it glimpses advances in the multi-professional work. Also, the medical visit stood out as a care management mechanism with potential to strengthen teamwork but needs to be rethought to become effectively inter-professional. In this context, Nursing Care Management understood as the articulation and integration between care and management actions, through the exercise of leadership, interactive, communicative and cooperative relationships is developed by a professional nurse with a care profile, who performs all the stages of the Nursing Process. However, the nurse sees herself as a manager since she organizes and mediates the relationships between the doctor, the patient and the different professional categories to provide the material conditions necessary for the care process. Similarly, other professionals see the nurses with a responsibility beyond care management, as a possible consequence of the nurses´ historical, cultural and social reproduction as the service organizer. Given this, nurses feel overwhelmed, hindering to integrate the managerial and care dimensions, as well as their communication and articulation with the Child Health Care Network. Finally, the physical structure of the university hospital and the patient safety project stood out as potential for the management of care. However, local fragilities related to the lack of definition of an organized care management model in the team and difficulties to continue home care were evidenced.