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Intensive and Critical Care Nursing (2016) xxx, xxx—xxx
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/iccn
CLINICAL RESEARCH ARTICLE
Intensive care nurses’ practice related to experience and shift worked Rafael Celestino da Silva a,∗, Márcia de Assunc ¸ão Ferreira a,b,1, Thémis Apostolidis c,2 a
Anna Nery School of Nursing (EEAN)/Universidade Federal do Rio de Janeiro (UFRJ), Rua Afonso Cavalcanti, n◦ . 275, Cidade Nova, Rio de Janeiro, CEP-20211-110, Brazil b Brazilian Scientific and Technological Development Council — CNPq, Rua Afonso Cavalcanti, n◦ . 275, Cidade Nova, Rio de Janeiro, CEP-20211-110, Brazil c Aix-Marseille Université, Laboratoire de Psychologie sociale, 29, avenue Robert Schuman, 13621, Aix-en-Provence cedex, France. Accepted 28 December 2015
KEYWORDS Intensive Care Unit; Nursing; Nursing care; Social psychology
Summary Objective: To analyse the social representations of nurses about intensive care practices comparing the variables 1) time since graduation and 2) shift worked. Method: Qualitative field research using social representation theory. Individual interviews were conducted and lexical analysis was applied. Study setting: Intensive Care Unit of a federal hospital with 21 clinical nurses. Findings: Day shift nurses are more pragmatic and operationally oriented because they deal directly with the general functioning of the unit. Less experienced nurses face difficulties dealing with intensive care contexts, but have a critical view of their practices, while more experienced nurses apply practical knowledge in their decision-making and actions. Conclusion: The relationship of proximity or distance from patients, mediated by technology, is related to the domains of knowledge that are required to manage technology and to the role technology plays in intensive care. © 2016 Elsevier Ltd. All rights reserved.
∗
Corresponding author. Tel.: +55 21 22930528. E-mail addresses: [email protected] (R.C. da Silva), [email protected] (M.d.A. Ferreira), [email protected] (T. Apostolidis). 1 Tel.: +55 21 22930528. 2 Tel.: +33 442953815/663023575. http://dx.doi.org/10.1016/j.iccn.2015.12.006 0964-3397/© 2016 Elsevier Ltd. All rights reserved.
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Implications for Clinical Practice • Nurses’ practice in the Intensive Care Unit is influenced by their work hours and professional experience. • Day shift nurses are more pragmatic, because of the daily reality of this shift; night shift nurses are less pragmatic, reflecting the difficulties during this shift. • Inexperienced professionals work based on theory, attempting to apply technologies to care and management. Experienced professionals use technologies according to their practical knowledge, integrating it in their activities. • Differences in the professional variables should lead to consideration of interventions to foster improvements in this clinical practice.
Introduction Nursing care practices in the Intensive Care Unit (ICU) influence the care modes of nurses. Nursing care in the ICU requires the ability to cope with complex situations rapidly and precisely, requiring competence to integrate information, make judgements and set priorities; understanding of technological language and mastery and interpretation of machine codes to take care of patients; and humanisation and valuing of the patients’ subjective experience (Backes et al., 2012; Mattox, 2012; Silva and Cruz, 2008). These aspects characterise clinical care practice that is typical of the ICU and of the nursing care to critically ill patients. This care involves objective and subjective elements that are combined with technical skills, technology and humanisation (Silva and Ferreira, 2013). The characteristic elements of this clinical nursing care influence professionals’ actions and organisation of care practices in the ICU. One of these elements is the intensive care nurse who delivers the nursing care. Various kinds of nurses work in the ICU and they understand, interpret and behave differently when confronted with the same situation (Jodelet, 2009) due to the different social conditions that define and distinguish them as social subjects. Two social conditions that distinguish them are professional education and work shifts, which influence their experience and their knowledge development process (Jovchelovitch, 2008). There is evidence from the analysis of knowledge on this theme that points up the role of psychosocial and professional variables and their influence on professional practice, particularly in intensive care contexts. Benner (1984) considers that knowledge is related to experience, which in turn leads to proficiency, a condition of authority based on the relationship between theoretical and practical knowledge, and distinguishes between novice and expert nurses. In an ethnographic study of how quality is incorporated into the ICU nursing culture, it was identified that one of the main themes affecting quality and safety that contributes to satisfaction with clinical practice was expert knowledge, gained through experience and formal learning (Storesund and McMurray, 2009). Inexperience negatively influences patient safety. It was one of the factors related to 1472 incidents involving medications, airways, equipment and procedures that were identified in an ICU in a study based on monitoring (Morrison et al., 2001).
A study of the profile of nurses working in an ICU presented the education and qualification characteristics of these professionals. A large number of nurses had worked in the ICU for less than three years, which showed the low theoretical and practical experience in this high-complexity care. It was concluded that the nurses needed to develop competence to deliver safe and high-quality care (Camelo et al., 2013). The introduction of novice nurses in work settings represents a period of transition from a known to an unknown social context. This causes concerns and changes, during which there are discrepancies between what they know and do and what they need to know and do (Silva et al., 2010; Valadares and Viana, 2009). With regard to work shifts, the authors of various studies have sought to establish a relationship with occupational health and professional performance, mainly for professionals working night shifts. In a study that assessed the effects of working during the night shift among 102 workers from the ICU and the coronary care unit, the effects found were stress, tachycardia and drowsiness after work (Veloz et al., 2009). Another study found that the correlation between the shift worked and stress and resistance levels among 72 nurses in a university hospital showed that night shift workers experienced higher levels of stress and less resistance and control, showing the impact of working during the night shift on the lives of workers (Batista and Bianchi, 2013). Working at night entails challenges and peculiarities that affect professionals’ behaviour. One study conducted with 18 Iranian nurses working the night shift highlighted the negative sociocultural image of the night shift, its effects on health and the opportunity to acquire greater clinical experience (Nasrabadi et al., 2009). These findings provide evidence that people’s social places and functions influence the way they cope with their daily experiences (Jodelet, 2009). The variables that characterize nurses are relevant to analysing clinical nursing care in the ICU, as they influence ways of thinking and acting on the other elements of that care. A previous study by the same authors of social representations about ICU nursing care practices showed differences in the construction of these practices and in the function of these professional variables (Silva et al., 2014). The findings of this analysis support the hypothesis that time since graduation and work shifts affected how nurses
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Intensive care nurses’ practice organised social representations concerning care practice in the ICU. The refore this study asks the research question ‘‘How do the variables time since graduation and work shift influence the clinical care practices of intensive care nurses for ICU patients?’’
3 professional variables of the study participants and the potential differences among them in the construction of these representations.
Method Design
Theoretical framework The social representation theory, proposed by Serge Moscovici and developed by Denise Jodelet, is based on social psychology. The theory explains the way individuals and groups construct knowledge in interaction with society, based on their social characteristics (Arruda, 2002). During a paradigmatic shift in the 1980s, it expanded through the development of a scientific paradigm focused on subjective phenomena. Its epistemology acknowledges the subjective, affective and cultural dimensions of human actions and the construction of knowledge, which should be explored in scientific production (Arruda, 2002). The theory posits that people use different ways to understand and communicate in the world: consensual, which consists of informal conversations; and reified, which occurs in the scientific sphere. Social representations are developed in the consensual, non-disciplinary universe, in which people are allowed to express an opinion about anything (Arruda, 2002). People talk about different themes and produce commonsense theories to interpret and construct social reality, based on contact with novel situations, especially in the scientific sphere. The dissemination of these novel situations through mass communication media generates the need to process them (Arruda, 2002). In particular, when they are relevant, current and socially important, they need to be known. Hence, people produce and communicate their social representations, proposing solutions for problems based on social interactions. Social representation theory concerns the social construction of knowledge, which is mediated by public discourse within groups, and how this knowledge is reflected in the actions of those who construct it. Everyone constructs representations, even those who have technical scientific knowledge regarding the object under study, because meanings, senses, affections and social knowledge are mixed with knowledge arising from the universe of science during the socio-cognitive process, which gives them new meanings. Understanding the representations concerning intensive care contributes to better understanding of the motivations from which they originated, beyond the universe of science that explains them. This, in turn, permits understanding how certain care actions and styles are constituted, which influences the quality of care delivery. These care practices are socially relevant for this group of nurses, since they change their behaviour in light of the existence of the practices, which then configure as an object of social representation (Jodelet, 2009). Reflection concerning who exactly was the subject constructing these representations and what the context was raises questions regarding the influence of the psychosocial and
In this qualitative study, the aim was to analyse the occurrence of the variables ‘‘time since graduation’’ and ‘‘work shift’’ in the social representations of registered nurses concerning the care delivered to ICU inpatients.
Sample and location of the study The location was the ICU of a federal hospital in the city of Rio de Janeiro, RJ, Brazil. The establishment consisted of 24 nurses and the sample included 21 nurses who provided direct care to patients. Three nurses were excluded because they were on sick leave or were active exclusively in management. The nurses were not selected based on their psychosocial and professional characteristics, but these data were collected to support the analysis of the conditions in which the representations were produced. Most of the nurses had graduated up to 10 years earlier (61.9%); 52.4% were up to 35 years old; 57.1% had two jobs, worked the day shift and were experts in intensive care; 66.7% chose to work in the ICU; while 71% had up to five years of experience in the location of the study. The nurses were categorized according to the variables selected for this study, and the remaining characteristics were used to complement the analysis. A total of 17 women and four men participated in the study; 11 women and one man worked the day shift, and six women and 3 men worked the night shift; 9 women and 4 men had graduated less than 10 years ago, and eight women had graduated more than 10 years ago. The shift was 12 hours a day with 60 subsequent hours off, similar to the schedule used in most Brazilian hospital facilities. The day shift was from 7 a.m. to 7 p.m. and the night shift from 7 p.m. to 7 a.m.
Data collection Data were collected from January to May 2011 through individual interviews based on a script containing closed questions addressing gender, age, time since graduation, number of jobs, choice of unit and expertise. There were open questions addressing ICU practices, style of care delivery and use of technology. The interviews lasted one hour and thirty minutes on average, were conducted in the afternoon in a private room in the ICU and were digitally recorded.
Data analysis The discursive data were analysed using Alceste 2010 software (lexical contextual analysis of a set of text segments) in cross-data analysis.
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This programme identifies significant lexical worlds based on study of the organisation and statistical distribution of the main words (substantives, adjectives and verbs) in a discourse fragment. The lexical worlds are defined in opposition to one another, granting rationality and coherence to what the speakers are saying (Alba, 2004). In the cross-data analysis, the material submitted to analysis is tested with regard to the existence of differences in the production of the discourse based on the selected variables. The programme crosses the variables and, if differences exist, thematic classes related to each variable are generated. The classes contain the most prevalent lexicons, considering the Chi-square and percentage of each word’s occurrence, and excerpts of interviews called units of elementary context (UEC) are where such lexicons are present. Interpretation is based on the analysis generated by the software. The data file was processed with the software in two testing cycles: The first cross-analysed the differences based on the categorization of the day and night shifts; the second was based on time since graduation. Two reports were developed; one addressed work shift and the other addressed time since graduation. The reports indicated what other psychosocial and professional characteristics were associated with each class. The lexical worlds were interpreted in conjunction with the study’s central question, the theoretical framework and the related literature. The findings were analysed from a comparative perspective, using the most significant lexicons and the most relevant units of elementary context for each variable, highlighting the differences in the production of discourse concerning the object.
Ethical aspects The project received approval by the Institutional Review Board (Protocol 35/10) according to the guidelines of the National Council regulating research in Brazil. The nurses participated voluntarily and signed an Informed Consent Form. The identification codes of the discourse were: N — nurse and a number corresponding to the order of the interview; Ni — night shift; D — Day shift; G1 — less than 10 years since graduation; G2 — more than 10 years since graduation; corresponding UEC number.
Findings and discussion The research findings are based on the authors’ preliminary research on nurses’ social representations about their ICU care practices (Silva et al., 2014). Therefore, the data presentation and analysis will rest on the two categories that organize these representations: the first is related to the patient and work in the ICU; and the second to technology. In the category that discusses daily care for ICU patients, the influence of the variable work shift was verified. The day shift nurses described more practice-centred thinking, with positive feelings, especially gratification because they were able to follow the recovery of critical patient. The discourses of the professionals from the day shift were in the first person singular, including verbs such as I say, I give, I am
and I speak, indicating the care style used for this recovery, referring to the routine and to the patients. My style of providing care, first with love, yesterday I got so happy, whenever I go to the ICU and take a look at the patients. UEC 2081, Nurse 14, day shift I’m a homecare person, regardless of whether it will take two or three hours, I pay attention to every detail; If I have to clean someone’s ears, I don’t do it superficially. I like combing, cutting and sanding nails. I take care of patients as if they were my own family. UEC 28, Nurse 1, day shift About care practice, those working the day shift described activities and elements of management and care practice, namely: procedures (e.g., bathing), technology (e.g., parameters), delegation of functions (e.g., leadership) and the human aspect (e.g., humanisation). I ask: begin giving the baths. UEC 844, Nurse 6, day shift I feel a blockage in certain situations that require leadership. I don’t mean in care delivery, because I know what I have to do and I know how to delegate tasks. UEC 1363, Nurse 9, day shift Technology is important to provide parameters: install the ventilator; the patient has metabolic acidosis due to diabetes; the patient suffered cardiac arrest. UEC 250, Nurse 3, day shift These lexicons illustrate the day in an Intensive Care Unit, which includes agitation, presence of the family, practice of procedures, interaction with the multiprofessional team, justifying the use of a language that indicates proximity, objective and subjective elements of care in relation to patients, the care tasks and the use of auxiliary instruments. The nurses working the night shift talked generically about the context of intensive care. They were concerned with training, the number of employees and structural problems affecting the performance of workers. The words training, care, intensive care and care exemplify their concerns. My greatest concern is with qualification, how a professional working with intensive care is trained: ‘‘Is this professional trained away from a hospital bed?’’ UEC 2339, Nurse 15, night shift First, I think that there are external factors, other variables that interfere with care delivery. Currently, my main concern is the fact that I work in a public service with a deficient structure. UEC 3694, Nurse 21, night shift The use of terms like professional, behaviour and role takes place in a context of detachment when referring to qualities required for the execution of care and the types of professional and work methods that are outlined based on these qualities. Someone who realises the changes that are necessary and act, seeking the best for the patient. If we were able to aggregate these qualities, factors or elements in a single
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Intensive care nurses’ practice professional, we would perform quality intensive care that also received professional acknowledgement. UEC 2403, Nurse 15, night shift It is obvious that there are people who seek more knowledge while others do not seek much knowledge; it’s the attitude of each. UEC 3651, Nurse 21, night shift These data indicate negative elements in the subjective experience of night shift workers. Because of this, they construct a peripheral representation of practice, in which the discourse raises concerns about one’s profile and qualifications, institutional structure and the number of employees, care processes and the implementation of knowledge, which impact the care style of these nurses and their level of commitment to care delivery. The discourse about practice rests on the particularities that characterise the day and night shift and differ accordingly. In the data, it was observed that, on the one hand, the focus was daily care and on the other, the factors that influenced the care practice, according to evidence from other studies, focused on the work shift variable. This evidence highlights that, on the day shift, the nurses were active in direct patient care. In an observational study that analysed daily work activities in an ICU, 3,081 activities were documented over the course of 10 days. Among these, 40.5% of nursing time was focused on direct patient care, 32.4% on indirect care, 21% on personal activities and 5% on activities related to the service. The conclusion was only a quarter of their time was not spent on patient care (Abbey et al., 2012). These data support the data from another study that quantified the duration and frequency of nursing tasks in an adult and paediatric ICU, and found that more than 75% of the time was spent on patient care activities and approximately 50% on direct care (Douglas et al., 2013). A more in-depth analysis of the differences between the shifts shows, for example, that workload is a distinctive aspect. When assessing workload per shift in the ICU of a teaching hospital using the Nursing Activities Score (NAS), the scores were lower on the night shift and on weekends (Debergh et al., 2012). Hence, the engagement of day shift nurses in direct and indirect care is important to the analysis of their social representation on the practice. On night shift, the work is reduced, but the number of employees is also reduced, increasing the work burden allied with the physiological burden of working at night (Schmoeller et al., 2011). Measures of fatigue and physiological indexes taken before and after work for nurses who alternate shifts (day and night) and those working only during the day showed that nurses who alternate shifts experienced more fatigue and poorer physiological indexes (Yuan et al., 2011). A systematic literature review highlights the effects of shift work and night work, which are: chronic effects on health, mainly cardiovascular problems, and immediate effects like sleep disorders, reduced alertness, fatigue and susceptibility to error (Gemelli et al., 2008). Working shifts and long hours increases the risk of sleep disorders, which implies the risk of errors caused by fatigue and may affect patients (Caruso, 2014). In a sample of 289 nurses, 56% experienced sleep deprivation and made more mistakes in patient care, a characteristic associated
5 with the night shift (Johnson et al., 2014). The highest occurrence of mistakes during the night shift can also be explained by fewer opportunities and less access to qualification programmes than nurses working the day shift (Mayes and Schott-Baer, 2010). Therefore, social belonging for night shift nurses is the basis of their social representation, implying countless factors that hamper their work and which they consider when they think of their practice. One factor is the reduction in the number of staff on night shift; another is the performance of night shift nurses in the care process, in view of the profile required to work this shift. These experiences raise questions about how the quality of education influences the quality of care delivery. The second category that organised the representation about practice was related to technology, especially its function in the ICU. This is direct patient care, requiring professionals to be close to patients, as well as to management, since the equipment-generated information enables nurses to manage care at a distance and, at the same time, dedicate time to administrative activities. The cross-analysis revealed that the time since graduation influenced this representation. Although the nurses who graduated less than 10 years earlier (Group 1) mentioned more difficulties in dealing with care-related aspects due to their lesser expertise, they were more critical-reflective. This critical-reflective view of the practice of Group 1 nurses rests on their ways of acting, in view of the technologies and the functions attributed to them. The nurses in Group 1 frequently used the word issue, reflecting on the ways of acting, analysing the interface between proximity and distance, and objective and subjective information, both mediated by interaction with the patient, translated into the words: manner, interaction, neighbour and nurse. We can live perfectly with the objective and subjective issues of intensive care. I’ll do it as I do it within or outside intensive care. People deal differently with this. There are nurses who will be closer and nurses who will not. UEC 2327, Nurse 15, G1 Each shift has its own characteristics. I see shifts are divided; one nurse is close to the bed, more concerned with the implementation of care and more attentive to changes in the patients’ parameters, while another nurse is more concerned with complying with administrative routines. UEC 2249, Nurse 15, G1 Due to their characteristics, Group 1 nurses faced the problem of not having sufficient knowledge to perform care actions, leading them to compare what they learned during their education with reality and conduct an analysis of their professional situation and practice in relation to the factors that interfered with providing ideal care. This is what Group 1 nurses did when dealing with styles of care delivery that were outlined based on uses of technology. The use of the words: objective, proximity and technology, present in 100% of UECs, is typical of this group and reveals their concerns about the analysis of the data from the machines in the ICU and the relations of proximity with patients.
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R.C. da Silva et al. Everybody acts in accordance with this extremely relevant information [from equipment], but machines do not replace clinical assessment, do not replace the analysis of signs and symptoms, a physical assessment, a conversation. UEC 2887, Nurse 18, G1
Nursing education is strongly humanistic. Hence, when the nurses in the study faced a reality filled with bureaucratic activities, professional conflicts, work overload and a reduced number of workers, they associated these factors with limitations on their work in patient care and reflected on the greater or lesser proximity with patients. Those with a heavy work load on the day shift have impaired night work. People who accumulate work on the day shift have a more distant relationship with patients due to fatigue. UEC 115, Nurse 7, G1 Some nurses provide humanised, more considerate care, while others arrive too tired and discouraged with their current contexts or with personal issues. UEC 2237, Nurse 15, G1 Nurses from Group 2 adopted a pragmatic narrative, defending care, which characterized the action dimension of the social representation and expressed the symbolic sense of these actions. The priority of direct care instead of the administrative role is stressed. Autonomy is a bit of a concern. Not autonomy of care, but autonomy when you delegate. Unfortunately, some colleagues only want to delegate, they don’t want to do, and when you get away from care delivery, you get away from the practice, you are no longer seen as a nurse who is playing the role. UEC 3368, Nurse 20, G2 This need to prioritise direct care adds to their range of tasks and the solution of daily situations in this care. The activities are portrayed in the UECs composed of the words: family, pharmacy, blood, pump, chart, catheter and request. I get concerned, pay attention, if I’m going to install a blood bag, I check the patient’s name, the box, no matter how well you know, we know we really have to do it UEC 3127, Nurse 19, G2 I need to change the respirator, get the transport monitor, change the pump, some things we end up solving, but during the day it is easier with the auxiliary services. There is the head nurse, they support workers who help to solve problems. UEC 626, Nurse 5, G2 To comply with their tasks, the nurses fragmented the care, particularly administering medications, followed by direct care to patients. The discourses also alluded to experience, indicating appropriate ways to act towards patients. When they described the practical knowledge that they applied in their decision making, these nurses reported the frameworks on which they were based and that gave meaning to their practice.
You do not generate more suffering or complicate things for the patient, in addition to all other complications they experience; rather you try to prevent other problems that may emerge. UEC 3505, Nurse 20, G2 The data on Group 1 supported the study by Matheus et al. (2006), which showed the effort expended by new graduates to cope with the challenges of training and practice and to gain visibility in the context where they were inserted. This adaptation revealed the limitations of the care learned and the obstacles imposed, implying the need to broaden thinking, adjust benchmarks, and redevelop concepts, attitudes and competencies (Matheus et al., 2006). The entry of new graduates into the job market leads them to perceive the complexity of their practice, conflicts, political issues and bureaucratic demands, which enables them to analyse the gaps in their training in comparison with the reality of care delivery (Silva et al., 2010). They suffer prejudice from other professionals due to their inexperience and youth, and perceive that theoretical knowledge and critical ability are their allies. Despite their practical inexperience, new graduates seek to overcome difficulties by strengthening their knowledge and interpersonal relationships (Mattosinho et al., 2010). The lack of practice, especially related to administrative aspects and leadership, generates insecurities that require daily effort to overcome (Souza and Paiano, 2011). Novice nurses do not yet exhibit all the characteristics of the profile required to act in the ICU, with particularities in the way they experience intensive care (Viana et al., 2014). Technology is a theme of interest to intensive care nurses, which various authors highlight strongly in the literature, adopting two perspectives: that of the risks and benefits deriving from the use of these technologies; and the relationships with them constructed by subjects to take care of the patients (Funk, 2011; Marques and Souza, 2010; O’KeefeMcCarthy, 2009; Schwonke et al., 2011; Silva et al., 2009). These studies certify that the discussion about intensive care technologies is part of the debate in academic education and in practice, so nurses understand and know how to clinically interpret the machinery codes, in order to take care of the patients without entailing any risks for their safety or human condition (Marques and Souza, 2010; Silva et al., 2009). The technology arouses fascination, fear, admiration and the desire to master it. Hence, when the characteristics of Group 1 nurses are contrasted with the technologically complex characteristic of intensive care, this explains the interest in the technologies and the critical analysis of their application by the nurses. In Group 2, the technologies were not highlighted, but were part of the context in which care was provided. The knowledge elaborated about practice emerged as a product of care experiences, based on the examples of past actions. In this research, these actions indicated a fragmented care process, highlighted in other studies that have shown the need to overcome this fragmented practice, which is based on a hegemonic model that increases the professionals’ concern with medical prescriptions, bed baths and exams, to the detriment of stronger dialogue (Campos and Melo, 2011; Pirolo et al., 2011).
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Intensive care nurses’ practice The learning that occurs in practice is based on a set of tools used in professional practice (Assad and Viana, 2005) and rests on the care model. Therefore, the professionals picture their practices in the light of this model, as in the case of Group 2 nurses. Experienced nurses have an accurate view of the situation and solve problems in different ways than novices, as experience leads them to solve problems more efficiently. Prior experience guides the perceptions and actions of expert nurses, as they enable the workers to compare current situations with prior ones (Benner, 1984). That is the case for a study that explored the behaviour of a nurse considered to be an expert, in which expertise and practical knowledge led to changes in practice because the nurse under study possessed the clinical judgement inherent to an expert nurse (Arreciado Mara˜ nón et al., 2011).
Conclusions Although at a first glance, social representations seemed to be consensual among the group under study, a second analysis revealed areas of tension and differences according to the nurses’ professional characteristics. Those working the night shift developed a more peripheral view of practice, with aspects of the professional practice context, while those working the day shift experienced a more pragmatic routine concerning care delivered to patients but also focused on operational and organisational issues in the ICU. The nurses from Group 1 had more difficulty providing care in the ICU, but were nonetheless critical and reflective in relation to the relationship between theory and practice. The nurses from Group 2 mastered and applied practical knowledge in their everyday professional work. By valuing knowledge in relation to the subject who produces it, the findings confirm the theoretical assumptions of social representation, integrating cognition and communication with the social relationships that affect them, as well as with the material, social and ideal contexts in which they will intervene. We recommend investigating other characteristics to deepen and validate comparative hypotheses among groups that enhance the social marks of the representations.
Funding The authors have no sources of funding to declare.
Conflict of interest The authors have no conflict of interest to declare.
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Silva RCL, Kaczmarkiewic CC, Cunha JJSA, Meira IC, Figueiredo NMA, Porto IS. O Significado da Tecnologia no Pós-Operatório Imediato de Cirurgia Cardíaca. Rev SOCERJ 2009;22(4):210—8. Souza FA, Paiano M. Desafios e dificuldades enfrentadas pelos profissionais de enfermagem em início de carreira. Rev Min Enferm 2011;15(2):267—73. Storesund A, McMurray A. Quality of practice in an intensive care unit (ICU): a mini-ethnographic case study. Intens Crit Care Nurs 2009;25(3):120—7. Valadares GV, Viana LO. Vivendo o choque da realidade: a inserc ¸ão do enfermeiro na especialidade. Rev Enferm UERJ 2009;17(1):81—5. Veloz MNT, Pérez LCG, Triguero TM, Hernández BF. Efectos del trabajo nocturno en trabajadores de la salud de un hospital público universitario en la ciudad de Pinar del Río, Cuba. Psicol: Teor e Prát 2009;11(3):54—62. Viana RAPP, Vargas MAO, Carmagnani MIS, Tanaka LH, Luz KR, Schmitt PH. Profile of an intensive care nurse in different regions of Brazil. Texto Contexto Enferm 2014;23(1):151—9.
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Intensive and Critical Care Nursing (2016) xxx, xxx—xxx
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/iccn
CLINICAL RESEARCH ARTICLE
Intensive care nurses’ practice related to experience and shift worked Rafael Celestino da Silva a,∗, Márcia de Assunc ¸ão Ferreira a,b,1, Thémis Apostolidis c,2 a
Anna Nery School of Nursing (EEAN)/Universidade Federal do Rio de Janeiro (UFRJ), Rua Afonso Cavalcanti, n◦ . 275, Cidade Nova, Rio de Janeiro, CEP-20211-110, Brazil b Brazilian Scientific and Technological Development Council — CNPq, Rua Afonso Cavalcanti, n◦ . 275, Cidade Nova, Rio de Janeiro, CEP-20211-110, Brazil c Aix-Marseille Université, Laboratoire de Psychologie sociale, 29, avenue Robert Schuman, 13621, Aix-en-Provence cedex, France. Accepted 28 December 2015
KEYWORDS Intensive Care Unit; Nursing; Nursing care; Social psychology
Summary Objective: To analyse the social representations of nurses about intensive care practices comparing the variables 1) time since graduation and 2) shift worked. Method: Qualitative field research using social representation theory. Individual interviews were conducted and lexical analysis was applied. Study setting: Intensive Care Unit of a federal hospital with 21 clinical nurses. Findings: Day shift nurses are more pragmatic and operationally oriented because they deal directly with the general functioning of the unit. Less experienced nurses face difficulties dealing with intensive care contexts, but have a critical view of their practices, while more experienced nurses apply practical knowledge in their decision-making and actions. Conclusion: The relationship of proximity or distance from patients, mediated by technology, is related to the domains of knowledge that are required to manage technology and to the role technology plays in intensive care. © 2016 Elsevier Ltd. All rights reserved.
∗
Corresponding author. Tel.: +55 21 22930528. E-mail addresses: [email protected] (R.C. da Silva), [email protected] (M.d.A. Ferreira), [email protected] (T. Apostolidis). 1 Tel.: +55 21 22930528. 2 Tel.: +33 442953815/663023575. http://dx.doi.org/10.1016/j.iccn.2015.12.006 0964-3397/© 2016 Elsevier Ltd. All rights reserved.
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Implications for Clinical Practice • Nurses’ practice in the Intensive Care Unit is influenced by their work hours and professional experience. • Day shift nurses are more pragmatic, because of the daily reality of this shift; night shift nurses are less pragmatic, reflecting the difficulties during this shift. • Inexperienced professionals work based on theory, attempting to apply technologies to care and management. Experienced professionals use technologies according to their practical knowledge, integrating it in their activities. • Differences in the professional variables should lead to consideration of interventions to foster improvements in this clinical practice.
Introduction Nursing care practices in the Intensive Care Unit (ICU) influence the care modes of nurses. Nursing care in the ICU requires the ability to cope with complex situations rapidly and precisely, requiring competence to integrate information, make judgements and set priorities; understanding of technological language and mastery and interpretation of machine codes to take care of patients; and humanisation and valuing of the patients’ subjective experience (Backes et al., 2012; Mattox, 2012; Silva and Cruz, 2008). These aspects characterise clinical care practice that is typical of the ICU and of the nursing care to critically ill patients. This care involves objective and subjective elements that are combined with technical skills, technology and humanisation (Silva and Ferreira, 2013). The characteristic elements of this clinical nursing care influence professionals’ actions and organisation of care practices in the ICU. One of these elements is the intensive care nurse who delivers the nursing care. Various kinds of nurses work in the ICU and they understand, interpret and behave differently when confronted with the same situation (Jodelet, 2009) due to the different social conditions that define and distinguish them as social subjects. Two social conditions that distinguish them are professional education and work shifts, which influence their experience and their knowledge development process (Jovchelovitch, 2008). There is evidence from the analysis of knowledge on this theme that points up the role of psychosocial and professional variables and their influence on professional practice, particularly in intensive care contexts. Benner (1984) considers that knowledge is related to experience, which in turn leads to proficiency, a condition of authority based on the relationship between theoretical and practical knowledge, and distinguishes between novice and expert nurses. In an ethnographic study of how quality is incorporated into the ICU nursing culture, it was identified that one of the main themes affecting quality and safety that contributes to satisfaction with clinical practice was expert knowledge, gained through experience and formal learning (Storesund and McMurray, 2009). Inexperience negatively influences patient safety. It was one of the factors related to 1472 incidents involving medications, airways, equipment and procedures that were identified in an ICU in a study based on monitoring (Morrison et al., 2001).
A study of the profile of nurses working in an ICU presented the education and qualification characteristics of these professionals. A large number of nurses had worked in the ICU for less than three years, which showed the low theoretical and practical experience in this high-complexity care. It was concluded that the nurses needed to develop competence to deliver safe and high-quality care (Camelo et al., 2013). The introduction of novice nurses in work settings represents a period of transition from a known to an unknown social context. This causes concerns and changes, during which there are discrepancies between what they know and do and what they need to know and do (Silva et al., 2010; Valadares and Viana, 2009). With regard to work shifts, the authors of various studies have sought to establish a relationship with occupational health and professional performance, mainly for professionals working night shifts. In a study that assessed the effects of working during the night shift among 102 workers from the ICU and the coronary care unit, the effects found were stress, tachycardia and drowsiness after work (Veloz et al., 2009). Another study found that the correlation between the shift worked and stress and resistance levels among 72 nurses in a university hospital showed that night shift workers experienced higher levels of stress and less resistance and control, showing the impact of working during the night shift on the lives of workers (Batista and Bianchi, 2013). Working at night entails challenges and peculiarities that affect professionals’ behaviour. One study conducted with 18 Iranian nurses working the night shift highlighted the negative sociocultural image of the night shift, its effects on health and the opportunity to acquire greater clinical experience (Nasrabadi et al., 2009). These findings provide evidence that people’s social places and functions influence the way they cope with their daily experiences (Jodelet, 2009). The variables that characterize nurses are relevant to analysing clinical nursing care in the ICU, as they influence ways of thinking and acting on the other elements of that care. A previous study by the same authors of social representations about ICU nursing care practices showed differences in the construction of these practices and in the function of these professional variables (Silva et al., 2014). The findings of this analysis support the hypothesis that time since graduation and work shifts affected how nurses
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Intensive care nurses’ practice organised social representations concerning care practice in the ICU. The refore this study asks the research question ‘‘How do the variables time since graduation and work shift influence the clinical care practices of intensive care nurses for ICU patients?’’
3 professional variables of the study participants and the potential differences among them in the construction of these representations.
Method Design
Theoretical framework The social representation theory, proposed by Serge Moscovici and developed by Denise Jodelet, is based on social psychology. The theory explains the way individuals and groups construct knowledge in interaction with society, based on their social characteristics (Arruda, 2002). During a paradigmatic shift in the 1980s, it expanded through the development of a scientific paradigm focused on subjective phenomena. Its epistemology acknowledges the subjective, affective and cultural dimensions of human actions and the construction of knowledge, which should be explored in scientific production (Arruda, 2002). The theory posits that people use different ways to understand and communicate in the world: consensual, which consists of informal conversations; and reified, which occurs in the scientific sphere. Social representations are developed in the consensual, non-disciplinary universe, in which people are allowed to express an opinion about anything (Arruda, 2002). People talk about different themes and produce commonsense theories to interpret and construct social reality, based on contact with novel situations, especially in the scientific sphere. The dissemination of these novel situations through mass communication media generates the need to process them (Arruda, 2002). In particular, when they are relevant, current and socially important, they need to be known. Hence, people produce and communicate their social representations, proposing solutions for problems based on social interactions. Social representation theory concerns the social construction of knowledge, which is mediated by public discourse within groups, and how this knowledge is reflected in the actions of those who construct it. Everyone constructs representations, even those who have technical scientific knowledge regarding the object under study, because meanings, senses, affections and social knowledge are mixed with knowledge arising from the universe of science during the socio-cognitive process, which gives them new meanings. Understanding the representations concerning intensive care contributes to better understanding of the motivations from which they originated, beyond the universe of science that explains them. This, in turn, permits understanding how certain care actions and styles are constituted, which influences the quality of care delivery. These care practices are socially relevant for this group of nurses, since they change their behaviour in light of the existence of the practices, which then configure as an object of social representation (Jodelet, 2009). Reflection concerning who exactly was the subject constructing these representations and what the context was raises questions regarding the influence of the psychosocial and
In this qualitative study, the aim was to analyse the occurrence of the variables ‘‘time since graduation’’ and ‘‘work shift’’ in the social representations of registered nurses concerning the care delivered to ICU inpatients.
Sample and location of the study The location was the ICU of a federal hospital in the city of Rio de Janeiro, RJ, Brazil. The establishment consisted of 24 nurses and the sample included 21 nurses who provided direct care to patients. Three nurses were excluded because they were on sick leave or were active exclusively in management. The nurses were not selected based on their psychosocial and professional characteristics, but these data were collected to support the analysis of the conditions in which the representations were produced. Most of the nurses had graduated up to 10 years earlier (61.9%); 52.4% were up to 35 years old; 57.1% had two jobs, worked the day shift and were experts in intensive care; 66.7% chose to work in the ICU; while 71% had up to five years of experience in the location of the study. The nurses were categorized according to the variables selected for this study, and the remaining characteristics were used to complement the analysis. A total of 17 women and four men participated in the study; 11 women and one man worked the day shift, and six women and 3 men worked the night shift; 9 women and 4 men had graduated less than 10 years ago, and eight women had graduated more than 10 years ago. The shift was 12 hours a day with 60 subsequent hours off, similar to the schedule used in most Brazilian hospital facilities. The day shift was from 7 a.m. to 7 p.m. and the night shift from 7 p.m. to 7 a.m.
Data collection Data were collected from January to May 2011 through individual interviews based on a script containing closed questions addressing gender, age, time since graduation, number of jobs, choice of unit and expertise. There were open questions addressing ICU practices, style of care delivery and use of technology. The interviews lasted one hour and thirty minutes on average, were conducted in the afternoon in a private room in the ICU and were digitally recorded.
Data analysis The discursive data were analysed using Alceste 2010 software (lexical contextual analysis of a set of text segments) in cross-data analysis.
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This programme identifies significant lexical worlds based on study of the organisation and statistical distribution of the main words (substantives, adjectives and verbs) in a discourse fragment. The lexical worlds are defined in opposition to one another, granting rationality and coherence to what the speakers are saying (Alba, 2004). In the cross-data analysis, the material submitted to analysis is tested with regard to the existence of differences in the production of the discourse based on the selected variables. The programme crosses the variables and, if differences exist, thematic classes related to each variable are generated. The classes contain the most prevalent lexicons, considering the Chi-square and percentage of each word’s occurrence, and excerpts of interviews called units of elementary context (UEC) are where such lexicons are present. Interpretation is based on the analysis generated by the software. The data file was processed with the software in two testing cycles: The first cross-analysed the differences based on the categorization of the day and night shifts; the second was based on time since graduation. Two reports were developed; one addressed work shift and the other addressed time since graduation. The reports indicated what other psychosocial and professional characteristics were associated with each class. The lexical worlds were interpreted in conjunction with the study’s central question, the theoretical framework and the related literature. The findings were analysed from a comparative perspective, using the most significant lexicons and the most relevant units of elementary context for each variable, highlighting the differences in the production of discourse concerning the object.
Ethical aspects The project received approval by the Institutional Review Board (Protocol 35/10) according to the guidelines of the National Council regulating research in Brazil. The nurses participated voluntarily and signed an Informed Consent Form. The identification codes of the discourse were: N — nurse and a number corresponding to the order of the interview; Ni — night shift; D — Day shift; G1 — less than 10 years since graduation; G2 — more than 10 years since graduation; corresponding UEC number.
Findings and discussion The research findings are based on the authors’ preliminary research on nurses’ social representations about their ICU care practices (Silva et al., 2014). Therefore, the data presentation and analysis will rest on the two categories that organize these representations: the first is related to the patient and work in the ICU; and the second to technology. In the category that discusses daily care for ICU patients, the influence of the variable work shift was verified. The day shift nurses described more practice-centred thinking, with positive feelings, especially gratification because they were able to follow the recovery of critical patient. The discourses of the professionals from the day shift were in the first person singular, including verbs such as I say, I give, I am
and I speak, indicating the care style used for this recovery, referring to the routine and to the patients. My style of providing care, first with love, yesterday I got so happy, whenever I go to the ICU and take a look at the patients. UEC 2081, Nurse 14, day shift I’m a homecare person, regardless of whether it will take two or three hours, I pay attention to every detail; If I have to clean someone’s ears, I don’t do it superficially. I like combing, cutting and sanding nails. I take care of patients as if they were my own family. UEC 28, Nurse 1, day shift About care practice, those working the day shift described activities and elements of management and care practice, namely: procedures (e.g., bathing), technology (e.g., parameters), delegation of functions (e.g., leadership) and the human aspect (e.g., humanisation). I ask: begin giving the baths. UEC 844, Nurse 6, day shift I feel a blockage in certain situations that require leadership. I don’t mean in care delivery, because I know what I have to do and I know how to delegate tasks. UEC 1363, Nurse 9, day shift Technology is important to provide parameters: install the ventilator; the patient has metabolic acidosis due to diabetes; the patient suffered cardiac arrest. UEC 250, Nurse 3, day shift These lexicons illustrate the day in an Intensive Care Unit, which includes agitation, presence of the family, practice of procedures, interaction with the multiprofessional team, justifying the use of a language that indicates proximity, objective and subjective elements of care in relation to patients, the care tasks and the use of auxiliary instruments. The nurses working the night shift talked generically about the context of intensive care. They were concerned with training, the number of employees and structural problems affecting the performance of workers. The words training, care, intensive care and care exemplify their concerns. My greatest concern is with qualification, how a professional working with intensive care is trained: ‘‘Is this professional trained away from a hospital bed?’’ UEC 2339, Nurse 15, night shift First, I think that there are external factors, other variables that interfere with care delivery. Currently, my main concern is the fact that I work in a public service with a deficient structure. UEC 3694, Nurse 21, night shift The use of terms like professional, behaviour and role takes place in a context of detachment when referring to qualities required for the execution of care and the types of professional and work methods that are outlined based on these qualities. Someone who realises the changes that are necessary and act, seeking the best for the patient. If we were able to aggregate these qualities, factors or elements in a single
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Intensive care nurses’ practice professional, we would perform quality intensive care that also received professional acknowledgement. UEC 2403, Nurse 15, night shift It is obvious that there are people who seek more knowledge while others do not seek much knowledge; it’s the attitude of each. UEC 3651, Nurse 21, night shift These data indicate negative elements in the subjective experience of night shift workers. Because of this, they construct a peripheral representation of practice, in which the discourse raises concerns about one’s profile and qualifications, institutional structure and the number of employees, care processes and the implementation of knowledge, which impact the care style of these nurses and their level of commitment to care delivery. The discourse about practice rests on the particularities that characterise the day and night shift and differ accordingly. In the data, it was observed that, on the one hand, the focus was daily care and on the other, the factors that influenced the care practice, according to evidence from other studies, focused on the work shift variable. This evidence highlights that, on the day shift, the nurses were active in direct patient care. In an observational study that analysed daily work activities in an ICU, 3,081 activities were documented over the course of 10 days. Among these, 40.5% of nursing time was focused on direct patient care, 32.4% on indirect care, 21% on personal activities and 5% on activities related to the service. The conclusion was only a quarter of their time was not spent on patient care (Abbey et al., 2012). These data support the data from another study that quantified the duration and frequency of nursing tasks in an adult and paediatric ICU, and found that more than 75% of the time was spent on patient care activities and approximately 50% on direct care (Douglas et al., 2013). A more in-depth analysis of the differences between the shifts shows, for example, that workload is a distinctive aspect. When assessing workload per shift in the ICU of a teaching hospital using the Nursing Activities Score (NAS), the scores were lower on the night shift and on weekends (Debergh et al., 2012). Hence, the engagement of day shift nurses in direct and indirect care is important to the analysis of their social representation on the practice. On night shift, the work is reduced, but the number of employees is also reduced, increasing the work burden allied with the physiological burden of working at night (Schmoeller et al., 2011). Measures of fatigue and physiological indexes taken before and after work for nurses who alternate shifts (day and night) and those working only during the day showed that nurses who alternate shifts experienced more fatigue and poorer physiological indexes (Yuan et al., 2011). A systematic literature review highlights the effects of shift work and night work, which are: chronic effects on health, mainly cardiovascular problems, and immediate effects like sleep disorders, reduced alertness, fatigue and susceptibility to error (Gemelli et al., 2008). Working shifts and long hours increases the risk of sleep disorders, which implies the risk of errors caused by fatigue and may affect patients (Caruso, 2014). In a sample of 289 nurses, 56% experienced sleep deprivation and made more mistakes in patient care, a characteristic associated
5 with the night shift (Johnson et al., 2014). The highest occurrence of mistakes during the night shift can also be explained by fewer opportunities and less access to qualification programmes than nurses working the day shift (Mayes and Schott-Baer, 2010). Therefore, social belonging for night shift nurses is the basis of their social representation, implying countless factors that hamper their work and which they consider when they think of their practice. One factor is the reduction in the number of staff on night shift; another is the performance of night shift nurses in the care process, in view of the profile required to work this shift. These experiences raise questions about how the quality of education influences the quality of care delivery. The second category that organised the representation about practice was related to technology, especially its function in the ICU. This is direct patient care, requiring professionals to be close to patients, as well as to management, since the equipment-generated information enables nurses to manage care at a distance and, at the same time, dedicate time to administrative activities. The cross-analysis revealed that the time since graduation influenced this representation. Although the nurses who graduated less than 10 years earlier (Group 1) mentioned more difficulties in dealing with care-related aspects due to their lesser expertise, they were more critical-reflective. This critical-reflective view of the practice of Group 1 nurses rests on their ways of acting, in view of the technologies and the functions attributed to them. The nurses in Group 1 frequently used the word issue, reflecting on the ways of acting, analysing the interface between proximity and distance, and objective and subjective information, both mediated by interaction with the patient, translated into the words: manner, interaction, neighbour and nurse. We can live perfectly with the objective and subjective issues of intensive care. I’ll do it as I do it within or outside intensive care. People deal differently with this. There are nurses who will be closer and nurses who will not. UEC 2327, Nurse 15, G1 Each shift has its own characteristics. I see shifts are divided; one nurse is close to the bed, more concerned with the implementation of care and more attentive to changes in the patients’ parameters, while another nurse is more concerned with complying with administrative routines. UEC 2249, Nurse 15, G1 Due to their characteristics, Group 1 nurses faced the problem of not having sufficient knowledge to perform care actions, leading them to compare what they learned during their education with reality and conduct an analysis of their professional situation and practice in relation to the factors that interfered with providing ideal care. This is what Group 1 nurses did when dealing with styles of care delivery that were outlined based on uses of technology. The use of the words: objective, proximity and technology, present in 100% of UECs, is typical of this group and reveals their concerns about the analysis of the data from the machines in the ICU and the relations of proximity with patients.
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R.C. da Silva et al. Everybody acts in accordance with this extremely relevant information [from equipment], but machines do not replace clinical assessment, do not replace the analysis of signs and symptoms, a physical assessment, a conversation. UEC 2887, Nurse 18, G1
Nursing education is strongly humanistic. Hence, when the nurses in the study faced a reality filled with bureaucratic activities, professional conflicts, work overload and a reduced number of workers, they associated these factors with limitations on their work in patient care and reflected on the greater or lesser proximity with patients. Those with a heavy work load on the day shift have impaired night work. People who accumulate work on the day shift have a more distant relationship with patients due to fatigue. UEC 115, Nurse 7, G1 Some nurses provide humanised, more considerate care, while others arrive too tired and discouraged with their current contexts or with personal issues. UEC 2237, Nurse 15, G1 Nurses from Group 2 adopted a pragmatic narrative, defending care, which characterized the action dimension of the social representation and expressed the symbolic sense of these actions. The priority of direct care instead of the administrative role is stressed. Autonomy is a bit of a concern. Not autonomy of care, but autonomy when you delegate. Unfortunately, some colleagues only want to delegate, they don’t want to do, and when you get away from care delivery, you get away from the practice, you are no longer seen as a nurse who is playing the role. UEC 3368, Nurse 20, G2 This need to prioritise direct care adds to their range of tasks and the solution of daily situations in this care. The activities are portrayed in the UECs composed of the words: family, pharmacy, blood, pump, chart, catheter and request. I get concerned, pay attention, if I’m going to install a blood bag, I check the patient’s name, the box, no matter how well you know, we know we really have to do it UEC 3127, Nurse 19, G2 I need to change the respirator, get the transport monitor, change the pump, some things we end up solving, but during the day it is easier with the auxiliary services. There is the head nurse, they support workers who help to solve problems. UEC 626, Nurse 5, G2 To comply with their tasks, the nurses fragmented the care, particularly administering medications, followed by direct care to patients. The discourses also alluded to experience, indicating appropriate ways to act towards patients. When they described the practical knowledge that they applied in their decision making, these nurses reported the frameworks on which they were based and that gave meaning to their practice.
You do not generate more suffering or complicate things for the patient, in addition to all other complications they experience; rather you try to prevent other problems that may emerge. UEC 3505, Nurse 20, G2 The data on Group 1 supported the study by Matheus et al. (2006), which showed the effort expended by new graduates to cope with the challenges of training and practice and to gain visibility in the context where they were inserted. This adaptation revealed the limitations of the care learned and the obstacles imposed, implying the need to broaden thinking, adjust benchmarks, and redevelop concepts, attitudes and competencies (Matheus et al., 2006). The entry of new graduates into the job market leads them to perceive the complexity of their practice, conflicts, political issues and bureaucratic demands, which enables them to analyse the gaps in their training in comparison with the reality of care delivery (Silva et al., 2010). They suffer prejudice from other professionals due to their inexperience and youth, and perceive that theoretical knowledge and critical ability are their allies. Despite their practical inexperience, new graduates seek to overcome difficulties by strengthening their knowledge and interpersonal relationships (Mattosinho et al., 2010). The lack of practice, especially related to administrative aspects and leadership, generates insecurities that require daily effort to overcome (Souza and Paiano, 2011). Novice nurses do not yet exhibit all the characteristics of the profile required to act in the ICU, with particularities in the way they experience intensive care (Viana et al., 2014). Technology is a theme of interest to intensive care nurses, which various authors highlight strongly in the literature, adopting two perspectives: that of the risks and benefits deriving from the use of these technologies; and the relationships with them constructed by subjects to take care of the patients (Funk, 2011; Marques and Souza, 2010; O’KeefeMcCarthy, 2009; Schwonke et al., 2011; Silva et al., 2009). These studies certify that the discussion about intensive care technologies is part of the debate in academic education and in practice, so nurses understand and know how to clinically interpret the machinery codes, in order to take care of the patients without entailing any risks for their safety or human condition (Marques and Souza, 2010; Silva et al., 2009). The technology arouses fascination, fear, admiration and the desire to master it. Hence, when the characteristics of Group 1 nurses are contrasted with the technologically complex characteristic of intensive care, this explains the interest in the technologies and the critical analysis of their application by the nurses. In Group 2, the technologies were not highlighted, but were part of the context in which care was provided. The knowledge elaborated about practice emerged as a product of care experiences, based on the examples of past actions. In this research, these actions indicated a fragmented care process, highlighted in other studies that have shown the need to overcome this fragmented practice, which is based on a hegemonic model that increases the professionals’ concern with medical prescriptions, bed baths and exams, to the detriment of stronger dialogue (Campos and Melo, 2011; Pirolo et al., 2011).
Please cite this article in press as: da Silva RC, et al. Intensive care nurses’ practice related to experience and shift worked. Intensive Crit Care Nurs (2016), http://dx.doi.org/10.1016/j.iccn.2015.12.006
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Intensive care nurses’ practice The learning that occurs in practice is based on a set of tools used in professional practice (Assad and Viana, 2005) and rests on the care model. Therefore, the professionals picture their practices in the light of this model, as in the case of Group 2 nurses. Experienced nurses have an accurate view of the situation and solve problems in different ways than novices, as experience leads them to solve problems more efficiently. Prior experience guides the perceptions and actions of expert nurses, as they enable the workers to compare current situations with prior ones (Benner, 1984). That is the case for a study that explored the behaviour of a nurse considered to be an expert, in which expertise and practical knowledge led to changes in practice because the nurse under study possessed the clinical judgement inherent to an expert nurse (Arreciado Mara˜ nón et al., 2011).
Conclusions Although at a first glance, social representations seemed to be consensual among the group under study, a second analysis revealed areas of tension and differences according to the nurses’ professional characteristics. Those working the night shift developed a more peripheral view of practice, with aspects of the professional practice context, while those working the day shift experienced a more pragmatic routine concerning care delivered to patients but also focused on operational and organisational issues in the ICU. The nurses from Group 1 had more difficulty providing care in the ICU, but were nonetheless critical and reflective in relation to the relationship between theory and practice. The nurses from Group 2 mastered and applied practical knowledge in their everyday professional work. By valuing knowledge in relation to the subject who produces it, the findings confirm the theoretical assumptions of social representation, integrating cognition and communication with the social relationships that affect them, as well as with the material, social and ideal contexts in which they will intervene. We recommend investigating other characteristics to deepen and validate comparative hypotheses among groups that enhance the social marks of the representations.
Funding The authors have no sources of funding to declare.
Conflict of interest The authors have no conflict of interest to declare.
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