Nurses’ social representations of nursing care systematization

Background: Nursing care systematization (NCS) is a methodology based on a solid theoretical and scientific framework that allows planning, organizing, and systematizing care. Objectives: To identify the meanings that nurses assign to NCS in a hospital located in the city of Itajubá, Minas Gerais Brazil. Methodology: This was an exploratory and descriptive study with a qualitative approach using a purposive sample of 30 nurses. Data were analyzed using the discourse of the collective subject method. Results: The following central ideas emerged as meanings assigned to NCS: it is a care guiding strategy; it is an activity that is carried out exclusively by nurses; and it does not work in practice. Conclusion: Although NCS is a widely discussed topic in professional training and practice, its implementation in clinical practice is still questioned. However, NCS is recognized as a care guiding strategy and a nursing activity.


Introduction
Nursing care systematization (NCS) is a methodology based on a solid theoretical and scientific framework that allows planning, organizing, and systematizing care. NCS aims to understand health-disease situations and nursing care needs, to support the implementation of promotion, prevention, recovery, and rehabilitation interventions directed to individuals, families, and communities, as well as to promote safety and quality during care delivery (Chaves, Silva, Motta, Ribeiro, & Andrade, 2016). Therefore, NCS is used as a scientific methodology that facilitates nurses' work, allowing them to achieve outcomes under their responsibility (Truppel, Meier, Calixto, Peruzzo, & Crozeta, 2009). However, in Brazil, despite being widely discussed and used in academic settings, the implementation of NCS in most healthcare services is still far from what is foreseen in nursing legislation. Although the use of NCS is compulsory, it is not yet part of nurses' daily routine, often due to work overload and inadequate staffing. Nurses tend to prioritize bureaucratic and administrative activities, which are also part of their professional responsibilities (Nery, Santos, & Sampaio, 2013). In addition, another barrier is the lack of a nurse paradigm. There are many barriers to the effective implementation of NCS in daily nursing practice. Some authors suggest that, besides being difficult to implement it in nursing practice, the barriers to the implementation of NCS seem to start during nurses' education. Teachers find it difficult to develop adequate, efficient, and standardized pedagogical strategies to teach this care methodology (Cavalcante et al., 2011). This study reinforces the need for the implementation of NCS as a guiding tool for nursing practice, thus allowing for the recognition of nurses' work, work organization, autonomy in decision-making, and, above all, care quality focused on comprehensive and individualized care. In addition, this study will provide and further support data that can be used in the development of studies in other contexts, thus calling the attention to the implementation of NCS in different healthcare institutions which, in turn, will result in the delivery of systematic, evidence-based care to patients. In this way, this study aimed to identify the meanings assigned to NCS by nurses working in a hospital located in the city of Itajubá, Minas Gerais -Brazil.

Background
The accumulation of new knowledge collected during nursing practice served as the basis for the development of nursing theories, thus enabling the recognition of nursing as a science. Theoretical assumptions emerged as a way of compiling nursing knowledge, which has contributed to care delivery based not only on the biological dimension of the human being but also on the idea of the individual as a psycho-social-spiritual being (Chaves et al., 2016). The first attempts to systematize nursing care in Brazil were proposed in the 1970s by Wanda de Aguiar Horta, who analyzed the nursing process (NP) in depth. Her considerations led to the development of the Basic Human Needs Theory, which was published in 1979. Currently, most healthcare units in Brazil follow Horta's methodological proposal, which establishes the development of the NP in six phases: nursing history, nursing diagnosis, care plan, nursing prescription, nursing evolution, and nursing prognosis (Garcia, 2016). Therefore, NCS emerged when nursing began to systematize its actions, with the purpose of integrating its theoretical knowledge into clinical practice, thus building its own body of knowledge in the search for the consolidation of the profession as a science. (Varela & Fernandes, 2013, p. 125) With regard to the legal aspects, the Resolution 358/2009 of the Federal Nursing Council (Conselho Federal de Enfermagem, COFEN) governs NCS and the implementation of the NP in public or private nursing care settings. NCS is an activity that is exclusively carried out by nurses, uses scientific work methods and strategies to identify health/disease situations, support nursing care actions that canto contribute to promotion, prevention, recovery, and rehabilitation interventions aimed not only at individuals but also at their families and communities (Carvalho & Barcelos, 2017;Oliveira, Coelho, Almeida, Lisboa, & Macêdo, 2012). NCS must be implemented in five interconnected, interdependent, and recurrent stages: nursing history, nursing diagnosis, nursing plan, nursing intervention, and nursing assessment. So, the integration of NCS into care delivery is a way of ensuring that nursing is more evidence-based and it provides individualized, humanized, continuous, fairer, and quality care (Carvalho & Barcelos, 2017;Chaves et al., 2016;Nery et al., 2013). NCS is operationalized through the NP, which is a methodological and systematic care delivery tool with interconnected and organized stages. These stages provide nurses with a comprehensive view of the patients and help them make evidence-based decisions concerning care delivery (Carvalho & Barcelos, 2017;Chaves et al., 2016). The implementation and operationalization of NCS require nurses to have extensive knowledge. Thus, the involvement of the whole nursing team is essential to share and disseminate knowledge, through study groups, discussions, and on-thejob training (Benedet, Gelbcke, Amante, Padilha, & Pires, 2016;Massaroli et al., 2015). There have been efforts to implement these work methodologies since the first studies on the NP and NCS. The Resolution 358/2009 of COFEN, although in force, does not provide the necessary support to their implementation, mainly due to the multiple difficulties faced by nurses in their clinical practice. The major challenge of nurses in the implementation of NCS is the lack of a theoretical-scientific framework and the work overload (Carvalho & Barcelos, 2017).

Research Question
What are the social representations of nurses working in a hospital about nursing care systematization?

Methodology
This is an exploratory and descriptive study with a qualitative approach. It was conducted in a University Hospital in the city of Itajubá, Minas Gerais -Brazil. The sample was composed of 30 nurses who were selected using a purposive or theoretical sampling technique. The eligibility criteria were being a nurse and being part of the permanent staff of the university hospital. Data were collected using semi-structured interviews, based on the following question: "What does nursing care systematization mean to you?". Participants gave their permission to record their answers, which were subsequently transcribed to ensure that the accounts were accurate. Individual interviews took place in an appropriate, noise-free place. All doubts were clarified before starting the recording. Nurses' anonymity was ensured by using the letter N (as in nurse) followed by a number, according to the sequence of the interviews (N1, N2, N3...). Data were analyzed and interpreted using the discourse of the collective subject (DCS) method, which proposes the organization and presentation of qualitative verbal data that are collected from interviews, newspaper articles, and magazines, as a way for the collective to speak directly (Lefèvre & Lefèvre, 2010). Three methodological procedures of this method were used: 1) Key-expressions (KE), which require the literal transcription of the recorded answers; 2) Central ideas (CI), which is a linguistic designation or statement that describes, in a precise and reliable way, the meaning of each account; and 3) DCS, which is a synthesis-discourse that is written in the first person singular and composed by all KEs with the same CI (Lefèvre & Lefèvre, 2010). Nurses' social representations were obtained using the methodological stages proposed by Lefèvre and Lefèvre (2010): The full content of all answers obtained using the semi-structured interview script was transcribed; the equivalent CI (those with the same meaning) were grouped; and a DCS was elaborated for each group of CI. This study was approved by the Research Ethics Committee, which issued the Consolidated Opinion no. 470.795, Certificate of Presentation for Ethical Consideration (CAAE) 25077713.3.0000.5559.

Results and discussion
The following central ideas emerged as meanings assigned to NCS: it is a care guiding strategy; it is an activity that is carried out exclusively by nurses; and it does not work in practice. The first central idea -it is a care guiding strategy -directs practice and assists in care organization and planning, thus contributing towards better outcomes when implementing the care plan. In this way, nurses feel more confident during care delivery, because NCS also allows for a more informed, evidence-based performance. Professionals stop acting intuitively or impulsively, merely fulfilling tasks as it is usually observed. NCS allows nurses to become autonomous in decision-making and build their own knowledge, thus contributing to consolidate nursing as a science. This method requires nurses to think critically and constantly update their skills to intervene with autonomy and based on technical-scientific knowledge (Garcia, 2016;Silva, Oliveira, Neves, & Guimarães, 2011). The following DCS is in line with the aspects mentioned above: NCS is a methodology that guides nursing care, by making it more scientific, which leads to better patient care outcomes. It is a way for nurses to organize, plan, and obtain good care outcomes. NCS guides towards better quality in patient care, which helps us plan for adverse situations that occur in daily practice. Nursing care is organized as a script, a sequence, a standard to deliver the best care to patients. NCS organizes nursing care when all its stages are implemented, providing nurses with autonomy to make decisions as needed for patient care. (N1, N2, N4, N10, N19, N20, N28, Feb. 2014) In view of the above, NCS can be understood as a methodology that promotes and directs nursing care, in addition to providing the necessary tools for the organization of nurses' work (Benedet et al., 2016;Varela & Fernandes, 2013). Silva et al. (2011) show that NCS is an instrument that allows organizing and standardizing professional practice, as well as managing and optimizing nursing care in an organized, safe, dynamic, and competent way. Despite the many criticisms to the use of this methodology, NCS has been considered as a tool that contributes to language standardization by systematizing nursing practice and expanding nurses' professional autonomy (Cogo et al., 2012). Studies also report that NCS allows nurses to recognize that care should focus on the patient. Its implementation leads to the identification of problems and needs, the promotion of well-planned, organized, and substantiated care, and the facilitation of nursing practice (Medeiros, Santos, & Cabral, 2012;Menezes, Priel, & Pereira, 2011). As a working method, NCS requires critical or reflexive thinking, individual reasoning, and a team of adequate size. The comprehensive approach helps to ensure that the interventions target the person rather than the disease (Medeiros et al., 2012;Menezes et al., 2011). NCS leads to a significant improvement in the quality of care, the scientification of the profession, as well as benefits such the promotion of the integration between the nursing team and other health professionals, patients, and family (Oliveira et al., 2012). With regard to the second CI -it is an activity that is carried out exclusively by nurses, it should be noted that nurses have specific professional responsibilities which cannot be delegated. The COFEN, in its Resolution 272/2002, which was later repealed by its Resolution 358/2009, describes NCS as an activity that belongs exclusively to nurses, who are responsible for its implementation in their practice (Carvalho & Barcelos, 2017). However, there is still a lack of awareness about the need to strengthen the implementation of NCS, with few institutions using this methodology, as shown by the following DCS: NCS is an action performed exclusively by nurses that should take place at admission. It consists of five stages: nursing history, nursing diagnosis, nursing planning, nursing implementation, and nursing assessment. It is an activity performed exclusively by  (Moreira, Santos, Oliveira, Reis, & Lima, 2013). As a nursing-only activity, NCS requires the use of technical-scientific and human knowledge in care delivery to characterize nurses' professional practice, thus contributing to the definition of their role. Nurses must implement all NP stages, based on a theoretical framework, to promote care and address patients' needs (Pains, Oliveira, Moreira, & Malta, 2009). The third CI was evident in the following representation: NCS is seen as an activity that does not work in practice. Although its use is required by law, and there are multiple studies on NCS and its importance in daily practice, some nurses are unable to implement it in their practice, do not understand its meaning, and view it as a waste of time and as an activity that does not contribute to the caring process, which is often explained by nurses' lack of time. Nurses' involvement in bureaucratic and complementary tasks does not contribute to the implementation of NCS. It should also be noted that nurses' lack of ideology, value, interest, and commitment to plan and implement NCS stages can contribute towards the lack of implementation of this methodology. Studies have shown that nurses' lack of preparation or professional training and failure of the institution to empower nurses are barriers to the implementation of NCS (Santos & Silva, 2013). There are also other factors that contribute to the non-implementation of NCS in institutions, namely: inadequate management of nurses' time and workload, the low cultural value assigned to NCS, the lack of familiarity with that routine, the diffi-culty to acquire these skills, and the resistance to new methodologies (Oliveira et al., 2012). The following DCS shows what was mentioned above: Within our reality, NCS is a waste of time, because we do not have enough time to implement it and even less time to execute it; there is also a shortage of technicians and nurses, because [nurses] accumulate functions, perform pharmaceutical services, maintenance, with no time to evolve. Here, because nurses are immersed in bureaucracy, technicians end up taking their place. In theory, everything is wonderful, but in practice, it leaves much to be desired. Stages are performed incorrectly or are not performed at all. If NCS was actually done as it should, it would be great. Unfortunately, that's not the case. (N29, N30, Feb. 2014). These accounts show that nurses only perceive NCS to be effective in theory and that, if it were adequately applied in practice, it would greatly facilitate nursing care delivery. However, participants reported several barriers to its implementation, namely lack of time, low staffing, and excessive bureaucracy, which make it impossible for nurses to perform the NCS stages. Studies on the professionals' perception of the importance of NCS showed that 75% of nurses considered it to be very important. However, 74% of them stated that they felt discouraged to implement it due to several reasons, namely low staffing/work overload/high number of patients (54%); inadequate conditions of the service (13%); and bureaucracy (4%), with 67% of problems being related to working conditions . Participants also mentioned the following impeding factors in the implementation of NCS: professionals' lack of motivation; the lack of institutional commitment, with policies that hinder its implementation; professionals' lack of knowledge, insufficient training or lack of it; difficulty to understand the nursing diagnosis and apply it in practice; excessive concern with the workload rather than with care quality; and the lack of forms to implement NCS (Silva & Carvalho Filha, Nurses' social representations of nursing care systematization 2017). The DCS above includes all these limitations and illustrates common problems in institutions which compromise significantly compromise the adherence to NCS. Other studies also emphasize some of the challenges that characterize the implementation of NCS in institutions, which may help in its implementation: nurses' knowledge, nurse staffing, nurses' involvement in the process, institutional recognition of its importance, and indicators of care outcomes. In addition, to implement this process, professionals must possess evidence-based knowledge, skills, and attitudes guided by an ethical commitment and responsibility for caring of others (Monteiro, Monteiro, Araújo, Gouveia, & Alencar, 2013). Unfortunately, the current context is still characterized by many barriers to the implementation of NCS, including not only the reduction and shortage of human resources, but also the way in which professionals acquire and apply the knowledge on the topic (Carvalho & Barcelos, 2017;Monteiro et al., 2013).
Even with the support of the Council COFEN and the entire professional class, and, despite having been introduced in Brazil in the 1970s, there is still a huge gap in this knowledge between its production and its application in nursing daily practice (Silva et al., p. 1381) The implementation of NCS involves more than a sequence of steps to be followed, requiring from the professional greater familiarity with nursing diagnoses and clinical reasoning and judgment to adapt the patients' needs to the working conditions, making them more complex than the theory suggests. (Silva et al., 2011, p. 1381) On the other hand, several studies contradict the DCS described above and highlight that NCS is an important work tool for nurses because it is a method that provides them with autonomy and allows assessing the quality of care delivery according to patients' needs (Santos & Silva, 2013). With regard to the question whether nurses should work with NCS, a study conducted in Brazil showed that the majority of nurses (92%) agreed that they should use it because, among other benefits, it improves the quality of care (44%) and promotes professional autonomy (18%; Silva et al., 2011). Therefore, NCS should be implemented in nurses' working environment, whether in public or private hospital institutions, outpatient services, clinics, primary care centers, and, above all, nursing schools, thus contributing to the acquisition of the necessary competencies, skills, and attitudes to apply this method. This will lead to the scientification, recognition, and promotion of the nursing profession, as well as to the delivery of qualified, individualized, and comprehensive care to patients, families, and communities.

Conclusion
Although it is a necessity in the health system, NCS is still not yet a nursing paradigm to the extent that some nurses are not yet fully aware of its essence, need, and importance in care delivery. Consequently, there is still gaps, resistance, and difficulties in its implementation. Some of these gaps result from the nature of the nursing profession itself. In most cases, there is insufficient staffing and nurses have no time to implement this methodology. However, this is not completely true since NCS is an organized, planned, evidence-based methodology which would facilitate nurses' work and, consequently, care delivery. Therefore, due to the difficulties experienced in the implementation of NCS, both nurses and institutions should increase professional development through greater involvement, ethical and professional commitment, and scientific knowledge. Unfortunately, nurses lack the ideology to implement NCS, because many of them are still used to the functional and routine activities, without attempting to gain autonomy. In addition, there is a lack of institutional support because NCS is not a matter of interest to both nurses and institutions. The results of this study are in line with those of other studies, which may mean that the implementation of NCS has not changed. There have been no advances in the introduction of new aspects that could contribute towards the expansion of its ideology in nursing care as if NCS is no longer a matter of concern.