INTRODUCTION

The quest for quality of care in health is, in actuality, one of the foci of the hospital medical institutions, which has invested in the continuous improvement of work processes, in adherence to scientific evidence-based practice, on the appropriateness of physical structures and promoted the qualification of human resources. Regarding the quality of care offered by health teams, professional interaction with the working environment appears as a crucial element for ensuring positive results and in keeping the prerogatives of patient safety ¹

To approach this issue of nurses and nurse technicians, met their perceptions about laborativas conditions in which they inserted, whether relating to tasks that perform and interactions with the multidisciplinary team, for example. These, for your time, impact on quality care offered and encourage the absenteeism, accidents at work and turnover². In this sense, the implications of a suitable working environment result not only satisfied, but also professionals in positive effects for patients, families and healthcare organizations ³.

Environments that promote emotional stress, physical and professional nursing teams worn, characterize critical units such as intensive care and emergency Centers, and there is a risk of low job performance ^{(4; 5)}. In Brazil, the Er units (UPA’S’s) are the main route of access of the population to the attention of urgencies and emergencies. The UPA’S has provided for in National Policy Attention to the emergency room and Resolute actions in order to minimize overcrowding in hospital emergency ⁶. To this end, these units work 24 hours every day of the week and rely on teams of doctors, pharmacists, radiographers, nurses and nurse technicians, being this last group responsible for a significant portion of users.

In General, the UPA’S’s feature a high number of calls per day, which results in long waiting lines and excessive demand. In addition, because public funding of the service, many feature human and physical resources disabled ⁷.

On these arguments, the perception of the team of nursing professionals active in UPA’S’s on the desktop which are inserted, appears as a strategy with a view to identifying the key issues that impact on assistance for critical patients, in addition to subsidize strategic actions of the managers of these units. In this context, the Nursing Work Index is a tool that enables the identification of the perception of nursing staff about your working environment and been used in Brazil ^{8 9 10 11}-¹². When we consider the importance of this subject, the influence that the urgent and emergency care generates for the Brazilian public health system and with a view to encouraging actions directed to the improvement work of the nursing staff of the UPA’S’s, the guiding question of this research was "what is the perception of the nursing staff of a ER customer service about your desktop?".

Therefore, the objectives that guided the methodological procedures of the research were:

METHODOLOGY

For the purposes of the survey, we opted for the quantitative approach, descriptive and exploratory character, and as a setting UPA’S of the municipality of Curitiba-PR, founded in 2014. In this unit are serviced approximately 5000 patients per month which access occurs by direct search or referral through the Mobile service of urgency of the city. The space consists of screening room, room for drug delivery and way for critical care, semi-critics and clinical trials, 23 beds. This unit also includes five doctor's offices and two rooms for support/administrative teams ¹³.

With regard to the target population, this made up of 87 nursing professionals (24 nurses and 63 nursing technicians). The criteria of inclusion were nurses and nursing technicians who were active in laborativas activities, active in the institution for a period exceeding 30 days, which agreed to participate in the research and complete an informed consent, excluded as those who do not met the pre-established criteria.

Thus, the final sample made up of 63 professionals, being 17 nurses and 46 nursing technicians. To guarantee the confidentiality preserved in accordance with the ethical principles of research with human beings, and the project received approval after approval on the Ethics Committee of the Municipal Health Secretariat of Curitiba, under number CAEE: 54697716.8.3001.0101.

In order to meet the first objective, we used the Nursing Work Index (NWI) version translated and validated to the Brazilian context (B-NWIR) ¹⁴. The instrument aims to measurer the presence of main characteristics of the work environment that promote the professional practice of nursing. This questionnaire consists of 57 items, divided into 25 subscales autonomy, control over the environment, the relationship betweendoctors and nurses e organizational support¹⁵.

The issues that make up the questionnaire are evaluated by using Likert-type scale which ranges from totally agree to totally disagree, in that for the first value is attributed with 4 weight and the last weight 1. The assessment follows by subscales and values below 2.5 are consistent with an environment conducive to professional practice, while over 2.5 indicates the opposite ¹⁴.

Data collection took place from May to July 2016. At first, the project and its objectives presented to managers of the UPA’S’s and explained to your purpose. Complete this step, the nursing professionals approached during the workday (early morning, evening and night) and was the application of questionnaires. The data from the B-NWIR were tabulated in Excel® spreadsheet and then analyzed using the software SPSS Statistics v. 20, as well as applied the Mann-Whitney and Kruskal-Wallis, for comparison between groups, Student's t test (age) and Fisher exact (sex and time of operation) for independent samples and p < 0.05 indicated statistical significance (...)

RESULTS

Among the 63 participants, there was the predominance of women in both groups surveyed, the average age of nurses from 33.1 years and 35.8 to nursing techniques. With respect to the time of operation, 13 middle-level professionals operating in the UPA’S for less than one year, which denoted a statistically significant difference between the groups for this variable.

In Table 1, the demographic data of the population studied.

Table 1 Profile of nursing professionals working in an Er unit. Curitiba, 2017. 

Source: The authors, 2017

** p < 0.05, t-Student's test and Fisher.

In the comparison of the results of the B-NWIR subscales between the professional categories, the average and median scores. For this analysis, there was no statistically significant difference between the groups.

Table 2 Comparing the average scores for the subscale B-NWIR between nurses and nurse technicians of a unit of ER Service. Curitiba, 2017. 

Source: The authors, 2017

* p < 0.05, Mann-Whitney test.

In Table 3, the average scores obtained by professional category to each item of B-NWIR, which allows a detailed assessment of the results obtained. Of the 57 items in 11 (2, 6, 13, 15, 17, 23, 24, 32, 33, 35, 53 and 56) average score less than 2,5, indicating positive perception to the work environment. However, 10 average scores were close to cutting value and the result was favorable only for one of the groups studied. Only in "flexibility in changing the scale of work”, there was agreement to values below, between 2,5 and nurses (1,47) and nursing (2,17).

Regarding the change of the values of the averages, which determine the homogeneity of the answers, provided by participants, through the standard deviation (SD), the results point to a greater dispersion of responses between nursing technicians. Attention DP for five items of B-NWIR in the results between nurses and nurse technicians obtained sharp divergence, namely: "opportunities for improvement" (Nurses = 0.49; Nursing technicians = 0.97); "I work with nurses who are clinically competent" (Nurses = 0.00; Nursing technicians = 0.99); "A program of mentoring for newly-hired" (Nurses = 0.47; Nursing technicians = 1.05); "The nurses who work regularly and permanently together never have to cover another drive" (Nurses = 0.51; Nursing technicians = 0.90) and "personal offset to balance the teams between units" (Nurses = 0.59; Nursing technicians = 1.15).

Even with this in mind, a statistically significant difference was observed for the items " A good orientation program for newly hired nurses "(p = 0.006);" A satisfactory salary" (p = 0.02); "Flexibility in changing the working range" (p = 0.02); "Sufficient Staff to do the job" (p = 0.02); " Freedom to take important decisions in the care to the patient and at work "(p = 0.006) and;" The contributions nurses make to patient care are publicly recognized"(p = 0.03).

DISCUSSION

Although the research carried out in only one of the nine Emergency Services Unitsin the city of Curitiba-PR, the results provide nursing teams and managers, for a wide-ranging discussion regarding the relationship between the workplace and quality of nursing care in urgency and emergency units. In addition, we highlight as limitation, restricted collection of socio-demographic data, since these could related to the values assigned to the items and subscales of the B-NWIR.

The prevalence of young female professionals meets Brazilian study recently depicts the profile of Brazilian nursing, consisting mainly of women, accumulating more than a job and has double workday ¹⁶.

The findings in this research indicate that there is agreement between nurses and nurse technicians that work in that environment UPA’S presents unfavorable conditions for the exercise of nursing care, with emphasis on subscale "control over the environment", which it measures how much control of the environment is favorable to activities of nurses ¹⁴. In this sense, it is valid to point out that the activities of the nurse in UPA’S are characterized in particular, assistance with regard to the implementation of administrative and managerial procedures, as reference material and human resources, plan and supervise the assistance performed by the technicians of nursing, describe routines and promote education on duty ¹⁷. Thus, the low perception of the group that drives the subscale assert that the location of the search does not offer the necessary conditions both for the performance of a quality and safe care, as for the Organization of the private activities of the nurse.

The subscales "relationship between doctors and nurses" and "organizational Support" obtained medium equal when compared the results in pairs (average for nurses 2.8 and nursing technicians 2.6). As far as relations between doctors and nurses, among the items that make up this subscale, the nurses and doctors work very hard as a team” for nursing (average equal to 3.00), followed by "Cooperation-Joint-practice between nurses and doctors” for nurses (average equal to 2.94). In this regard, it is pertinent to point out that the care offered at health services is dependent, first, the performance of doctors and nurses, who must work in harmony once the goal of his actions is the same: improving the health and well-being of the patient. However, the study points to problems and conflicts from the relationship between such professionals because of differences in decision-making, ineffective communication, influences on the health team, professional recognition and wage differences ¹⁸. On these questions, and to relate to urgent and emergency services, it is clear the negative impact of problems inter-for user assistance professionals in critical condition, which is dependent on the effectiveness of multidisciplinary work.

The "Organizational Support" corresponds with the perception of the workers about the recognition of the work of their organization, associated with the performance of their workload, support materials and human resources and salary increase ¹⁹.

In the B-NWIR this subscale consists of 10 items and in this research, two negative averages were obtained (up to 2.5), perceived by nurses in "time and enough opportunity to discuss, with other nurses, patient care-related problems" (average equal to 3.35) and nursing technicians in "team with enough nurses to provide patients with quality care" (equal to average 3.24).

About these data, the discussion about the State of the patient and the collaborative work between the nursing staff is considered to be one of the means to an individualized nursing care, quality and humane, independent of health care context ²⁰. Factors that hinder or prevent the execution of the nursing process, fragmentation of care create opportunities, the occurrence of failures in the care process and, consequently, of adverse events ²¹. The Brazilian nursing constantly faced with insufficient in the context of professional influence on task overload, occupational stress, emotional Burnout, increase in the number of accidents at work and of adverse events, as well as offer the occurrence of occupational diseases as the Burnout⁴.

On the other hand, to the above-mentioned medium positive subscale (below 2.5) were assigned to " Nursing has control over your practice "evaluated by nursing technicians (average equal to 2.43), and “Freedom to take important decisions in the care to the patient and at work “for both groups (averages for Nurses: 2.00; Nursing technicians: 2.76) which denotes autonomy of nursing staff about patient care. These items are also contained in the subscale "Autonomy", which was the only one to be evaluated positively, however, only nursing technicians (average equal to 2.4). Attention the item "nursing Manager supports your team, in its decisions, even if they conflict with those of the doctor" which received 2.5 average for nurses, which reinforces the importance of nursing managers committed to their teams and, above all, to understand the needs of teams that are under your supervision. The autonomy of the nursing staff, in particular in the perspective of the nurse, been discussed for years by nursing, due to the need of the profession constitute a body of knowledge that support the professional practice and lead to social recognition of the profession ²². On the urgency and emergency units, in the patient care record, with definite risk of life, the nurses as nursing team leader, if faced with ethical dilemmas and questions about the professional autonomy in relation to other professionals, especially the doctor ²⁴. Thus, the knowledge of the legal bases of the profession, by means of legislation in force, in addition to institutional support, especially of managers, promotes attitudes directed, safe and effective in UPA’S.

In Brazil, studies that used the B-NWIR, applied both to nurses as nursing technicians, achieved generally positive results ^{8 9 10 11}-¹² which demonstrates the peculiarity of working environments of urgent and emergency, in particular the UPA’S’s, spaces that are increasingly sought after by the population to the resolution of health problems, whether of high or low complexity.

CONCLUSION

The research demonstrated that in the Emergency Service Unitworking environment not conducive to nursing care, which implies in reducing the quality of care. Under this argument, there is the need for a broad discussion among nursing staff, managers and other multidisciplinary authorities of the emergency services and the Municipality in order to fit the gaps that interfere in assistance to critical patients who depend on the effectiveness and efficiency of the care of this unit.

Several are the associated factors for a working environment is adequate, however, provide nurses and nursing technicians, who are the driving force of the health assistance, the support required for the implementation of the activities inherent to the profession, is one of the means to ensure a care free of damage.

The answers to the questionnaire, which obtained the greatest disparity between the analyzed groups, indicate that nursing technicians perceive weaknesses in the skills required by the emergent nurse and report on the importance of continuing education actions in this service so that the leaders and leaders of the nursing team recognized by their peers.

The comparison between groups, nursing technicians and nurses allowed the identification of the gaps that influence daily care in complex environments and with high demand of activities that are commonplace to the sites with the same service profile of the research site.

The present Situational diagnosis can direct the local leaders to intervene in the weaknesses, especially those with negative results. The relevance of more studies on the perception of environmental health teams working in ER units to the encouraging improvement in the service provided in urgent and emergency services.