Enfermeiros na operacionalização do Kanban: novos sentidos para a prática profissional em contexto hospitalar?

Abstract

Resumo O Kanban, uma tecnologia de gestão do cuidado caracterizada pela valorização do trabalho multiprofissional e o uso intensivo da informação, tem sido crescentemente utilizado para enfrentar a superlotação dos serviços de emergência hospitalar (SEH). Pesquisadores acompanharam durante dez meses o Kanban em vários setores de um SEH municipal. Suas observações, registradas em diários de campo, foram discutidos em reuniões quinzenais por um coletivo de pesquisadores. O material empírico foi organizado a partir de duas questões: Há mudanças nas “atribuições tradicionais” da enfermagem atuando no Kanban? Há transformações nas relações interprofissionais entre Medicina e Enfermagem na operacionalização do Kanban? Observou-se forte adesão dos enfermeiros ao arranjo, pari passu com uma maior especialização e fragmentação do seu trabalho. Os diaristas assumem funções administrativas tradicionais da enfermagem, enquanto os plantonistas desenvolvem assistência direta aos pacientes. Os enfermeiros consideram que a decisão clínica ainda é do médico, embora o Kanban propicie sua maior influência na decisão. A gestão de grande massa de dados clínico-operacionais pelos enfermeiros, central na operacionalização do Kanban, reforça sua autoridade profissional.

Nurses and the Manchester: rearranging the work process and emergency care?

“…The technical content of traditional roles is renewed and restored, as it starts to incorporate technological innovation for its performance to gain more speed, efficiency, and rigor. The functional logic of organizing nursing work in an emergency service remains intact, such as welcoming patients, assessing their clinical condition and creating the conditions for the production of a more integrated and coded decision chain that allows feeding the dynamics of work in each care flow, as well as the therapeutic resolution in each patient (13,15) .…”

“…The change in content of professional roles is added to the greater stratification of nurses' positions in these services (stratifying nurses; nurse auditors of MTS; coordinating nurses of the Internal Regulation Center and the Patient Safety Center; coordinating nurses of continuing education; coordinating nurses) of the axes); however, this greater complexity of hierarchical positions does not necessarily result in a change in the structural position of nursing in the organization of hospital labor division. Although this importance is recognized in the spaces and times associated with the exclusive execution of this protocol, it is nonetheless directly monitored, controlled and audited by the management organizations of coordination and regulation of care flows (13,15) . MTS nurses narrate repeated conflict relations that erupt in the daily work processes in which they are involved, when subjected to the combined effect of management pressures and professional tensions, especially with regard to disagreements in the stratification of patients' risk and respective color assignments of bracelets and flow ordering.…”

“…In this regard, some authors argue that nursing practices, in contrast to those of medicine, have shown themselves to be more open, relativistic, subject to experience, to personal interpretations and based on less codified knowledge, as an expression of a kind of indeterminacy (13,17) . Thus, the position of nursing in MTS is reduced to visible and technically readable practices, deductible from the combined exercise of management authority and medical authority.…”

“…This autonomy ends up being subjected to a chain of successive reassessments, confirming or not the stratification performed, in which the professional tensions of care management are played. The repeated situations of questioning the stratification of risk and the definition of the priority of care suggest that the professional autonomy of nurses who operate MTS is always in production, gaining greater or less elasticity when placed in relation to other professional autonomies (13) . That is, the fulfillment of all the technical procedures provided for does not necessarily reduce the conflict relations, which unfold in the relations between the different professions and professional categories involved in EH health teams.…”

“…Emergency services welcome the repression of demand generated in other points of care in the health system, resulting in great dissatisfaction from users, either due to the waiting time for care or the unavailability of hospital beds for admissions, resulting in the permanence of a large number of patients, for long periods, on stretchers in the halls (7,13,15) .…”