THE DRAMATIC "USE OF SELF" IN THE WORK OF THE NURSING TEAM IN THE SURGICAL IN-PATIENT UNIT

DRAMATIZACIÓN DEL “USO DE SÉ” EN EL TRABAJO DEL EQUIPO DE ENFERMERÍA DE CLÍNICA QUIRÚRGICA

ABSTRACT

Objective:

to know how the nurse's "use of self" occurs in a surgical in-patient unit from the perspective of ergology.

Method:

a qualitative case study based on historical and dialectical materialism and the theoretical reference of ergology. The study participants were 12 nurses working in a surgical unit of a high complexity hospital. The evidence sources for the data production were systematic observation, document analysis and semi-structured interview. The data were produced between March and September 2015. Data were analyzed according to the thematic content analysis.

Results:

The thematic category: Dramatic "use of self" in the work of the nurse in a surgical in-patient unit, emerged from the analysis. It was evidenced that nurses organize themselves in different ways to carry out the work process, concretizing the use of themselves in several situations, which is related to the management of care. It should be noted that, although there is prescribed work, the knowledge, experience and values influence the use of self by these workers, with a view to renormalizing work.

Conclusion:

the nurses in a surgical in-patient unit develop their work based on previous norms, as well as their knowledge, experience and subjectivity, effective use of self, aiming to renormalize activities, exercising autonomy for the improvement of care.

DESCRIPTORS
Nursing; Job; Subjectivity; Ergology; Nurse; Health Service

RESUMEN

Objetivo:

comprender cómo actúa el "uso de sé" del enfermero en unidad de internación clínica de acuerdo con la ergología.

Método:

investigación de abordaje cualitativo, tipo estudio de caso, fundamentada en el materialismo histórico y dialéctico, y en el referencial teórico de la ergología. Participaron 12 enfermeros actuantes en unidad de internación clínica quirúrgica de un hospital de alta complejidad. Fueron fuentes de evidencia para producción de datos: observación sistemática, análisis documental y entrevista semiestructurada. Datos recopilados de marzo a setiembre de 2015, estudiados por análisis de contenido temático.

Resultados:

del análisis surgió la categoría temática: Dramatización del "uso de sé" en el trabajo del enfermero en unidad de internación clínica quirúrgica. Se evidenció que los enfermeros se organizan de diferentes maneras para ejecutar el proceso de trabajo, aplicando el sentido común en diversas circunstancias relacionadas con la gestión del cuidado. Se resalta que aunque el trabajo esté predeterminado, los saberes, la experiencia y los valores tienen influencia en el sentido común por parte de estos trabajadores, apuntando a renormatizar el trabajo.

Conclusión:

el enfermero en unidad de internación quirúrgica desarrolla su trabajo en base a normas y antecedentes; sin embargo, basándose en su conocimiento, experiencia y subjetividad, aplica el sentido común apuntando a renormatizar las actividades, ejerciendo su autonomía en pro de mejorar la atención.

DESCRIPTORES
Enfermería; Trabajo; Subjetividad; Ergología; Enfermero; Servicio de salud

RESUMO

Objetivo:

conhecer como ocorre o “uso de si” do enfermeiro em unidade de internação clínica cirúrgica sob a ótica da ergologia.

Método:

pesquisa de abordagem qualitativa, do tipo estudo de caso, fundamentada no materialismo histórico e dialético e no referencial teórico da ergologia. Os participantes foram 12 enfermeiros atuantes em unidade de internação clínica cirúrgica de um hospital de alta complexidade. As fontes de evidência para a produção dos dados foram observação sistemática, análise de documentos e entrevista semiestruturada. A produção dos dados foi realizada entre os meses de março a setembro de 2015. Os dados foram analisados conforme a análise de conteúdo temática.

Resultados:

a partir da análise surgiu a categoria temática: Dramáticas do “uso de si” no trabalho do enfermeiro em unidade de internação clínica cirúrgica. Evidenciou-se que os enfermeiros se organizam de diferentes formas para efetivação do processo de trabalho, concretizando o uso de si em diversas situações, as quais tem relação com o gerenciamento do cuidado. Destaca-se que, embora haja o trabalho prescrito, os saberes, a experiência e os valores têm influência sobre o uso de si por parte destes trabalhadores, com vistas a renormatizar o trabalho.

Conclusão:

o enfermeiro em unidade de internação cirúrgica, desenvolve seu trabalho baseado em normas antecendentes, entretanto, com base em seu conhecimento, experiência e subjetividade, efetiva o uso de si, com vistas a renormatizar as atividades, exercendo autonomia em prol da melhoria do cuidado.

DESCRITORES
Enfermagem; Trabalho; Subjetividade; Ergologia; Enfermeiro; Serviço de saúde

INTRODUCTION

Nowadays, being alive means being in permanent transformation, both personally and professionally, as it denotes being in a constant movement of changes before society. From this perspective, over time, human work has been modified according to the different stages of the evolution of society, culminating, at present, in the prerogatives of the capitalist model.

The human being forms its social history producing and reproducing, in life, through work, which, therefore, also becomes a method of analysis of intellectual, social, political and economic life. From this point of view, it can be said that the challenges of daily life lead us to follow paths that have, on purpose, a continuous and reflective experience of the activities of human life, referring people, especially, "to think" of work in their personal, professional plan and about its repercussions.1^-2

Work is a condition for social life, and fundamental for human life.3 The human work process involves intervention on an object, promoting a transformation in order to meet needs. This process involves three elements: the activity suited to an end, which is the work itself / the transforming action; the matter that applies to work, the object of work; the means of work / the instrumental work. 4 In the meantime, the health work process is characterized as being complex and composed of numerous participants involved in the execution of actions: nurses, physicians, physiotherapists, nutritionists, pharmacists, cleaning staff, as well as management sectors, among others.1

In the hospital environment, nursing work is largely performed by nursing technicians and nurses who, according to their degree of training, perform activities and occupy different positions in the hierarchical work ladder. In addition to patient care and care functions, nurses assume management, administrative and organizational tasks, as well as supervising the work of nursing technicians.1

With regard to the work in the surgical in-patient unit, this study setting highlights the multiplicity of activities performed by nurses, directed to the management of the care of individuals who experience surgery and their relatives. These activities involve both the aforementioned activities and the managerial actions related to the organization of the care process, in which different professionals participate.

In order to perform their activities, nurses use various work instruments, highlighting knowledge involved in decision-making and actions. In this way, the nurses use their accumulated subjective knowledge in their work which influences the way in which they work.

From this perspective, the French philosopher Yves Schwartz6^-7 proposed the ergological approach to the production of knowledge in relation to work. The proposal of ergology consists in producing knowledge, considering the knowledge and experience of the workers, discussing the work in its essence, the general and specific aspects involved in the activity, which includes the constant questioning about knowledge, its norms and variabilities.

The use of self by the workers, according to the ergological approach, is characterized by " the use of self for oneself", when the worker himself creates particular conditions and strategies, using his subjectivity and autonomy in order to act and overcome the challenges of work, modifying prescriptions and norms.² It is assumed that no worker can perform some activity without using his "self", from his autonomy and subjectivity.9

From the perspective of the ergological approach, life is a dramatic constant of negotiations with the obligation to do, in the sense of the here and now in a world full of temporarily established, deeply ambiguous norms. In this dramatic use of self, there is not only an execution of the activity, but the worker is summoned in all his subjectivity.10 The worker experiences the dramatic use of self when he is in moments of choice, of doubts regarding the prescribed work and what really needs to be accomplished.

In view of the above, it can be seen that the work of the nurse, which although supposedly has characteristics linked to the fulfillment of tasks, which gives it a simplistic connotation, in fact constitutes a delicate and complex network involving different aspects and dimensions.

Thus, it is considered that the ergologic approach is a strategy which evaluates work, in order to provide support for reflections on the work of the nurse in a surgical in-patient unit and the multiple aspects involved in this work. Thus, the guiding question of this reseach was: how does the use of self in nurses occur in a surgical in-patient unit from the point of view of ergology? The general objective of the study was to know how the use of self of the nurse occurs in a surgical in-patient unit from the point of view of ergology.

METHOD

The present study consists of a qualitative case study,11 based on the philosophical strand of historical and dialectical materialism and on the theoretical reference of ergology.9 The case studied involved the use of self in nurses in a surgical in-patient unit of a highly complex hospital in the State of Rio Grande do Sul, Brazil. During the research period, the surgical unit contained 52 beds; however, four were blocked, leaving 48 operational. Patients from different clinics from following areas are treated in this unit: General Surgery, Urology, Traumatology, Head and Neck, Digestive, Thoracic, Vascular and Proctology. On average, 403 hospitalizations occur per year. The average patient stay in this clinic is 12.78 days. At the time of the study, the unit had a total of 14 nurses, ten being federal public servants and four were contracted by the Brazilian Hospital Services Company (EBSERH).

Participants consisted of 12 nurses who were eligible to participate in the study. The following inclusion criterion was applied: to have worked in the department for at least six months. Two other nurses were excluded after applying the inclusion/exclusion criteria, due to the fact that they had not worked in the unit for more than six months. The anonymity and confidentiality of the study participants was guaranteed by using fictitious names chosen by the researchers in sequence (E1, E2, E3, E4 ...). All participants signed the Informed Consent Term.

The data production was carried out between March and September 2015, after approval from the Research Ethics Committee. The following sources of evidence were used: 11 documental research, systematic observation and semi-structured interview. Firstly, documentary research and systematic observation and then semi-structured interviews were performed. The documentary research was based on the list of beds containing the list of hospitalized patients, with daily update, and meeting minutes, and those belonging to the nursing team that occurred from October 2009 until March 24, 2015, were analyzed, totaling 73 minutes. Nursing observations, performed by the nurse and the nursing technician; nursing reports, which were handled by the nurses and contained all beds, patient names, surgery performed and some relevant annotations were also analyzed, along with documentary research during the observation phase. The Standard Operating Procedures (SOPs) of the institution which describe how the nursing procedures must be performed were also analyzed.

The observation phase occurred together with the documentary research stage and prior to the individual interviews with the participants. The observation included the 12 actively working nurses who accepted to participate in the research. There was a total of 35 hours of observation, divided into twelve periods, observing the three work shifts on the different days of the week. The records consisted of cursive (continuous) annotations, use of keywords, checklist and field diary codes.¹¹ The periods consisted of two hours of observation on average, which was based on the quality of attention paid to this activity.

Following the period of observations and documentary research, individual interviews were performed. The interviews were conducted in a reserved room and had an average duration of between 45 minutes and one hour. All the interviews were recorded and transcribed for analysis. The exhaustion criterion was used to finish the interview period.12 Thematic content analysis13 was used to anaylze the material resulting from observation, documentary research and the transcription of the interviews. In the case study, the analysis and reflections of the findings are present from the beginning of the data production, i.e., from the beginning of the observation and documentary research. Triangular analysis was also used to identify convergences or divergences, providing a chain of evidence.

RESULTS

The category: Dramatic "use of self" during the work of the nurse in a surgical in-patient unit, emerged from the anaylsis of the results, evidencing characteristics of the nurse's use of self at work.The use of self is particularly important in the various activities/procedures, and the different modes of organization during work shifts in multiprofessional relationships, which interfere with professional autonomy, especially taking the personal experience of every nurse into account.

The nursing activities are prescribed and standardized. However, there is an essence, characterized by the subjectivity/individuality, both personal and historical of each nurse, which can be perceived and described in the following statements:

[...] I still perceive quite a difference in the performance of the technical procedure, even though it is described that it is to be done in a particular way; difference in the performance of each, each [nurse] ends up bringing his/her way of working and does not do exactly as it is there [standards, standard operating procedure] (E12). [...] but nobody is the same; that does not mean that the colleague's technique is wrong or mine is wrong, each person has a way, we follow principles (E6).

It can also be seen from the statements and the observation that the way in which nurses organize themselves and their work differs between them: [...] we already have a very long working day, organize yourself and to take your report and confront or compare and see (E9).

Each research participant is organized in the way that they consider best for themselves, taking into account the previous norms and prescribed work, as confirmed in the observation and interviews. When E9 mentions in their statement about the report, it refers to the nursing report, which is performed by the nurse the previous night and the nurses in the morning, afternoon and evening the next day, who use it to know all the information of all the patients in the unit. This report is updated for every shift and during the shift. During the observation period, it was observed that the report is very important for nursing work, and is often used to guide the activities that will be carried out during that shift. Regarding the nursing report, E1 stated the following:

I closed my eyes, I knew everything my patient had, I did not need a report. The nurse must have total control of her patient; if 25 patients have been designated, you must have control of those patients; Imagine ridiculous thing the doctor comes to ask the patient, but I do not know, like you will not know! This is unacceptable, you can´t do that: I do not know, I think. These words could not exist for nursing: I think, maybe, I do not know (E1).

From this statement, it can be seen that the standard of the institution is to use the nursing report. However, the same does not do so, but even so, does not consider that his work is disqualified. During the observation period, some nurses used the nursing report and others did not use it, creating different forms for their own organization, which is highlighted in the following reports:

I'm very organized. I try to organize in the best possible way in order to take care of the patient. So I have my report and I have my sheet of paper in my pocket, I write all the questions that the patient asks me on my piece of paper and I try to deal with them all until the end of the shift, [...] I try to organize myself like this (E11).

I have a habit of jotting down here [paper in the pocket]. When they are doing the shift handover I start to write things down, which things were pending, patient of the bed 20 had a central catheter inserted and did an Xray and that it was not evaluated, so I write: bed 20 evaluate x-ray. In the shift, when I receive the handover, I start making notes and then when I do the patient rounds, I take care of the issues together with the patient (E7).

With regard to this organization of nurses' work, each one is organized in a unique way, and one of the ways that stands out, both in observation and in interviews, is the organization of "the self" with regard to the priorities of the nursing process:

[...] we help these patients who are in need of immediate help, care, or because they are seriously ill or an infusion pump is beeping or bleeding, wet dressings, patient in pain, these things are the first things that we do (E5). I prioritize according to complexity, to the patient's clinical status, I prefer to go to the patients on mechanical ventilation with the girls [nursing technicians] (E10). [...] I organize myself and do what is a priority (E6).

It should be noted that, in the investigated setting, due to the characteristics of the institution, which is a reference for high-complexity care in its area of coverage, and the lack of sufficient intensive care beds that is very common to have critical patients hospitalized in the wards. This fact results in an additional need for organization, by all care staff, especially nurses, as identified in the observation.

During the nurses' work process in the surgical in-patient unit, it can be observed that the latter is organized trying to solve the priorities with respect to the patients, as explained and corroborating with the statements of E5, E10, E6. This issue is also the subject of discussion in a team meeting, and found in the minutes (Min. No. 005/2013), that nurses should be prioritized for the care of critically ill patients, as well as an emphasis on requesting the assistance of nurse technicians. Thus, the nurses emphasize the priority of attending to the serious patients:

[...] in the shift handover, youalready have an overview of how the patients are, how the unit is. Then, you can determine, for example, if you have a serious patient, if you have a patient on mechanical ventilation, that is your priority or if you have an unstable patient (E1).

With respect to the nurse's work with the nurse technician, different situations through which nurses performed different uses of themselves were evidenced, as observed in the following statements:

[...] I have the impression that I still have good know how, I am able to do a lot of things with the employees, even with very complicated employees (E9). Another thing is to really give individual attention to all employees. Tonight I'm going to work with two employees, I've already talked to the two employees: so and so, what we're going to do, I'm going to help you in this and that (E6). One thing that I always try to do, every time I go to join a different group, is to know the people with whom I work, to try to get to know them (E10).

The statements show that, in addition to the nurse performing their routine activities, there is a whole team, composed of different health workers, who must work together for the provision of qualified care. From this perspective, in which nurses act in a singular way, making different uses of themselves, during the work process, it appears that there is a greater or lesser use of autonomy, taking into consideration the activities which they are responsible for. In addition, autonomy also has implications directly related to the nursing team itself as well as the multiprofessional team.

Autonomy was discussed in the team meetings, as explained in Minutes nº 10/2011 and 06/2010: [...] emphasizes the importance of the nurses' autonomy in the unit. And that the nurse must commit and strive to have good progress and success [...],(Minutes nº 10/2011) the nurse can do any activity inside their scope without demeaning their position (Minutes nº 06/2010).Through what was explained in the minutes, it is noticed that, during the meetings, the theme of nurse autonomy became an important aspect in the discussions in order to have good progress and success during the work process and also, in view of the stimulus and promotion of nurse autonomy. In this sense, participants reported the following:

I think that here, this floor [surgical in-patient unit] gives you a great autonomy as a nurse and because it is a teaching hospital too, you [nurse] have autonomy to deal with the doctor, resident; at least, I strive for this in my work, to talk a lot with people [multiprofessional team] to talk about patients' cases (E11). [...] I think we have enough autonomy to make decisions about some things (E10). You achieve autonomy and respect. Through your actions. For example, when some [nurse technician] calls to evaluate a patient, you [nurse] go there, evaluate, do, give an answer, so you gain autonomy [the nurse] (E2).

Participants highlighted the use of their autonomy in different ways in relation to the decisions to be made with the patient, specific activities (patient assessment), respect and trust with the team. These aspects are extended throughout the course of the nurses' work process, becoming something particular and delicate, which is extremely different between one nurse and another, since it is linked to the different uses of themselves which could occur.Regarding the positions / uses of themselves that should be adopted by nurses, these can be observed in the following testimony:

[...] for example, I decide something in front of the patient, this patient has a temperature of 37.4, we will not give this blood, I say you can give the blood, I think this is autonomy. Or, then, the patient is retaining urine [bladder with more urine than its normal capacity] and we will insert a catheter, we will pass the intermittent catheter or an indwelling catheter ; No, the intermittent catheter; this patient is severe. No, it's working well. (E2)

From the perspective of this statement, it is highlighted that, in the investigated setting, the nurse has autonomy to make decisions regarding the problems that arise during the work process. During the observation, it was noticed that the nurse was faced with several situations in which decisions regarding the patient needed to made. When this occurred, after making the decision, he needed to communicate with the doctor and/or nursing technician. When communicating and at the same time discussing and clarifying the reason for the decision, the other professionals did not question or doubt the nurse's actions. These situations represent greater nurse autonomy, which can be observed in the following statement:

autonomy is to arrive at work and to be able to do the whole work plan for that shift, to see a patient who needs a specific mattress, a blanket [cover for skin injuries], the nurse has the autonomy to get there and say No, but there has to be a basis for this. Example: I think alginate is the best [type of coverage for skin damage] and have the power to make that decision, no matter how much the residents come in and want charcoal. You have to have autonomy and know how to argue. [...] A lot of knowledge, because there is no use saying: use alginate; but I do not know what the alginate is for, if I say it has to be alginate, they're going to ask me why it has to be alginate and why not charcoal, there's no point saying 'I think it's better', but why do you think it is better? [...] (E7).

E7´s statement demonstrates that the effectiveness of nurses' autonomy involves aspects of personal development (self-use and subjectivity) and the issues that encompass the work itself. In relation to these aspects, the following statement is highlight: one day I had the displeasure of meeting a resident [doctor], [...] he said he would have to teach the nurses how to change the chest drains. I said: what do you mean? [...] I think you spoke to the wrong person in the wrong unit [surgical clinic] at the wrong time. What do you mean teach? You have to be a little more humble to talk to people. So if you think that [nurses] are doing something wrong, this is not wrong, we are doing what we have been doing, but if there is a new way of doing something, we are always open to all innovations. Another example: one patient was discharged, and I said no, this patient will not be discharged. He can not leave with this open wound. There, the resident went on to say: who I thought I was, that I was interrupting a discharge. I say: I am a professional with a higher level education as much as you, I understand wounds and this patient can not go homelike this [...]. She went to back to the hospital in her city, but after two weeks (E1).

In this statement, one can emphasize its use of "firm" self, imposing itself in relation to the discharge of a patient from the surgical in-patient unit and promoting its autonomy in relation to the other health care professional. In order to have autonomy, the nurses reported in the statements that it is necessary to have knowledge during the work process. The same can be seen in the following statements:

autonomy, I think it is the ability I have to decide on what is best for the patient within my competence, within my knowledge. The more knowledge I have, the more confidence I will have and I will develop my autonomy. Consequently, if I have the confidence to make my decisions, I pass this on to the other professionals, which also leads to autonomy (E1). [...] When you speak of autonomy, what comes to my head is knowledge, because for you to have autonomy, you must first have knowledge (E11). Knowledge. [...] you can only have autonomy if you have knowledge; if you do not have knowledge, you can not stand your ground with anyone, you can not articulate anything, you just have to accept (E9).

Regarding the statements, it is evident that knowledge is an essential aspect for the exercise of autonomy among the nurses. When they have knowledge regarding the care activities, they can make successive and resolutive uses of themselves to the point of providing autonomy during the work process. Knowledge is also involves the nurses' experience: I see that the people who have worked longer have more experience, more autonomy, do not call the doctor asking if they can or can not, they know (E7).

The participant (E7) reported that when the nursing professional has a longer working career, they have more experience and greater autonomy. Finally, it should be noted that, although there is the prescribed work and the previous norms and standards, which govern nursing work, nurses make use of their personal and historical subjectivity in each activity that they perform, putting their use of self into practise.

Thus, the work of the nurse in a surgical in-patient unit is a dramatic one, in which the previous norms (the prescribed work) are involved and the activity effectively performed, mediated by use of self, which is anchored in knowledge, past experience and values of the worker - in the use of self. By knowing the way nurses in the surgical clinical in-patient unit make use of themselves, consequently, one can seek strategies to foster greater autonomy at work, with a view to more qualified care and greater professional visibility.

DISCUSSION

The results of the investigation allow us to infer that nurses, in their work in surgical in-patient unit, carry out their work taking into account previous norms, i.e., the prescribed work. However, based on their knowledge, experiences and values, they feel called to standardize activities, being involved in the dramatic use of self.

The dramatic use of self by the nurse, refers not only to the performance of activities or factors that influence the work process, but a 'use' of their subjectivity and professional experience. Collective and individual knowledge, acquired through experience and scientific knowledge, involves this dramatic dimension of the use of self in nursing work, in the production of standards, knowledge, and values in practise.14

The statements of the participants emphasize that, during work, there are previous standards and the prescribed work, that they must follow. However, for the accomplishment of the activities (techniques and procedures which the nurse is responsible for), they affirmed that each one has their 'way' of accomplishing their work. This 'way' is marked by their use of self.

In this dramatic use of self, the activity is not only performed, but the worker is summoned in all his subjectivity.15 It can also be said that the realization of the activity involving the use of self pervades the verbal and nonverbal, crosses the body and soul, the biological and the cultural, the effective and the rational, involving the nurse´s unconscious, preconscious and the conscious.¹⁶ Thus, it is considered that the use of self involves not only the physical, but emotional, affective and historical-social.

Through the use of self, the nurse is not considered a "soft mass", which would passively inscribe the memory of the reproduction of work activities.When it is affirmed that the work is also use of self, it is considered that it is a place of problem, of a problematic tension, of a space of constat negotiation: there is not a simple execution of na activity, an essence, a use. It is the worker, in his being, who is summoned, with infinitely vast capacities and personal resources.7

In view of the results, it can be seen that nurses, despite having a similar work routine, they each have a particular way of organizing themselves, aiming to ensure quality care to patients. From this context and the ergological view, it is ensured that the worker is involved in the activities with their values, their unique history and, mainly, with their capacity to institute work. This allows one to transform themselves and their work by renormalizing the previous norms by making use of self.

No work is mere performance, repetition of movements, gestures, sequences of activities. All activities are resingularized and consist of a renormalization involving how each nurse organizes, both through the report and through priorities. From this perspective, health work, especially that of the nurse, can be characterized as a context and space in which debates between norms and renormalizations take place. Renormalization considers the knowledge and power effectively concretized during the practice of the nurse, through the relationships that are established therein.1^-2 Thus, nursing work consists of a space of microdecisions; it is the place to question the norms and the prescribed.

The shift handover was mentioned by the participants as an important moment, since it allows the planning of an initial organization for the activities of the work shift. The recognition of the nurses' shift is a relevant theme for the daily life of the hospitals, since, from this ritual, there is an opportunity for support among nursing workers who are leaving and those who are coming to work.

The code of ethics for nursing professionals includes duties and responsibilities that guarantee the continuity of nursing care in safe conditions, as well as the provision of verbal, comprehensive and reliable information, necessary to ensure the continuity of care. 17^-18 However, the data reveal that, although this moment is a prescribed activity, a very particular apprehension of the activity is revealed, on the part of each worker which directs their work.

In addition, it can be emphasized that the use of self different of each nurse can be characterized when the participants reported on the dialogue and the coexistence with other professionals, giving greater and better possible care to the patient, gaining confidence. These particularities of the nurses´ use of self occur mainly with nursing technicians, who work directly with nurses during the work process. Each nurse communicates in a specific manner with the nursing technicians, in view of the organization of the care given to the patient.

Considering the observation, the analysis of the documents and the statements, it is noticed that the autonomous nurse is the one capable of managing their activities with competence. It should be emphasized that, in order for this autonomy to occur effectively during work, the nurse must utilize use of self when performing activities and making decisions, which should also be based on ethics, respect and social commitment.

Regarding this, the nurses' posture, when developing activities, involving the use of self, to exercise autonomy, is perhaps one of the main challenges that are imposed on them in the work in a surgical in-patient unit, which is composed of a large number of health professionals and often has extremely complex patients. The confluence of these problematic or dramatic use of self, also involves a debate of norms and values that serve as construction of the work environment, causing the nurse to experience facilities and difficulties in using their use of self.17 The nurse develops experience improving practice, acquiring knowledge and developing their skills through their experience in the world of work.

Use of self by the nurse occurs simultaneously between "use of self for oneself" and "use of self for others," including the micro-management commitment to the workplace; therefore the negotiation between these dramatic ones is always difficult.9 Thus, the bad and the good use of self of the nurse will influence the final product and, consequently, the posture adopted will guarantee the perception of the other workers in a negative or positive way with relation to their professional autonomy.

As reported by the research participants, autonomy implies knowledge and experience as a way to overcome unforeseen problems, conflicts, and renormalizations. In this sense, it is important to highlight the importance of the knowledge acquired, which is related to the knowledge, concepts and disciplinary academic and/or professional competences. In other words, the knowledge is necessary, however, it is prior and external to the work situation to which the subject is found.17 This knowledge enables the foundation of the prescribed work and the renormalization of the activity, when the worker, in this case, the nurse, is summoned to participate in this dramatic of use of self.

Therefore, it is necessary to rely on the protocols, however the use of self is pertinent in order to deal with non-standardized aspects of the activities, thus calling for experience to deal with unique aspects of the situation. Currently, in the working environments, which are regulated by prescribed, management, technical and economic norms, it is perceived that all work activity is always, in part, the application of previous norms. If there were only normalization, the work situations would be equivalent to an experimental protocol, in which the activities would be completely manipulable and operative by any worker, since the experimentation would try to eliminate all the biases, not involving the experience/subjectivity of the worker and, consequently, making use of self more difficult.9

Finally, it must be highlighted that, although there is the prescribed work and the previous norms, which govern nursing work, nurses make use of their personal and historical subjectivity in each activity, implementing their use of self. By developing the work activity in this way, they open up the possibility of a more autonomous professional practice.

This study is limited due to it being performed in a single institution and the scarcity of studies based on this theoretical reference, especially in a surgical in-patient unit. Therefore, the need for further research on the subject, based on this reference and the need to foster discussions on nurses' work in terms of autonomy and visibility is highlighted.

CONCLUSION

Based on the results of this research, it was possible to understand how the use of the nurse's self occurs in a surgical in-patient unit from the perspective of ergology. Based on the proposed framework to anchor the analysis of the data of the present investigation, it can be concluded that the work of the nurses working in a surgical in-patient unit is based and strongly linked to the prescribed work (legislation, previous norms), which outlines the activities which the nurse must perform. However, the possibility of changes / alterations, described as renormalization, that they can perform, is ample. From the moment nurses modify their practice, involving their knowledge and their own experience, they concretize/establish their use of self

The use of the nurse's self in a surgical in-patient unit occurs in several specific manners. It also covers subjective, historical and experience aspects related to nursing work. The nurse implements use of self when faced with unscheduled demands that arise during the work shift, especially in relation to the care given to patients considered to be priority (serious patients), on duty, among others. The observations reiterated the singularity and the different uses of self in different situations experienced by nurses.

Knowledge that the nurse possesses is fundamental in order for the nurse to effectively make use of their self and their subjectivity, providing greater autonomy in the work environment. In this way, each nurse, with their "self", weaves the collective work tapestry, while at the same time, with the other professionals of the team, the care of the patient hospitalized in a surgical clinic. Through the ergology referential, prerogatives that better understand and transform the nurses' work in the hospital setting are established. In this sense, it contributes so that the activities can go beyond the technique/procedure, increasing the autonomy of the nurse and, consequently, the quality of care.

REFERENCES

• 1. Fischborn AF, Viegas MF. A atividade dos trabalhadores de enfermagem numa unidade hospitalar: entre normas e renormalizações. Trab Educ Saúde [Internet]. 2015 Dec [cited 2017 Oct 17];13(4):657-74. Available from: Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S19817462015000300657&lng=en&nrm=iso
  » http://www.scielo.br/scielo.php?script=sci_arttext&pid=S19817462015000300657&lng=en&nrm=iso
• 2. Schwartz Y. Manifesto por ergoengajamento. In: Bendassolli PF, Soboll LAP, editors. Clínicas do trabalho. São Paulo (BR): Atlas; 2011.
• 3. Antunes R. A dialética do trabalho. Escritos de Marx e Engels. São Paulo (BR): Expressão Popular; 2013.
• 4. Marx K. O capital: crítica da economia política: livro I. Rio de Janeiro (BR): Civilização Brasileira; 2013.
• 5. Pinno C, Camponogara S. O trabalho de enfermeiros em unidade de internação cirúrgica sob a ótica da ergologia. Biblioteca Lascasas [Internet]. 2015 July [cited 2017 Mar 17];11(3):80-9. Available from: Available from: http://www.index-f.com/lascasas/documentos/lc0855.php
  » http://www.index-f.com/lascasas/documentos/lc0855.php
• 6. Schwartz Y. Trabalho e saber. Trab Educ [Internet]. 2003 [cited 2017 Nov 17];12(1):21-34. Available from: Available from: http://www.portal.fae.ufmg.br/seer/index.php/trabedu/article/viewFile/1227/989
  » http://www.portal.fae.ufmg.br/seer/index.php/trabedu/article/viewFile/1227/989
• 7. Schwartz Y. Le paradigme ergologique ou um métier de philosophe. Toulouse(FR): Octares; 2000.
• 8. Schwartz Y. A abordagem do trabalho reconfigura nossa relação com os saberes acadêmicos: as antecipações do trabalho. In: Souza M, Faita D organizadores. Linguagem e trabalho: construção de objetos de análise no Brasil e na França. São Paulo (BR): Cortez; 2002.
• 9. Schwartz Y, Durrive L. Trabalho e ergologia: conversas sobre a atividade humana. Niterói(BR): EdUFF; 2010.
• 10. Campos LF, Melo MRAC, Telles PCP Filho. Ergologia como referencial teórico: possibilidades para assistência e pesquisa em enfermagem. Rev Enferm Cent O Min [Internet]. 2014 Mar [cited 2017 Mar 17];4(2):1222-8. Available from: Available from: http://www.seer.ufsj.edu.br/index.php/recom/article/view/613/757
  » http://www.seer.ufsj.edu.br/index.php/recom/article/view/613/757
• 11. Yin RK. Estudo de caso: planejamento e métodos. Porto Alegre(BR): Bookman; 2015.
• 12. Fontanella BJB, et al. Sampling in qualitative research: a proposal for procedures to detect theoretical saturation. Cad. Saúde Pública [Internet]. 2011 Feb. [cited 2019 May 05];27(2):388-94. Available from: Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0102-311X2011000200020&lng=en
  » http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0102-311X2011000200020&lng=en
• 13. Minayo MCS. O desafio do conhecimento: pesquisa qualitativa em saúde. São Paulo(BR): Hucitec; 2014.
• 14. Santos TM, Camponogara S. A look at the work of nursing and ergology. Trab Educ Saúde [Internet]. 2014 Apr [cited 2017 Nov 14];12(1):149-63. Available from: Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1981-77462009&lng=en&nrm=iso
  » http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1981-77462009&lng=en&nrm=iso
• 15. Campos LF, Melo MRAC, Telles PCP Filho. Ergologia como referencial teórico: possibilidades para assistência e pesquisa em enfermagem. Rev Enferm Cent O Min [Internet]. 2014 Mar [cited 2017 Mar 17];4(2):1222-8. Available from: Available from: http://www.seer.ufsj.edu.br/index.php/recom/article/view/613/757
  » http://www.seer.ufsj.edu.br/index.php/recom/article/view/613/757
• 16. Beyer FM. Penser le politique dans l’activité à partir des orientations du travail. Ergologia [Internet]. 2014 Mar [cited 2017 Nov 17];1(11):25-69. Available from: Available from: http://www.encadrer-et-manager.com/pdf/6-ANVIE.pdf
  » http://www.encadrer-et-manager.com/pdf/6-ANVIE.pdf
• 17. Gonçalves MI, Rocha PK, Anders C, Kusahara M, Tomazoni A. Communication and patient safety in the change-of-shift nursing report in neonatal intensive care units. Texto Contexto Enferm [Internet]. 2016 [cited 2018 May 17];25(1). Available from: Available from: https://dx.doi.org/10.1590/0104-07072016002310014
  » https://dx.doi.org/10.1590/0104-07072016002310014
• 18. Conselho Federal de Enfermagem. Código de ética dos profissionais de enfermagem [online]. 2012 [cited 2012 Oct 12]. Available from: Available from: http://www.portalcofen.gov.br
  » http://www.portalcofen.gov.br
• 19. Peres AM, Ezeagu TNM, Sade PMC, Souza PB, Gómez-Torres D. Mapping competencies: identifying gaps in managerial nursing training. Texto Contexto Enferm [Internet]. 2017. [cited 2017 Dec 20];26(2):e06250015. Available from: Available from: https://dx.doi.org/10.1590/0104-07072017006250015
  » https://dx.doi.org/10.1590/0104-07072017006250015

NOTES

• ORIGIN OF THE ARTICLE
  Article extracted from the dissertation - The work of the nurse in surgical in-patient unit from the perspective of ergology: a case study. Graduate Program in Nursing, Federal University of Santa Maria, in 2016.
• ETHICS COMMITTEE IN RESEARCH
  Approved by the Research Ethics Committee of the Universidade Federal de Santa Maria, nº 980.591 and CAAE 41040815.9.0000.5346.

Publication Dates

• Publication in this collection
  29 July 2019
• Date of issue
  2019

History

• Received
  30 Jan 2018
• Accepted
  30 May 2018