CHALLENGES OF THE ORGANIZATIONAL DIMENSION OF CARE IN THE DAILY WORK OF NURSING WORKERS

Objective: to investigate challenges of the organizational dimension of care from the perspective of nursing workers. Method: qualitative, descriptive study, carried out with 18 professionals, of a Public Oncology Hospital. The data were gathered from participant observation and interview, based on a semi-structured script and submitted to the Content Analysis technique, in the Thematic Analysis modality. Results: the data showed differences of perception, between management and care workers regarding the challenges of the organizational dimension of care; the main challenges presented by the management nurses are related to the resolution of the proposed actions regarding patient safety. Conclusion: the study contributes to elucidate that the protagonism of the subjects should be considered to implement changes in management or assistance, emphasizing the importance of the bond and teamwork, revealing that inadequate working conditions facilitate the worker's suffering and discouragement. The picture is mitigated by the cooperative work of the teams and mediation of conflicts by the leaderships. Descriptors: Nursing; Hospital Care, Quality of Health Care; Health Service Administration; Nurses; Health Services. RESUMO Objetivo: investigar desafios da dimensão organizacional do cuidado sob a perspectiva dos trabalhadores de enfermagem. Método: estudo qualitativo, descritivo, com 18 profissionais de um Hospital Público Oncológico. Os dados foram reunidos a partir de observação participante e entrevista, com base em roteiro semiestruturado, e submetidos à técnica de Análise de Conteúdo, na modalidade Análise Temática. Resultados: houve diferenças de percepção, entre trabalhadores da gestão e da assistência, com relação aos desafios da dimensão organizacional do cuidado; os principais desafios estão relacionados à resolutividade das ações propostas referentes à segurança dos pacientes. Conclusão: o estudo contribui elucidando que o protagonismo dos sujeitos deve ser considerado no intuito de implementar mudanças na gestão ou assistência, enfatizando a importância do vínculo e do trabalho em equipe, revelando que condições inadequadas de trabalho facilitam o sofrimento e a desmotivação do trabalhador. O quadro é atenuado pelo trabalho cooperativo das equipes e a mediação de conflitos por parte das lideranças. Descritores: Enfermagem; Assistência Hospitalar; Qualidade da Assistência à Saúde; Administração de Serviços de Saúde; Enfermeiros e Enfermeiras; Serviços de Saúde. RESUMEN Objetivo: investigar desafíos de la dimensión organizacional del cuidado bajo la perspectiva de los trabajadores de enfermería. Método: estudio cualitativo, descriptivo, realizado con 18 profesionales de un Hospital Público Oncológico. Los datos fueron reunidos a partir de observación participante y entrevista, con base en guión semiestructurado, y sometidos a la técnica de Análisis de Contenido, en la modalidad Análisis Temático. Resultados: los datos mostraron diferencias de percepción, entre trabajadores de la gestión y de la asistencia, con relación a los desafíos de la dimensión organizacional del cuidado; los principales desafíos mostrados por los enfermeros de la gestión están relacionados con la resolución de las acciones propuestas referentes a la seguridad de los pacientes. Conclusión: el estudio contribuye dilucidando que el protagonismo de los sujetos debe ser considerado en el propósito de implementar cambios en la gestión o asistencia, enfatizando la importancia del vínculo y del trabajo en equipo, revelando que condiciones inadecuadas de trabajo facilitan el sufrimiento y la bdesmotivación del trabajador. El cuadro es atenuado por el trabajo cooperativo de los equipos y la mediación de conflictos por parte de los líderes. Descriptores: Enfermería; Atención Hospitalaria; Calidad de la Atención de Salud; Administración de los Servicios de Salud; Enfermeros; Servicios de Salud. Master's student, Professional Master's Program in Health Education, Aurora de Afonso Costa Nursing School, Fluminense Federal University/EEAAC/UFF. Rio de Janeiro (RJ), Brazil. E-mail: vmazzoni@inca.gov.br ORCID iD: http://orcid.org/0000-0001-6894-3484; PhD student, Alfredo Pinto School of Nursing, Federal University of the State of Rio de Janeiro/EEAP/UNIRIO. Rio de Janeiro (RJ), Brazil. Email: lbittencourt@inca.gov.br ORCID iD: http://orcid.org/0000-0001-9484-9643; 3Nursing Academic, Alfredo Pinto School of Nursing, Federal University of the State of Rio de Janeiro/EEAP/UNIRIO. Rio de Janeiro (RJ), Brazil. E-mail: marcellelealr@gmail.com; ORCID iD: http://orcid.org/0000-0002-7198-1112; PhD, Department of Health Planning, Institute of Collective Health, Professional Master's Program in Health Teaching, Aurora de Afonso Costa Nursing School, Fluminense Federal University/EEAAC/UFF. Niterói (RJ), Brazil. Email: monicagouvea@gmail.com ORCID iD: http://orcid.org/0000-0002-6552-8004 ORIGINAL ARTICLE Mazzoni VG, Bittencourt LP, Ribeiro ML et al. Challenges of the organizational dimension... English/Portuguese J Nurs UFPE on line., Recife, 12(1):11-8, Jan., 2018 12 ISSN: 1981-8963 https://doi.org/10.5205/1981-8963-v12i01a230392p11-18-2018 The performance of Nursing workers constitutes the greatest expression of the workforce in the hospital context. In the dynamics of work processes, not infrequently, each team member operates the activities related to care in a fractional way. The piecemeal work in Nursing can result in the valorization of technicality by the workers.1 The division of work in the Nursing team can sometimes lead to disarticulated work, non-shared care, whose way of organization of the objective assistance, mainly, increase the productivity of services.1 Nursing work involves a composition of nurses, technicians and auxiliaries, which implies a managerial effort to coordinate actions and relationships for compliance with routines and protocols, being the nurse responsible for planning and determining the various activities of the other components of the team, responding legally

The performance of Nursing workers constitutes the greatest expression of the workforce in the hospital context.In the dynamics of work processes, not infrequently, each team member operates the activities related to care in a fractional way.The piecemeal work in Nursing can result in the valorization of technicality by the workers.¹ The division of work in the Nursing team can sometimes lead to disarticulated work, non-shared care, whose way of organization of the objective assistance, mainly, increase the productivity of services.¹Nursing work involves a composition of nurses, technicians and auxiliaries, which implies a managerial effort to coordinate actions and relationships for compliance with routines and protocols, being the nurse responsible for planning and determining the various activities of the other components of the team, responding legally to their acts.¹ In this way, it can be considered that the organization of work in Nursing is increasingly parceled out and fragmented, hampering expanded health care and intensifying the technical and segregator care model.In addition, it reinforces the verticalization of power within health institutions, resulting in a diversity of tensions that range from the issue of compensation, to the status of power and autonomy of different health workers.² In this sense, it adds value to this discussion, when it identifies that the management of health care is carried out in multiple dimensions (individual, family, professional, organizational, systemic and societal) that present specificity that can be known for the purposes of reflection, research and intervention.³Included, in the study, were Nursing workers linked to management and care, with at least three months of stocking in the sector or the current position/function.Those who were on leave or leave during the data collection phase were excluded from the study.
Information was also provided, on the right to privacy and confidentiality of information, identified by fictitious names, namely: NURS MAN for nurses in charge/management function; NURS for care nurses; and NURS TEC for Nursing technicians.The participants signed the Free and Informed Consent Term (FICT) in two copies, one of which was retained by the participant and one filed by the researcher.
A total of 18 workers participated in the study: six nurses in charge/management function filled in different sectors; four Nursing assistants and eight Nursing technicians from different hospitalization sectors.The choice of the hospitalization sector was due to the fact that it brought together a larger contingent of workers and its interface with all other sectors of the hospital.
Data were collected through participant observation and interviews conducted during May, April and June 2017.The participant observation was based on the daily observation of the daily work of the care teams and the management sectors whose managers accepted to collaborate with the study.The interviews were carried out with the support of a semi-structured script in single sessions with each collaborator and had an average duration of ten minutes, being recorded with authorization.
The observations were recorded in a field diary and the interviews were transcribed.This material was taken as the source of oral documents and the data were submitted to the Thematic Analysis, as directed by Minayo. 4reading of the material, was carried out, first, considering the criteria of exhaustiveness, representativeness, homogeneity, pertinence and exclusivity, in order to apprehend the central meaning of the concept.Afterwards, the material was explored, through an exhaustive reading of the statements, for the definition and the identification of significant expressions or words by similarity, thus, identifying, the most relevant themes. 4his study was evaluated and approved by the Research Ethics Committee (REC), according to CAAE nº 62128916.0.3001.5274.
The interviewees were, predominantly, female, with a mean age of forty years, ranging from the only male participant to a twenty-seven-year-old technician, and one of the fifty-three-year-old care nurses.Four participants report having between twenty and twenty-eight years of service in the public service, and the others have, on average, twelve and a half years of experience in this area.
Managers who agreed to collaborate work in the areas of Risk and Quality Management, Continuing Education, Nursing Supervision, Emergency Management and Head of the Internment Unit.Two interviewees have shorter time in the current position (six months and one year), but these have, respectively, twelve and six years of experience in public service.All of them have Stricto ou Lato sensu courses, four of which have a master's degree and two with specialization in an area related to the field of oncology.
The participating Nursing assistants work in two different sectors/floors and conform the less experienced group, despite having a specialization in the area of Oncology.They have between three months and a year in office and only one participant, in this category, has been in the current position, with 26 years of public service for five years.
The participating technicians work in the Clinical Oncology, Connective Bone Tissue and Gynecology sectors and comprise an experienced group that has, on average, thirteen years of service in the public service and five years in the current position in the hospital.Among the eight technicians, two have a Nursing degree, one of them being post-graduate.
The general analysis showed different points of view on the challenges related to the organizational dimension of care.It should be clarified that the aspects related to this dimension correspond to managerial responsibility and team relationship. 3he main result of the study pointed to differences in perception among management and care workers regarding the challenges of the organizational dimension of care.Among the additional results, the following challenges were pointed out: the nurses in charge/management function are concerned with the resolution of the actions proposed by their respective sectors regarding patient safety; on the other hand, care nurses and Nursing technicians are, especially, concerned with the difficulties of personnel dimensioning and its consequences in the assistance and in the labor relations.
The main challenges pointed out by the nurses in position/management function are related to the consequences of the actions proposed by their managerial sectors for patient safety.They question whether the work of the management comes to impact on the quality of care provided, as: We seek to tailor our role, to the needs of the Nursing team, so that, they can provide quality patient care.(NURS MAN 4).
The biggest concern is that the patient's complaint be supplied and that the processes are round to avoid failure, especially, with regard to patient safety.(NURS MAN 5)   It is observed that the statements are in accordance with the guidelines of Administrative Rule no.529, of the Ministry of Health regarding the National Patient Safety Program (NPSP), which establishes actions aimed at patient safety, integration and multiprofessional articulation in management processes and risk management. 5eally, there should be the exchange of experiences from the point of view of an integral and resolutive approach, which allows the planning of more effective health actions.The construction of cooperative work presents itself as an effective tool for doing it in a group, but implies overcoming many obstacles.

RESULTS
English/Portuguese J Nurs UFPE on line., Recife, 12(1):11-8, Jan., 2018  14 The participating nurses/management role demonstrate an expanded team vision: I understand that, for the process to happen, this team is bigger, it is multiprofessional, it involves the doctor that works here in our assistance, it involves the operational ones, either the receptionist, the handyman or the cleaner, who together will try to maintain the quality of the care that, is done here in the emergency room.So in the care itself, there is a team, but it does not work alone because it depends on other vectors that will impact as well.(NURS MAN 5)   On the other hand, the Nursing assistants and the Nursing technicians reported, in particular, concern with the difficulties of personnel dimensioning and its consequences in the assistance and in the labor relations, as pointed out: The fragility in nurses' knowledge about the care management can result in a disarticulation between managerial and care work, 6 and may involve aspects related to quality of care, patient satisfaction, work overload and hours of Nursing care.
In some situations, problem solving depends not only on capacity building, but, on other factors that are influenced by the lack of financial and/or human resources 7 , in addition to fragile work processes.In this scenario, insufficient staffing sometimes leads to high absenteeism and sick leave, as well as favoring the occurrence of interpersonal conflicts.
When considering the hospital Nursing worker, the quantitative aspect can be evidenced, for example, in the assumption of responsibility for more than one sector or service.The qualitative aspect, in turn, can be verified in the difficulty in dealing with the complexity of the human relations, that present themselves in the daily life, involving patients, family members, the Nursing workers of different levels (managers, head nurses, and technicians) and other health professionals.
In the workers' speeches, the emotional exhaustion, generated by the overload, associated with the nature of the work with the oncological patient can be perceived, as shown by: I feel that the staff in general, is unmotivated.Our complaint is not only the amount of work itself, which is heavy, it is also emotional exhaustion[...] The category does not feel valued as a human being.The speech is: 'Patients have cancer, but what about us?We are human beings as the patients.(NURS TEC 2) In the context of the oncological hospital, Nursing workers may present difficulties in their daily lives due to their contact with pain, suffering and death.The professionals experience different feelings in the face of the experiences of work, which vary from grief to escape movements and denial of suffering, 8 as is reinforced: The main problem I think is the lack of human resources.This affects a lot, because here is a heavy sector, outside the psychological.The work is manual and also emotional and ends up getting heavy because of the small amount of people to work, so, we get overwhelmed.(NURS TEC 5) Knowledge of the factors that cause suffering can be the starting point for organizations and the workers themselves to build individual and collective defensive and coping strategies, specific to the organization of the work, where the worker is inserted, to alleviate suffering. 9n this context, the workers take care of the people and, sometimes, the daily contingencies, do not worry about their own quality of life, especially their health.In addition, the workday, sometimes doubled, experienced by a large number of these professionals, despite the benefits related to the increase of income, in a way, ends up favoring a reduction in the time devoted to self-care and leisure, thus, increasing fatigue and increasing stress.
It should be noted that, despite the reported situation, no action was taken, on individual or collective initiative, of the workers to claim better working conditions.Therefore, it does not seem to be a leading role in this regard, which could engage them in the fight, both for the quality of care provided to users, and for promoting their own health.
For care nurses, this personnel sizing issue needs to be handled with care, as is pointed out: I try to be observing the complexity of the patients, to divide, in the best way, between one shift and another.I try to English/Portuguese J Nurs UFPE on line., Recife, 12(1):11-8, Jan., 2018  15 show them the complexity that has remained with the colleague, I try to make this division so as not to weigh anyone.(NURS 1) When recognizing the problem, the interviewee points out how he deals with the issue: As I need to come to work, I adapt.The team helps a lot, it's a cool group, which I like to work with, so it softens a bit.(NURS TEC 6)   In general, the participants stated that there is team work in the hospital and that the discussions are shared.However, both care nurses, and Nursing technicians, reported that Nursing care has not yet been adequately performed: In my experience here for six years in the hospital, has shifts that have a better team spirit, others not so much.(NURS TEC 1) The speech emphasizes the importance of the team as mitigating the mentioned physical and emotional overload.The interaction and communication are recognized as essential for the development of teamwork.  Theonstruction of a link, associated with good communication among professionals, should be part of the daily work exercise, allowing articulations necessary for the development of healthy work activities and aiming at exchange of experiences under the perspective of an integral, resolutive approach and more effective health actions for both the team and the patient.
On the other hand, the cooperation, solidarity and care that permeates group activities depends on the willingness of the subject to open himself to the other, to seek in the other what he does not know or what he lacks. 12In this sense, the nurses of the assistance resent the lack of team involvement in daily life: The staff, sometimes, seem a little more concerned about doing their job, complying with your prescription and that's it.Sometimes, it is: he does his, I do mine.And I'm responsible for everything.(NURS 3) The reported problems can easily influence people and compromise processes, especially, with regard to bonding, since work overload and emotional impairment do not favor the investment of time in interpersonal relationships.The care nurses report that it is common to need to mediate conflicts in the daily work at the hospital: Resolving conflicts is my main concern.

Unresolved interpersonal conflicts will have consequences for the quality of care. We have to use a lot of creativity and have a lot of persistence, availability and versatility. (NURS 4)
In a contemporary view, organizational conflict should not be avoided or stimulated, but, administered.Thus, managers should provide a work environment in which conflicts can be used as a source of growth, innovation and productivity. 13Note that participants, who refer more closely to their teams, report greater peace of mind and ability to cope with suffering related to work, as reported by: There are times that are very stressful.Even so, in my team, we are very close.When one is looser, help the other.We have this comfort, from one to the other.(NURS TEC 7)   The bond results from the willingness to accept some and the decision to seek support in others.Links therefore, refer to the circulation of affection between people.However, in general, they are not aware of the bonding pattern that they establish and that this does not always follow the convenience. 14n this context, the participating managers report distancing in relation to the larger management represented by the hospital management, indicating that they feel isolated in their decisions or actions due to a lack of involvement in the reflection on the problems found in daily life, as reported:

I miss this greater concern, I feel this absence. It's a gap, a void that one misses to drive things. (NURS MAN 2)
On the other hand, there is the recognition that the sectorial management, represented by the Division of Nursing and Sector Managers, are participative and they are accessible, getting involved with daily care, as it points out:

I always see Nursing management, very close to us here. As a tip, I do not see her absent. I have nothing to complain about, they are too open to hear. (NURS TEC 7)
Thus, a new management architecture should allow for an increase in contact between people, allowing the encounter of differences, as guided by the National Humanization Policy.By humanization, is understood the valorization of the different subjects, involved in the process of health production.The values that guide this policy are the autonomy and protagonism of the subjects, the co-responsibility between them, the solidarity bonds and the collective participation in health practices. 15n the nurses' report of the assistance, the need to mediate conflicts was recognized as daily action: With age, we see the importance of relationships being well resolved.This impacts on our motivation to work.Our group is not matured in this respect yet, it needs follow-up.(NURS 4)   This management profile corresponds to the orientation of the National Humanization Policy, regarding the inseparability between the ways of producing health and the ways of managing the work processes, between attention and management, between clinical and political, between health production and production of subjectivity. 15he new managerial competences, in a conception of participative management, are based on the construction of collective spaces, promoting exchanges of knowledge, reflections and evaluations, glimpsing paths towards the design of new modes of production of the care that requires the apprehension of reality, not for the adaptation to it, but to intervene in it. 16e data allow us to reflect on possible ways of managing in the perspective of the organizational dimension of care in the research scenario.The organizational dimension of care is that performed in health services, marked by the technical and social division of labor, and highlights elements such as: teamwork, coordination and communication activities, as well as the management function itself.In it, the cooperative action of several actors, to be achieved in territories often marked by dissent, by difference, by disputes and by asymmetries of power, becomes central. 3mong the management strategies, there is the instrumental paradigm, more "authoritarian", vertical, in the sense of being more controlling, the autonomy of the workers, and the more democratic and participative way.It regroups, in part, the management experiences that stimulate the workers of an organization to participate in different levels of decision making. 17The two strategies, almost always, present themselves in a mixed way, hardly being found in isolation.
When teams participate in decision making by building consensus, and partnerships with users and managers, the quality and outcome of actions are better and longer lasting, whether these are managerial or managerial actions. 17The great challenge for participatory management is to implement teaching processes and learning that are supported by critical-reflexive actions capable of promoting changes in the different realities of each service. 16einventing the ways of governing institutions is an improvement exercise necessary to enable institutional democracy.The places of care production, aimed at completeness, co-responsibility and resolutiveness are, at the same time, scenarios of pedagogical production, since they concentrate, the creative encounter between workers and users. 16he creation of collegial management spaces is the construction of collectives of both managers and health workers, as well as users.Spaces where there is discussion and decision making in their field of action, according to the directives and contracts defined. 15These spaces should, par excellence, be the place for collective decisions and analysis of the situations lived "with a greater degree of implication of the subjects with respect to what is produced in health services ".
Finally, to understand that Nursing plays a fundamental role in the management of care and its actions permeate most of the care and management flows of a hospital unit, it becomes necessary the involvement of its multiple agents and the articulations between them, as well as with the other members of the multidisciplinary team.It is emphasized, that, the various assistance practices do not configure each of them, isolated and independent work, but, rather, connected and interdependent work processes.
The organizational dimension of care management, from the point of view of Nursing workers, at a public cancer hospital was considered, in this analysis.Among the challenges pointed out by the study, it is noticed that the dimension is highly dependent on the perspective of team work.There were differences in perception between management and care workers.While management's main concern is the ability of its action to impact on the quality and resolution of the care provided by care, nurses and care technicians are concerned with the physical and emotional overload resulting from difficulties in staffing.

CONCLUSION DISCUSSION
This situation, especially in the context of work with cancer patients, interferes negatively in the establishment of links in general relations, generating psychic suffering and demotivation at work.It is noted that, the picture is attenuated, within the daily care of the cooperative and solidarity work in the teams, and by the daily mediation of conflicts by the sectorial management.
The data allowed a reflection on the organizational dimension of daily life of Nursing workers, but it is worth noting the difficulty of considering, this dimension separately, since they interpenetrate and condition each other.
This study has as a relevant contribution to elucidate that the protagonism, coresponsibility and autonomy of subjects and collectives should be stimulated, by enabling the manifestation of the will of the people who share responsibilities in the work, and should be considered in order to implement changes in the various dimensions of care, management or direct assistance.
The deepening of the theme elucidates paths for the better understanding and the elaboration of future care management strategies, providing a significant breakthrough for the professional practice of Nursing care.