Systematization of nursing care in the perspective of professional autonomy

Objetivo: analisar a percepção do enfermeiro acerca da sistematização da assistência de enfermagem na perspectiva da autonomia profissional. Métodos: pesquisa descritiva e exploratória, realizada com 24 enfermeiros em cinco clínicas de internação de um hospital de ensino, público, de grande porte, por meio de um questionário estruturado e avaliado por especialistas. Os dados foram analisados utilizando a estatística descritiva. Resultados: os enfermeiros afirmaram que a sistematização da assistência de enfermagem promove a autonomia. Enfatizaram que a busca do conhecimento para o desenvolvimento da sistematização da assistência de enfermagem recebe um reforço com a troca de experiência entre os colegas. Conclusão: aplicar a sistematização da assistência de enfermagem gera autonomia, demonstra que os enfermeiros percebem-se mais aptos a desenvolvê-la gerando acréscimo da autonomia profissional. Descritores: Cuidados de Enfermagem; Autonomia Profissional; Processos de Enfermagem; Planejamento de Assistência ao Paciente.


Introduction
The systematization of nursing care began in the 1950s with the purpose of joining nursing activities as part of a process and not as isolated actions (1) .It promotes better care quality, providing satisfaction and professional contribution in nursing actions with efficiency and quality (2) .Therefore, it should be established in health services to enable nurses' clinical practice in their daily activities (3) .
Nurses use the systematization of care as a work process model that promotes safety and directs care, representing an instrument that enables the assessment of the client's needs with a proposal for care (4) .To systematize is to organize and plan the execution of activities that will be implemented by the nursing staff in the care of individual and collective dimensions on an individual basis, and is a personal imprint of nurses (5)(6) .Nurses perceive the significant benefits provided by the systematization of nursing care, despite the challenges they endure in their implementation; however, they are aware that in order to apply and transform this conception there must be an availability of nursing professionals (7) .It is expected that legislators of nursing organs, the local health management and the federal government support the implementation of nursing care systematization as a fundamental axis for it to be an effective process of the nursing profession (8) .
The Federal Nursing Council discusses the systematization of care through the application of nursing processes in public or private environments through Resolution No. 358 of 2009, noting that this action is a methodological tool that guides nursing care and documentation of professional practice, highlighting the contribution of nursing health care for the population and increasing the visibility and the recognition of this category, thereby developing the autonomy of these professionals.
Autonomy is an essential attribute to achieve professional status and can be developed individually or in groups.Nursing has sought professional autonomy throughout its history.However, questioning whether the nurse practices their actions autonomously and whether they make independent decisions that bring positive results to the patient (9) .
Professional autonomy is defined as the freedom to make discretionary and mandatory decisions that are consistent with the practice of nursing, as well as the freedom to act on those decisions (9) .The systematization of nursing care is considered a pathway to professional autonomy because it represents a work process recognized by the nurses (4) .
Autonomy stands out for the balance and responsibility conquered by nursing professionals, therefore nurses must demonstrate knowledge and utilize it in practice in order to provide quality care, not just as something linked to professional behavior, but also related to innovative habits.However, this is not a fact which is often introjected into practice (10) .Autonomy is linked to the organization of work method, and due to differences in care, assuming care in its entirety (11) .
This study is justified by the perception of difficulties encountered by the authors in implementing the systematization of nursing care in the Hospital where the research took place.In order to overcome such problems, it is necessary to seek knowledge to meet the challenges and achieve autonomy in nursing actions.In focusing on ensuring that the systematization of nursing care is designed in light of the perceived competence by nurses, we pose the question: Does the application of the systematization of nursing care ensure professional autonomy for nurses in their practice?
The aim of the study was to analyze the perception of nurses on the systematization of nursing care in the perspective of professional autonomy.

Methods
This was a descriptive and exploratory research, carried out from August to September 2013 in a large-scale public teaching hospital located in Goiânia, Goiás, Brazil.Nurses were interviewed at the following clinics where nursing systematization was already implemented: Surgical, Tropical Medicine, Internal Medicine, Orthopedic and Pediatric Clinics.
Using inclusion criteria for a total of 32 nurses, 24 professionals who worked in inpatient units participated in the study.Inclusion criteria were nurses working in the hospital units for a minimum of six months, excluding those on vacation or leave.
A questionnaire with 23 open and closed questions with quantitative variables was applied containing: a) personal and professional demographics (gender, age, time of graduation; job title/credentials; working time in the institution and workplace); b) nurses' knowledge about the systematization of care; c) professional autonomy using the systematization of nursing care; d) time using systematization of nursing care and more effective teaching strategies for learning the systematization of nursing care.
The questionnaire was evaluated by experts in the field, and a pilot test was conducted with nurses from the emergency sector of the same hospital in order to verify its operability and functionality.
Data analysis was performed using descriptive statistics, using absolute and relative frequencies for qualitative variables and confidence intervals for proportions.Means and standard deviations were described for quantitative variables.Comparisons were established using Fisher's exact test, with a significance level of p <0.05.
The study complied with the formal requirements contained in the national and international regulatory standards for research involving human beings.

Results
A predominance of females (83.3%) was observed.Mean age was 46.7 ± 9.3 years, and most professionals were over 40 years of age.The average time of completion of graduation and employment at the institution were 20.2 ± 8.3 and 15.8 ± 7.9 years, respectively, with the majority of professionals being over 10 years since graduating and also more than 10 years of employment at the institution.Most had specializations (58.3%) and worked at the surgical clinic (29.2%) or at the medical clinic (33.3%) (Table 1).All professionals responded that using nursing care systematization contributed to professional autonomy; they use the nursing process steps in the workplace and feel able to develop nursing care systematization (Table 2).Professionals who have been using the systematization of nursing care for more than five years mentioned that this knowledge always or most of the time permits the use of its various elements independently (Table 3).Nurses judged that study groups (37.5%) and lectures (29.2%) were the most effective teaching strategies for learning nursing care systematization (Table 4).Activities described by nurses (n=24) for the pursuit of knowledge regarding the systematization of nursing care were exchange of experiences with colleagues (87.5%), books (70.8%), courses (70.8%), scientific articles (50.0%), internet sites (45.8%), conferences (25.0%) and workshops and meetings (4.2%), respectively.

Discussion
Female predominance in the profession is consistent with data presented in the study "Profile of Nursing in Brazil," taken from Goias State (12) that registers the existence of 90.1% of female nurses.However, males had a higher rate in the hospital researched than the profile shown by the State of 9.9%.
The age of the nursing study participants is higher than the average presented in the profile of nursing in Brazil taken from Goias State (12) , which shows 71.5% of nurses aged up to 40 years, while in the population studied the same average was 25.0%.
Comparing the age group of nurses interviewed with the Profile of Nursing in Brazil taken from Goias State (12) , we observed that 33.3% of nurses from the surveyed hospital are in the Deceleration phase of their Working Life (term used in the Profile of Nursing in Brazil for professionals who are between 51-60 years) that refers to having a smaller interest in developing the systematization of nursing care while One possible explanation for the difficulties encountered in implementing the systematization of nursing care and the nursing process is the academic training in nursing.The teaching of systematization of nursing care should be delivered by people with experience in its application (13) .Much is done in educational institutions, but these actions are mainly developed at the beginning of the undergraduate program and they do not converse with the applied disciplines or activities carried out in practice.This is the big challenge to be overcome.
Nurses who use the systematization of nursing care feel more able and perceive the increased professional autonomy, and reported accordingly in the indicators of improvement, totaling 58.4%, as well as feeling able to develop the systematization of nursing care to raise their professional autonomy level (Table 2), with higher rates among those who claimed that there was sufficient increment in professional autonomy.
The systematization of care provides autonomy to nurses for being a method of care accepted by them, allowing for a relationship between nurses and clients in care, with quality and demonstration of scientific expertise and commitment (4) .
In order to obtain autonomy, nurses must use knowledge, skills and attitudes in decision-making in achieving their space, through their actions, demonstrating professional competence and an ethical profile, since only then will they be able to practice their profession independently (14) .
It is possible to infer that nurses' experience with the systematization of care enables them to act independently without resorting to assistance (Table 3).The opposite is also true, because those who are less experienced demonstrate dependence in carrying out systematization, thereby feeling insecure.Even some experienced nurses develop steps of the process autonomously, although seeking some help.According to the statements of the participants, this is because they do not fully develop the steps of the process and have little adherence to systematization.
Nurses felt that the most effective strategy for the learning of systematization of care is through study groups.As for the pursuit of knowledge, they highlighted the exchange of experiences with colleagues.This reflects the initiative of the participants in developing activities to share knowledge towards more autonomous actions.
Nurses seek knowledge through both strategies based on group activities, study groups (Table 4) or sharing experiences with colleagues.The interaction is a significant process of communicating, which is a key instrument for the nursing staff in continuing care and needs to be consistent among team members (15) .In their everyday lives, nurses experience internal and external situations following the biomedical practices conditioned by the historical practices of the profession, and realize the need for a boost provided by the systematization of care in order to gain autonomy (16) .
Autonomy is guaranteed by a gain in knowledge and by analyzing data relating to the teaching-learning process; the nurses pointed to educational strategies developed in groups.These strategies have enabled experiential exchanges between the participants, identifying weaknesses and strengths that happen in the pursuit of knowledge process (17) .

Conclusion
The application of the systematization of nursing care generates nursing autonomy, considering that an increase in professional autonomy was perceived among the respondents who used it.
The teaching strategy considered by nurses as the most important was the one developed in groups.Regarding the tools in the pursuit of knowledge, they highlighted: sharing of experiences with colleagues, doing courses and studying books.It was noticed that nurses used group strategies to strengthen their knowledge in the search for professional nursing autonomy, which is gained through knowledge acquisition and group actions.Therefore, we consider that developing continuing education activities to ensure improvements in nursing care is essential.
This study does not allow for generalizations due to being confined to one local reality, but it describes ways through which further research can be carried out on this subject, demonstrating the gaps in understanding between systematization of care and autonomy.We especially emphasize that continuing education is a consolidated way to ensure the implementation of nursing care systematization.

Collaborations
Ferreira EB, Pereira MS, Souza ACS, Almeida CCOF and Taleb AC contributed to the conception and design, the analysis and interpretation of data, writing and critically revising the article for important intellectual content, and final approval of the version to be published.
recognizing its relevance.Considering training time, 83.33% of the nurse respondents had over 10 years of training, having graduated before 2003.The systematization of nursing care now required by the Federal Council of Nursing from August 27, 2002, by resolution of the Federal Council of Nursing number 272 from 2002, was repealed by Resolution 358 in 2009 by the same Council.

Table 1 -
Distribution of nurses (n = 24) considering their personal and professional profile

Table 2 -
Distribution of nurses (n = 24), according to the assertion that the systematization of care promotes growth in professional autonomy, considering the use of the Nursing Process steps in the workplace *Fisher's test

Table 3 -
Distribution of nurses (n = 24), considering their knowledge and usage time of the systematization of care

How the knowledge of nursing care systematization enables the use of its various elements Usage time of nursing care systematization (p=0.007)* 1-5 years > 5 years n(%) n(%)
*Fisher's test

Table 4 -
Distribution of teaching strategies that nurses (n = 24) judged more effective for learning nursing care systematization