Current Analysis of High-Complex Services in Northeastern Brazil : Education Experience Report

Methods and Results: Report on the students' experience of the sixth period of the undergraduate course in Nursing Federal University of Rio Grande do Norte; during the practical activities of the discipline of High Complexity, held at the Emergency Clovis Sarinho annexed Hospital Complex Monsignor Walfredo Gurgel, located in Natal, Rio Grande do Norte, in the period 17-27 November 2015. The results were divided into categories: physical structure, services and staff; nursing care and nursing procedures.


Introduction
The urgency and emergency sectors are identified as complex and deficient areas within the Brazilian health system, where the imple-mentation of its principles and guidelines are fragile [1].The high demand for these services can be explained by the structural limitations of the Primary Health Care, which culminates in the insufficient number of spare beds and the consequent impoverishment of care provided to patients [2].
In this context, Decree No. 1600 of July 7, 2011, reformulates the National Policy for Emergency and establishing the Emergency Care Network to the Sistema Único de Saúde (SUS).This organized in order to promote the coordination and integration of all health facilities, aims to expand access to urgent and emergency services and the training of professionals, in order to allow a humanized, agile and timely to customers [3].
It is important to consider the changes in health care seen in recent years, where we can see an improvement of technicist rationalism, which has the effect of fragmentation and mechanization of health care.It hurts the principle of comprehensiveness [1].These changes have unfolded in the preparation by the Ministry of Health, the National Humanization of Hospital Care with a view to substantially change the user the standard of care in the Brazilian public hospitals, through a set of integrated actions, improving the quality and effectiveness of services [4].
With regard to the urgency of the scenario, it is essential interdisciplinary work, the scientific expertise combined with the ability, the use of a policy that measures the quality of service, as well as coordination with other care levels belonging to the SUS, one since these functions contribute to increased quality of care [5,6].
Regarding the health work process, the nurse must have a modern attitude, evidenced by proactivity and critical analysis, aware of their rights and duties; especially with regard to political, ethical and professional levels.In this perspective, the development of general skills is key, which only are present to reality during the supervised training for nursing students, where their skills undergo continuous evaluation process [7,8].
According to the curriculum guidelines for undergraduate courses, the approach is essential skills in all areas related to academic training [9].The pedagogical design of educational institutions in nursing need to have systematic, political, philosophical and conceptual influences, presando for ensuring future critical professionals -reflective, proactive and dynamic meet the needs imposed by the labor market and, moreover, able to identify the relevance the continued training [10].
It is in this context that this article, which aims to report the experience of nursing students in an Intensive Care Unit and Emergency Room of a hospital in Rio Grande do Norte State of reference, outlining the framework in which they are and pointing out their strengths and weaknesses.

Method
This is an experience report that enables the researcher to report their experiences and experiences as related to the scientific knowledge [11].This study was developed by students of the sixth period, enrolled in the course entitled High Complexity, compulsory curricular component of the undergraduate course in Nursing at the Federal University of Rio Grande do Norte, Campus Christmas Central for the practical activities of the discipline of High Complexity held the Emergency Clovis Sarinho annexed Hospital Complex Monsignor Walfredo Gurgel, located in Natal, Rio Grande do Norte, from 17 to 27 November 2015.
To better understand the experience of the Intensive Care Unit and the Emergency Room, it was divided into three categories, among them: 1) physical structure, services and staff; 2) nursing care; 3) nursing procedures.The theoretical framework used to analyze the first and second category was the Board Resolution No. 26/2012, which provides the minimum requirements for the operation of the Intensive Care Unit [12].
The role of academics in practical activities, was guided by the use of the nursing process, which di-rects and systematize professional nursing care.The nursing process is the basis for the clinical practice of nursing by providing a framework for nursing actions are consistent, using problem-solving strategies in place of intuition.

Results
In order to develop skills with nursing care in the Intensive Care Unit and in urgent and emergency situations, and stimulate the clinical reasoning to promote care systematized to critically ill patients and a critical, reflective, creative and ethics, High complexity discipline provided performance spaces at the Hospital Monsignor Walfredo Gurgel, in the areas of Emergency Room and Intensive Care Unit respectively.

Physical Structure, Services And Staff
The Hospital Complex Monsignor Walfredo Gurgel, based in Tyrol neighborhood in the city of Natal, is the largest public hospital in Rio Grande do Norte state.The complex refers to the structure of the Hospital Monsignor Walfredo Gurgel, along with the Emergency Room Dr. Clovis Sarinho.
In all, the hospital complex has 280 beds distributed between the Hospital Monsignor Walfredo Gurgel and Emergency Clovis Sarinho, and receives approximately 13,000 patients per month, for the consultations in various specialties such as internal medicine, general surgery, cardiology and orthopedics [13].
The Walfredo Gurgel has a team of 2,300 employees, of which about 200 are contractors.The permanent duty team consists of 30 doctors at every turn, and the hospital also has a team of professionals who can, at any time, have their services requested [13].
With regard to Human Resources, the Intensive Care Unit, there was the performance of the following personnel: a diarist doctor, a nurse care (for nine beds), a physical therapist, four technicians and nursing staff for cleaning services; the availability of assignments/nurse's responsibilities for consultation by other professionals.Nurses, doctors, physiotherapists and nursing technicians were present full time.
Given access to care resources, the following services at the bedside offered, the practice period: nutritional, dental, nephrology care (including hemodialysis); clinical laboratory services (including gas analysis and microbiology), mobile radiography and endoscopy; In addition, the hospital offers surgical center, conventional radiological service and Doppler echocardiography.
Concerning the provision of personal protective equipment and collective professionals are contemplated considerably, especially with sterile gloves, hat and greatcoat; however, there was lack/availability of other devices such as goggles and examination gloves.
Thus, from the comparison of the Board Resolution and the reality experienced on stage, it is observed that the Intensive Care Unit of Emergency, which has 10 beds, with a disabled, follows in parts of the recommended criteria, as regards the physical structure the external environment, as issues of electrical, hydraulic and others were not analyzed, but also human resources.
Under the emergency room, we have is subdivided into three parts, they are the Polytrauma, Clinical Services and the "Polinho".On stage, it is bound up in clinical care, which had a nurse, five nursing technicians, one physician on duty for a number of different patients, and 10 or more beneficiaries.
On services and procedures offered in this sector, it was observed: nutritional counseling, medication administration, dressings, nasogastric/nasogastric probing, indwelling catheter, oxygen therapy, mechanical ventilation, electrocardiogram, continuous monitoring, conducting opinion by specialized physicians (ophthalmologist and angiologist), cleaning by specific team.

Process Work And Care
We looked at whether their patients comprehensive and interdisciplinary care Intensive Care Unit, as well as their changes in clinical status, assisted care and complications were recorded in medical records, at every turn, signed and dated, however, sometimes illegible handwriting.
It identified good interpersonal relationships between themselves professionals involved in this work process, as well as those with patients.In this sense, there was the promotion of decent and welcoming, however, the performance-driven health humanization proved failure in assisted care.It is worth noting the opportunity of a first contact with some procedures, such as bladder catheterization delay; assembly and mechanical ventilator handling; conducting water balance; preparation and administration of low and high cost drugs, as thrombolytics; and gas analysis.

Procedures For Nursing
We have this opportunity helped to fix the theoretical knowledge, and the opportunity to redo procedures performed in previous practices, such as bed bath, medication administration and survey contributed significantly to the acquisition of security for performing these procedures, and consequently, for a quality nursing care.
The curriculum of the course addresses the skills and abilities that are expected to get the student.They are: identify and prevent risks and injuries to individuals assisted in highly complex services; analyze the nursing work process related to the promotion, protection, recovery and rehabilitation of critically ill patients; understand the care lines that permeate the Health Care Network with a view to comprehensive care, with emphasis on high complexity.
Also, identify and act in situations that put the patient at risk of imminent death; seek integration with the multidisciplinary team aimed at interdisci-plinary care in situations of emergency, emergency and intensive care and high complexity; and develop skills to perform the nursing care of critically ill patients.
Thus, it is worth noting the importance of oportunização of various procedures and simulation, which was used in the discipline in the form of OSCE Objective Structured Clinical Examination), also known as structured clinical examination stations, and for being a teaching strategy allowing the error, in si- tuations that are not tolerated in actual clinical practice, pointed directly to the best performance during the practical activities and meaningful learning.

Discussion
Regarding the Intensive Care Unit on May 11, 2012, the National Health Surveillance Agency published the Board Resolution 26 amending the Board Resolution 07, of 24 February 2010 on the minimum requisites for the functioning of intensive care units .This resolution aims to establish minimum standards for the functioning of intensive care units, in order to reduce risks to patients, visitors, professionals and environment.
With regard to Personal Protective Equipment, it was found that both the Emergency Room as the Intensive Care Unit, follow the Regulatory Norm number 32, which establishes the basic guidelines for the implementation of security protection measures and the health of workers of service health [14].
In this study with a view, human resources, it was found that the composition of the multi-professional team in the Intensive Care Unit sector was in line with the established standards, however, there was provision of the duties of only one of the professionals, the nurse, should If release of all professionals working in this sector [12].
Due to routine experience the occurrence of emergency, the high technological density technology and predominance of critically ill patients susceptible to sudden changes in the general condition, will be given-a stressful ambience, which raises emotional commitments with regard to the healthcare professionals, and patients their families [15].
Situation-like faces in the Emergency Room industry sector where it was found a countless number of patients, disproportionate to the amount of professionals, resulting in precarious work, which can be a potential creator of psychological distress [16].
Concerning the humanization, they were found two distinct realities in the sectors where the PS, many patients did not receive appropriate assistance, culminating in a frail care, revealing the humanization related optimization service (attention/ management).
On the other hand, we identified a frail care by some professionals regarding the humanization of professional/patient relationship.Therefore, it is understood that the more specialized the health service, more present are the conditions that support the Cartesian paradigm.being the Intensive Care Unit characterized by maintenance of specialized knowledge and fragmented scientific, nullifying the human right of patients and families.[17] The National Humanization Policy (PNH), and the principles and guidelines of the Sistema Único de Saúde (SUS), respects itself in offering comprehensive care to the population and the direct means to provide conditions of rights and citizenship.[18] It is worth noting that the humanization of care optimization strategy and management of work, objective "changes in the scope of production services (changes in processes, organization, resolution and quality) and production of subjects (mobilization, growth, autonomy of workers and users) " [18].
With regard to nursing procedures, we have it is necessary that the students acquire, in a consistent and emphatic way, knowledge and skills throughout the degree, as they will be the future professionals working in the practice of nursing and reproduced the fundamentals assimilated [19].
The theoretical knowledge associated with experiences with supervised training generate skills, or a practice; know-how.Therefore, it is necessary that the teacher seek to identify the student's weaknesses and subsequently oportunize procedures so that knowledge is consistent and meaningful for the students.

Conclusions
The supervised training period is considered a critical time for academics as it is a time of reconstruction of their ways of thinking and acting in the various situations often not experienced yet.
This moment is potential for stimulating the exercise of the maturing of their professional role with more quality, skill and safety, to articulate the theoretical knowledge with the experienced fact.
In both fields of practices, there was difficulty in applying, in its fullness, the nursing process and its five stages.This was due to the high turnover of users in both services, for various reasons, such as discharge, referral, industry transfer or death.However, it noted that the nurse must constantly exercise the clinical reasoning through the systematization of nursing care.
Thus, there is considerable relevance and usefulness of this process experienced by the academic, since the provides a unique experience, making it able to face a reality that is not constant, but rather changeable, according to team work health who is operating at that time, the context in which the nursing students is inserted.

Table 1
refers to procedures performed in the Intensive Care Unit and the Emergency Room of the Hospital Complex Monsenhor Walfredo Gurgel/ Emergency Room Clovis Sarinho.

Table 1 .
Procedures performed in the Intensive Care Unit and Emergency Room.Natal, Rio Grande do Norte, Brazil.
Source: Own author.