Resumen: Objetivo: comprender los nexos y reflejos de la adaptación del enfermero a la cultura organizacional del cuidado de enfermería en el ámbito hospitalario. Método: investigación cualitativa, exploratorio-descriptiva; los datos fueron recolectados por medio de entrevistas semiestructuradas con 12 enfermeros. Para el análisis de los datos fue elegido el método de análisis de contenido, por involucrar y aprehender aspectos subjetivos, y del cual emergió dos categorías: la normalización del cuidado y sobreponiendo la adaptación normalizadora. Resultados: el enfermero, al desarrollar el cuidado, permite que la cultura de la organización haga un agenciamiento sobre sí, siendo esta adaptación optimizada por la falta de ejercicio de la autonomía por los enfermeros y por una identidad poco consolidada. Consideraciones finales: el reflejo de la adaptación a la cultura organizacional fragiliza el cuidado disponible, fomentando de forma insuficiente la proactividad del enfermero. Un tiempo más largo de trabajo favorece la producción de subjetividad singular.

Descriptores: Cultura organizacional; Adaptación; enfermeras; Cuidados de enfermería

Introduction

In the history of the human being, adaptive movements have always been present to meet the demands of the environment, but also to keep up with the evolutions that arose and imposed different demands. Adaptation can be seen as a permanent response to what may threaten the balance of every human being, since the demand imposed on the development of adaptive responses to achieve certain goals emerges as a pressing need.¹

When nurses provide care, either directly or indirectly, they assume specific contours drawn by the organizational culture, thus establishing a collective conduct that is the reference and guides behaviors and attitudes. This adaptation of nurses to the organizational culture, conceived by others and incorporated by them most of the times without resistance, entails an organizational structure anchored in established beliefs and values in a given socio-historical-cultural context, and may be related to processes of submission to what is instituted.²

In this context, nurses have been developing and expressing individualities guided by the standardization of rules and conducts already established. Therefore, a process of (de) construction of the nurse as a professional may be occurring in these institutions, that is, it seems that nurses generally put their knowledge and conceptions in the background, and have their work delineated by aspects that permeate the organizational culture of the work environments of the places in which they operate.

It is important to remember that, through the production of goods and values that build society, the worker does a social self-identification and present himself to it, thus producing not only objects, but a condition that is particularly his own. Thus, because the meaning of the nurses' work of caring for the needs of others represents this trajectory, they need to transcend the socioeconomic structure, culture and values, incorporating its production of subjectivity, as proactive subjects.³

Realizing the interrelationship between the adaptation to the organizational culture and the care provided by nurses to patients, this study had the following question: what are the links and reflexes of the adaptation of nurses to the organizational culture in the nursing care provided? Thus, the aim of the study was: to understand the links and reflexes of the adaptation of nurses to the organizational culture in nursing care in the hospital environment.

Method

This is a qualitative, exploratory-descriptive study that focused on non-measurable aspects of people's lives which imply adaptive and normative behaviors. Fieldwork was chosen because conducting qualitative research presupposes interaction between researcher and participants, aiming to achieve the expected results.⁴

Data collection took place in the context of a hospital in the municipality of Bagé (Rio Grande do Sul) in October and November 2015 through semi-structured individual interviews. Twelve nurses from a total of 25, linked to the abovementioned institution, were included in the research, according to the Consolidation of Labor Laws (CLT).

Interviews were conducted in a meeting room to maintain the privacy of participants. The questions made addressed the nursing work process. The interviews had an average duration of 30 minutes and were recorded and later transcribed verbatim. The sample size was determined based on data saturation.

The data were analyzed using the content analysis technique.⁵ This technique involves an initial quick reading for the systematization of data and then the identification of units of meaning in the statements, for understanding the reports. Finally, the data were grouped in units of meaning, according to their similarities.

All ethical precepts established in resolution 466/12 were followed and the research was approved by the Research Ethics Committee of the Federal University of Rio Grande under Opinion n 161/2015 (CAAE: 46809715.8.0000.5324). All participants signed two copies of the Informed Consent Form before the interviews. Interviews were identified by the letter “I” followed by a number that corresponds to the sequence of interviews.

Results and discussions

Regarding the characteristics of participants of the study, there were 12 nurses, represented by eight women and four men, with ages ranging from 23 to 49 years. Time elapsed after graduation ranged from 3 to 15 years and all had post-graduate training (specialization) in different areas. However, none of the participants attended or were attending specialization or master courses focused on the managerial/organizational axis. Time of work at the institution ranged from 1 to 14 years.

It was noticed that there was a predominance of females (66.66%) among the participants. However, this particularity added to age and time elapsed after graduation were not decisive for adaptation to the organizational culture, because the study showed that time in the workplace was the aspect that most contributed to the establishment of normalization. Perhaps a greater empowerment of nurses on organizational issues through specialization or master's degree in management would allow a change in the explored scenario, since knowledge and reflection on work practices are fundamental for the reorganization of the work process.

The normalization of care

Caring for people is the essence of the professional performance of nurses, and especially in the hospital sphere they authentically act in the production of links, in the process of hospitalization which often produces feelings of pain, loss and limitations. As professionals, they have the ability to observe health problems, whether biological, social, psychic or spiritual, because the essence of their profession is to perceive people as integral and interactive beings.⁶

However, in order to fully develop their activities in accordance with ethical and moral principles, it is essential that nurses assume and become owners of their identity, cultivating and exercising their autonomy so as to escape some patterns of conduct and transcend a modulated care, increasing their capacity for self-determination.⁷Some participants reported that they can not be who they really would like to be, and that the exercise of greater autonomy could enrich the work processes to, reflecting in a more troubleshooting and proactive provision of care, favoring the recovery of patients.

The more autonomy the nurse has, the better the care provided. [...] If we had more autonomy, surely the patient would be favored. [...] It's hard to make a difference when you are doing what others want. (I5)

The nurse has little autonomy, he is always doing things he does not believe he would have to do. [...] This makes it hard to do your best. (I2)

I think autonomy helps nurses do things the best way. [...] When a person does not authorize or accept what you do, this already poses a barrier in your work, your assistance. (I12)

I always complain a lot about the lack of autonomy of nurses. [...] I think for nurses to do a good work, to do a good job, either in the supervision or as a nurse in the unit, I mean at the hospital level, he has to have autonomy. (I11)

There is a close relationship between the production of authentic subjectivity and the autonomy that is granted or conquered. Adaptation to the organizational culture may have as one of the guidelines the lack of autonomy of nurses, because when autonomy is not exercised and is not a fundamental desire, the professional starts to (re)produce the pre-established practices, internalizing the subjectivity produced by others, thus becoming an immovable pillar.⁸The causal nexus of this adaptation may be the framing into the organizational culture, either conscious or unconscious, because the singular subjectivity entailed is not always intentional or voluntary.

The autonomy of nurses is one of the fundamental factors to carry out a differentiated work, but for this, they need to have courage to take on the role of professional, showing competence, responsibility and unique way of working.⁹ Contrary to these reports, it was mentioned that autonomy is not an important and differential factor in the work of nurses, and some highlighted that the important thing is to have willingness and love for work.

I think that autonomy does not help the nurse at all. If he has goodwill, that will make the difference.(I3)

It is noteworthy that this report seems to be consistent with the professional attitude of those who spread the culture of the organization to others and who made them adapt unconditionally to the established norms. Perhaps, by assuming an institutional rather than a personal identity, nurses do not view the exercise of professional autonomy as an essential factor at work, but this brings negative consequences to their profession, for they become just another gear in the work process.

Thus, it is important to discuss the professional autonomy of nurses not as mere corporate and private interest, but as a possibility of affirming their identities, as active and indispensable professionals in the construction of more competent, supportive and humanized health services.¹⁰ In a perspective of construction and consolidation of identity, nurses can incorporate the mission of active, proactive and reactionary subjects, that is, they can demobilize the massification of subjectivity involved in their work. By doing so they can circumvent the normalizing reflexes of the organizational culture, enabling a new way of caring.

Subjective normalization implies an identity marked by the signification that the subject has of himself and of other fellow nurses. Each culture has a way of delineating identities,¹¹but reports reveal that the philosophies, values, and ideas of nurses are assumed to be a modular system that reduces everything to standard structural confinement. Such system makes them unable to be themselves in their work, consequently producing little dynamism, and an identity that does not match the one built during their training. Nurses yearn for a solid professional identity, in which they have freedom and decision-making power over specific issues within their area of competence, free from manipulation of their actions.¹²

Thus, the care provided by nurses follows an itinerary that reflects a Cartesian codified identity. New ways to discuss, reflect and implement practices are close to an abyss in which the will to overcome this limit may be the beginning of an end. The reports highlighted that nurses are prevented from being themselves during work activities, especially soon after being hired, assuming an identity programmed by the organizational culture. With this, the care provided becomes conditioned and little evolutionary.

You can't be yourself at work, because you seem to hurt the principles of someone else, and so forth. [...] It's something weird. I always found it all very strange. [...] The patient is the one who loses with this. (I5)

I can't be myself at work [...] The one who refuses, who scowls, the one there, he is not taken into account. [...] There is no way to have your own way of working and making a difference. (I4)

You cannot talk about everything, you cannot interfere if you are not invited, so we no longer have that authenticity we had when we entered the University to be a transformative member, creator [...] The result is that care is impaired. (I9)

As a consequence of adapting to the organizational culture, nurses often have difficulties in defragmenting their identity because, if they overcome this barrier, they will cease to be a model member in the institution, evading the normal pattern culturally constructed by the hospital organization, confirming that the identity is built upon standards offered by the social structure.¹³ In other words, the person develops his or her identity through articulations between equality and difference, which favor the promotion of self-awareness through comparisons in social relations.¹⁴

It is noticed that the consolidation of identity is related to the production of singular subjectivity. The less consolidated the identity is, less singular subjectivity is produced because, by leaving the essence of the self in the background, nurses assume a transient identity that is an adaptive product easily influenced by the factors of organizational culture. This reflection of the adaptation to the organizational culture makes the care provided weaker, as new practices are no longer discussed and analyzed to be implemented.

Overcoming the normalizing adaptation

Overcoming the normalizing adaptation stimulated by the organizational culture is not an uncomplicated task, as the institutionalizing and serializing forces act synergistically, making it difficult to produce and articulate actions that may shake their structures. However, the reports emphasized that older nurses note that after a certain time of work, the identity is singularly strengthened, enabling them to acquire a personality closer to the one they planned during their training.

In this way, they begin to exercise the power to determine some organizational and care aspects, starting to have possibilities to produce an authentic and transforming subjectivity, even when this subjectivity eventually impacts against the massifying interests of the institution. Care becomes more contextualized and resolute, and is more permeable to change.

Now, because of the time I have in the work, I think I can be more myself at work and determine some things to do. [...] The institution does not see this, but the patients do. (I3)

I see that nurses with a certain tim of worke, like me, we can be more authentic and make things flow better and we end up helping patients more. (I6)

When we enter the institution, it is not easy, especially when you are new. [...] I think we can show who we really are and our good work with patients only after a good time here. (I7)

Until nurses develop self-confidence and initiative to change some things in work or for the patients, they go through a slow process, which can last from months to years. (I8)

There is a prospect of changing the profile of nurses within the hospital unit over time. After a few years of work, nurses begin to take on a role guided by a new look at core competencies and skills so that they can promote a transformation in the developed practices and thus point to new ways of authenticity.¹⁵ After some time working in the hospital, nurses have a different perception of the importance of producing legitimate subjectivity, seeing this process as an evolution of their productive force, in a more advanced form. This phenomenon can be perceived as a “rebound effect” of the time of serializing normalization that nurses experienced.

In this way, they start to unify their conceptions, revolutionizing their own work production, using knowledge and tools in a particular and different way. However, this new constructed subjectivity seems to be based on a rock coated with truth and absolute reason, so that the other nurses have to congregate these conceptions without being able to demonstrate their innovative and subjectivist potential.¹⁶It seems that the cycle of normalization to the organizational culture is a reflex that feeds back into the hospital environment; a nurse normalizes the other in a continuous way.

Nurses need to focus on building a more horizontal capacity of management, accepting an open communication, guilt, teamwork and continuous knowledge of organizational culture.¹⁷ If some nurses present some resistance to submerge in this subjective universe owned by others, they may have to experience changes in their work routine, such as changing units or work shifts. It is noteworthy that the established ties with a given space become an important factor for the provision of specialized and resolute care, because the greater the knowledge of the place, the greater the possibilities of a good situational analysis of the environment, identifying strengths and weaknesses, as well as favoring prospective planning.¹⁸

Based on this explanation, it is understood that a nurse who knows and masters his work environment with excellence can and should provide specialized, resolute and comprehensive care to those who are at the end of the process, i.e. the patients who directly or indirectly receive the products generated in their adaptive process. It is clear from the statements that some nurses were relocated from their workplace because questioning or counteracting some commands established by older nurses, or suffered threats of dismissals.

I even tried to change some things, but couldn't continue because after a month they sent me to another unit. [...] This is bad not only for us but for the patient as well. (I4)

If you try to implement a routine, it's complicated. [...] If you insist, the outcome is a change of unit. [...] Then what you had planned, for the well-being of the patient, goes down the drain. (I1)

They wanted to fire me once. [...] Because of my thoughts, not because of my work in care. [...] I wasn't sent away, but they changed me to another unit. (I10)

The issues discussed are evident in the report of a normalizing nurse about possible unit changes.

I try to make things well developed and executed. [...] If you have a problem, I will try to solve, and if it is not possible, I ask for relocation. (I6)

In the work of nurses, a mismatch is of interests is common, causing a temporary disorganization in activities, resulting in increased stress, work overload and turnover of professionals.¹⁹ Nurses cannot always assume their uniqueness with consistency, because they clash with other more subjectivated nurses, from the point of view of production and reproduction of meanings.

The nexus to assume this stance may be the fear of being dismissed, because when the person is subjected to the threat of dismissal, he consents to aspects with which he disagrees, because fear is above all a subjective experience that generates psychological repercussions.²⁰ Thus, the care provided is limited to the way it was pre-programmed, which is watertight before a rapidly changing and dynamic universe, which is health care, and specially health care in hospitals, leading to disadvantages to the most valuable piece, the patient.

Nursing performs its activities by entering the production subsystems that are part of a complex care, being influenced by organizational characteristics and this, in turn, outlines the generated product, that is, generates reflections on the quality of care provided.²¹

It is hoped that nurses see adaptation a way of professional growth, so that they develop tools capable of promoting effective care and meeting the health needs of their patients. To do so, they have to put aside inhibition and omission, creating defense mechanisms against the nexus that make them adapt to the organizational culture, without internalizing the commands of others as unquestionable truths.

Final considerations

By providing care, nurses allow the organizational culture to act as an agencying element over them, making them follow commands without thinking much about the value of their actions. Thus, the care provided by nurses follows an itinerary that reflects a Cartesian codified identity. New ways to discuss, reflect and implement practices are taken closer to an abyss in which the will to overcome this limit may be the beginning of an end.

Adaptation to organizational culture is enhanced by the nurses' lack of autonomy, but also by a poorly consolidated singular identity, as well as fear of dismissal. Another factor that emerged intensely in the reports was the fact that older nurses use punishments, such as change of units to force a normalization over others, thus making care to become Cartesian and poorly evolving.

However, some participants reported that after some time of institutional bonding, nurses have the power to determine some organizational and care aspects, starting to have possibilities to produce an authentic and transforming subjectivity, even when impact against the massifying interests of the institution. Care becomes more contextualized and resolute, as well as more permeable to change.

The study favors the nursing practice because it promotes reflections and raises issues peculiar to the work. However, there is a limitation in the study, which is the fact that it was developed in only one hospital and with nurses who had the same work regime, all hired by the CLT system. Furthermore, it is imperative to develop more studies that approach and seize the relationships established in the adaptation of nurses to the organizational culture.

The causal nexus of this adaptation may be the framing into the organizational culture, either conscious or unconscious, because the singular subjectivity entailed is not always intentional or voluntary. However, the fear of dismissal seems to be the strongest nexus for serializing normalization to occur.

The reflex of the adaptation to the organizational culture makes the available care weaken, insufficiently fomenting proactivity in nurses. The normalization cycle is a feedback reflex, where one nurse normalizes, and another nurse is normalized in a repetitive way.

References

1. Gonçalves FGA, Leite GFP, Souza NVDO, Santos DM. O modelo neoliberal e suas repercussões para o trabalho e para o trabalhador de enfermagem. Rev Enferm UFPE Online [Internet]. 2013 nov [acesso em 2017 dez 10];7(11):6352-9. Disponível em: https://periodicos.ufpe.br/revistas/revistaenfermagem/article/viewFile/12279/14933 doi: 10.5205/reuol.3794-32322-1-ED.0711201306

2. Hahtela N, McCormack B, Paavilainen E, Slater P, Helminen M, Suominen T. The relationship of workplace culture with nursing-sensitive organizational factors. J Nurs Adm [Internet]. 2015 jul-ago [acesso em 2018 set 01];47(7-8):370-6. Disponível em: https://www.ncbi.nlm.nih.gov/pubmed/26204378 doi: 10.1097/NNA.0000000000000217

3. Souza DO, Gonçalves FGA, Pires AS, David HMSL, Valéria N. Influência do neoliberalismo na organização e processo de trabalho hospitalar de enfermagem. Rev Bras Enferm [Internet]. 2017 jan [acesso em 2018 set 01];70(5):961-9. Disponível em: http://www.scielo.br/pdf/reben/v70n5/pt_0034-7167-reben-70-05-0912.pdf doi: http://dx.doi.org/10.1590/0034-7167-2016-0092

4. Minayo MCS. O desafio do conhecimento: pesquisa qualitativa em saúde. São Paulo: Hucitec; 2013.

5. Bardin L. Análise de conteúdo: Laurence Bardin. São Paulo: Edições 70; 2015.

6. Kinchen E. Development of a quantitative measure of holistic nursing care. J Holist Nurs [Internet]. 2015 set [acesso em 2017 dez 08];33(3):238-46. Disponível em: https://www.ncbi.nlm.nih.gov/pubmed/25536967 doi: 10.1177/0898010114563312

7. Souza GJ, Paula MAB. Construção da identidade do enfermeiro: revisão integrativa da literatura. Rev Rede Cuid Saúde [Internet]. 2016 jun [acesso em 2017 dec 13];10(1):1-17. Disponível em: http://publicacoes.unigranrio.edu.br/index.php/rcs/article/view/2727

8. Ramos AM, Barlem ELD, Barlem JGT, Rocha LP, Dalmolin GL, Figueira AB. Adaptação cultural e validação da Moral Distress Scale Revised para enfermeiros. Rev Bras Enferm [Internet]. 2017 mar [acesso em 2018 set 01];70(5):1063-70. Disponível em: http://www.scielo.br/ scielo.php?script=sci_arttext&pid=S0034-71672017000501011&lng=en&nrm=iso&tlng=pt doi: http://dx.doi.org/10.1590/0034-7167-2016-0518

9. Avila LI, Silveira RS, Lunardi VL, Fernandes GFM, Mancia JR, Silveira JT. Implicações da visibilidade da enfermagem no exercício profissional. Rev Gaúch Enferm. 2013;34(3):102-109.

10. Pereira MS. Lei do exercício profissional de enfermagem e a autonomia profissional do enfermeiro. Enferm Foco (Brasília) [Internet]. 2015 jun [acesso em 2017 dez 08];4(3/4):171-4. Disponível em: http://revista.cofen.gov.br/index.php/enfermagem/article/view/543/226

11. Ettinger VMM, Jesus Júnior G, Setenta AM, Cavalcante AL. Cultura, identidade e gênero: tecendo a rede de mulheres de comunidades extrativistas e pesqueiras do sul da Bahia. Rev Interdiscip Gest Soc [Internet]. 2016 set [acesso em 2017 dez 01];4(3):151-9. Disponível em: https://portalseer.ufba.br/index.php/rigs/article/view/10188/11562 doi: http://dx.doi.org/10.9771/23172428rigs.v4i3.10188

12. Umpiérrez AHF, Merighi MAB, Muñoz LA. Percepções e expectativas dos enfermeiros

sobre sua atuação profissional. Acta Paul Enferm [Internet]. 2013 [acesso em 2017 dez 08];6(2):165-71. Disponível em: http://www.scielo.br/pdf/ape/v26n2/v26n2a10.pdf doi: http://dx.doi.org/10.1590/S0103-21002013000200010

13. Hoeve Y, Jansen G, Roodbol P. The nursing profession: public image, self-concept and professional identity. A discussion paper. J Adv Nurs [Internet]. 2013 [acesso em 2017 dez 05];70(2):295-309. Disponível em: https://www.ncbi.nlm.nih.gov/pubmed/23711235 doi: 10.1111/jan.12177

14. Lima MM, Reibnitz KS, Prado ML, Kloh D. Integralidade como princípio pedagógico na formação do enfermeiro. Texto & Contexto Enferm [Internet]. 2013 [acesso em 2017 dez 09]; 22(1):106-13. Disponível em: http://www.scielo.br/pdf/tce/v22n1/pt_13.pdf doi: http://dx.doi.org/10.1590/S0104-07072013000100013

15. Sebold LF, Carraro TE. Autenticidade do ser-enfermeiro-professor no ensino do cuidado de enfermagem: uma hermenêutica heideggeriana. Texto & Contexto Enferm [Internet]. 2013 [acesso em 2017 dez 09];22(1):22-8. Disponível em: http://www.scielo.br/pdf/tce/v22n1/pt_03.pdf doi: http://dx.doi.org/10.1590/S0104-07072013000100003

16. Guattari F, Rolnik S. Micropolítica cartografias do desejo. Petrópolis (RJ): Vozes; 2010.

17. Ammouri AA, Tailakh AK, Muliira JK, Geethakrishnan R, Al Kindi SN. Patient safety culture among nurses. Int Nurs Rev [Internet]. 2015 [acesso em 2017 dez 10];62(1):102-10. Disponível em: https://www.ncbi.nlm.nih.gov/pubmed/25495946 doi: 10.1111/inr.12159

18. Vaughan L, Slinger T. Building a healthy work environment: a nursing resource team perspective. Nurs Leadersh (Tor Ont). 2013;26(Spec No 2013):70-7.

19. Guse C, Carvalho DR. Rotatividade nos profissionais de enfermagem. Publ UEPG Ciênc Biol Saúde. 2015; 21(1):47-64.

20. Dejours C. A banalização da injustiça social. Rio de Janeiro (RJ): Fundação Getúlio Vargas; 2011.

21. Schwonke CRGB, Lunardi Filho WD, Lunardi GL, Silveira RS, Rodrigues MC, Guerreiro MO. Cultura de segurança: a percepção dos profissionais de enfermagem intensivistas. Enfermería Glob [Internet]. 2016 [acesso em 2017 dez 07];15(1):208-43. Disponível em: http://scielo.isciii.es/pdf/eg/v15n41/pt_administracion3.pdf

Corresponding author

Cristiano Pinto dos Santos

Email: enfcristiano.ps@hotmail.com

Address: Rua Claudio Manoel da Costa 101, Tiaraju neighborhood, Bagé, Rio Grande do Sul, Brazil.

Postal Code: 96422-080

Authors Contribuitions

1 – Cristiano Pinto dos Santos

Research Project planning, Analysis and interpretation of datas, critical writing and revision.

2 – Giovana Calcagno Gomes

Analysis and interpretation of datas, critical revision.

3 – Wilson Danilo Lunardi Filho

Analysis and interpretation of datas, critical revision.

4 – Ariane da Cruz Guedes

Analysis and interpretation of datas.

5 – Adriane Maria Neto de Oliveira

critical writing and revision.

6 – Ivanete Santiago da Silva Strefling

critical revision.

How to cite this article

Santos CP, Gomes GC, Lunardi Filho WD, Guedes AC, Oliveira AM, Strefling ISS. Nexus and reflections of nurses’ adaptation to organizational culture. Rev. Enferm. UFSM. 2019 [Accessed on: Jun 15, 2019 ]; vol 9 ex: 1-17. DOI:https://doi.org/10.5902/2179769230699