THE NORMATIVE LEGAL (IN)VISIBILITY OF STAFF SIZING IN BRAZILIAN NURSING

LA (IN)VISIBILIDAD NORMATIVA JURÍDICA DEL DIMENSIONAMIENTO EN LA ENFERMERÍA BRASILEÑA

ABSTRACT

Objective:   to reflect on the (in)visibility of the normative-legal apparatus on the workforce sizing in Brazilian nursing.

Method:  a theoretical-reflective essay was conducted by researchers who are part of the Brazilian Network of Studies and Research on Healrh Workforce Sizing and Planning. Past and current resolutions (product of a revocation) of the Federal Nursing Council on the subject, related studies and interpretative inferences guided the reflection.

Results:  the reflective positioning was based on two axes: Nursing workforce sizing: looking to the past to understand the present; and Normative and legal obstacles to nursing sizing.

Conclusion:  Brazil is a pioneer in proposing and updating technical and scientific standards that recommend methodologies and criteria for sizing the nursing workforce. On the other hand, the lack of a legal framework on the subject, linked to a plurality of “regulations”, shows that, in practice, staff sizing is commonly neglected. The revocation of Resolution number 543/2017 of the Federal Nursing Council, based on legalistic premises, reveals this reality. Advances of a political and, consequently, legal nature are required.

DESCRIPTORS:
Personnel downsizing; Nursing; Workload; Law; Professional practice; Nursing Team

RESUMO

Objetivo:  refletir sobre a (in)visibilidade do aparato normativo-legal sobre o dimensionamento da força de trabalho na enfermagem brasileira.

Método:  ensaio teórico-reflexivo, conduzido por pesquisadores que integram a Rede Brasileira de Estudos e Pesquisa em Dimensionamento e Planejamento da Força de Trabalho em Saúde. As resoluções passadas e a vigente (produto de uma revogação) do Conselho Federal de Enfermagem sobre a matéria, estudos correlatos e inferências interpretativas nortearam a reflexão.

Resultados:  o posicionamento reflexivo fundamentou-se em dois eixos: Dimensionamento da força de trabalho de enfermagem: olhar para o passado para entender o presente e Entraves normativos e legais no dimensionamento em enfermagem.

Conclusão:  o Brasil é vanguardista na proposição e atualização técnico-científica de normas que recomendam metodologias e critérios para dimensionar a força de trabalho da enfermagem. Em contrapartida, a incipiência de um marco legal sobre o assunto atrelado a uma pluralidade de “regulamentações” demonstra que, na prática, o dimensionamento de pessoal é comumente negligenciado. A revogação da Resolução nº 543/2017 do Conselho Federal de Enfermagem, ancorada sob premissas legalistas, descortina tal realidade. Avanços de teor político e, consequentemente, legais, são demandados.

DESCRITORES:
Dimensionamento de pessoal; Enfermagem; Carga de trabalho; Lei; Exercício profissional; Equipe de enfermagem

RESUMEN

Objetivo:   reflexionar sobre la (in)visibilidad del aparato normativo-legal sobre el dimensionamiento de la fuerza laboral en la enfermería brasileña.

Método:  ensayo teórico-reflexivo, realizado por investigadores que forman parte de la Red Brasileña de Estudios e Investigaciones en Dimensionamiento y Planificación de la Fuerza de Trabajo en Salud. Resoluciones pasadas y actuales (producto de una revocación) del Consejo Federal de Enfermería sobre la materia, estudios relacionados e inferencias interpretativas guiaron la reflexión.

Resultados:  el posicionamiento reflexivo se basó en dos ejes: Dimensionamiento de la fuerza laboral de enfermería: mirar al pasado para comprender el presente; y Obstáculos regulatorios y legales en el dimensionamiento de enfermería.

Conclusión:  Brasil es vanguardista en proponer y actualizar normas técnico-científicas que recomiendan metodologías y criterios para dimensionar la fuerza laboral de enfermería. Por otro lado, la falta de un marco legal sobre la materia vinculado a una pluralidad de “reglamentos” demuestra que, en la práctica, el dimensionamiento del personal es comúnmente descuidado. La derogación de la Resolución n.º 543/2017 del Consejo Federal de Enfermería, anclada en premisas legalistas, revela esta realidad. Se exigen avances de carácter político y, en consecuencia, jurídico.

DESCRIPTORES:
Reducción del personal; Enfermería; Carga de trabajo; Ley; Práctica profesional; Grupo de enfermería

INTRODUCTION

Health systems and organizations are constantly challenged to maintain sustainability and seek to improve quality of care, which, in addition to attesting to social commitment, is a sustainable differentiator. Among these challenges, the adequate provision of human resources, both in terms of numbers and qualifications, is a persistent problem in the health sector in many countries, including Brazil¹.

The provision of human resources in health is a challenge because it involves technical/methodological aspects that are sensitive to support workforce planning and sizing, but also institutional, financial and political aspects². Concerning technical aspects, nursing stands out among the different professional categories in proposing parameterized criteria capable of measuring its workforce, as indicated by a recent literature review that analyzed 62 primary studies¹.

Nursing staff sizing is conceived as the initial stage of forecasting the number of workers, adjusted between categories, to meet the care demands of a given clientele³. It is a planning action focused on human resources, but which has direct applicability in nursing care, since this is dependent on the human factor. Like other planning activities, nursing staff sizing has been broken down into procedural steps, guided by the measurement of variables and knowledge of other measures that imply both the workload, possibly the main variable of the process, and the availability of professionals for (in)direct care⁴.

Studies with a high level of evidence support that insufficient nursing staff negatively affects quality of care and patient safety, although the difficulty of establishing cause and effect relationships between nursing staff adequacy and clientele clinical outcomes is recognized^5-6.

Researchers from England argue that patients who receive more nursing care and are also cared for by more qualified professionals have a lower chance of dying^5-7. In Finland, nursing staff shortages have also been slightly associated with patient deaths⁸. Other English authors suggest that the composition and availability of nursing teams may have an effect on different outcomes/results for patients in addition to mortality⁷, which supports Brazilian research, which found that the increase in patients per nursing worker had an impact on average length of stay, urinary catheter-related infection and user satisfaction⁹.

Although the technical-scientific support for planning and adapting nursing staff is robust, as explained, this problem also involves aspects beyond the methodological ones, such as political and deontological ones. In this regard, recently (March 2024) in Brazil, Resolution 543/2017¹¹ of the Federal Nursing Council (COFEN - Conselho Federal de Enfermagem) was revoked, which established the parameters for sizing nursing professionals in the country¹⁰. The aforementioned standard was replaced by Resolution n.º 743/202411, which no longer sets the parameters in question, but rather recommends, in a technical opinion, such criteria. This opinion states that legal actions argue for the Professional Oversight Boards’ incompetence to regulate matters related to workforce sizing¹², thus justifying the revocation of the previous resolution.

Considering that the problem of nursing professional sizing is critical and chronic, and that decisions that regulate the profession deserve debate, this study aims to reflect on the (in)visibility of the normative-legal apparatus on workforce sizing in Brazilian nursing. The proposal is to contribute with critical and dialogical thinking about reality, in the collective search for improvements in the category’s workforce composition, with a view to promoting quality of care and patient safety.

METHOD

This is a theoretical-reflective essay from the normative perspective of nursing workforce sizing (NWS) in Brazil, anchored in the historical trajectory of COFEN resolutions as well as national and international scientific studies on the subject.

In order to add criticality and reduce regionalisms, nursing sizing scholars from different regions of Brazil (Central-West, Southeast and South) conducted the reflection presented here, supported by the aforementioned framework, in addition to studies that touch on the topic. The authors are members of the Brazilian Network of Studies and Research on Healrh Workforce Sizing and Planning (ReDimensiona - Rede Brasileira de Estudos e Pesquisa em Dimensionamento e Planejamento da Força de Trabalho em Saúde). For organizational purposes, the reflection is presented in guiding axes, described below.

Nursing workforce sizing: looking to the past to understand the present

Determining the number of nursing professionals to meet patient care needs has always been a concern for nurses. The question “How many nursing professionals do we need?” has been asked by nurse researchers throughout the world over the years. In Brazil, nursing has been recognized for over 30 years as the professional category that has made the most progress in accumulating technical-scientific knowledge on the subject of NWS sizing¹.

Nursing professional sizing originated in the hospital sector. The first way of thinking about human resources planning emerged in the 17^th century in the figure of Florence Nightingale. The method, initially intuitive, was based on Florence’s experiences and knowledge, who grouped patients according to their severity, establishing the distribution of wards according to patients’ needs¹³. Over the years and with advances in technical-scientific knowledge, in the mid-1940s, discussions began on average hours of nursing care by type of unit and percentage distribution among professional categories¹⁴.

In Brazil, until 1939, nursing staff sizing was done mainly intuitively, similar to the Florence method, or through simple proportional relationships to determine the daily number of professionals per bed¹⁵. In keeping with the premise of bringing reflections on the topic, it is important to highlight that the method of relating patients to nursing workers is used very frequently to this day, even in hospitals with high technological density and appropriation of scientific knowledge¹⁶. Furthermore, the patient-to-nurse indicator is used to monitor the quality of human resources management, in addition to being the most common international measure to establish relationships between nursing staff adequacy and care outcomes⁶.

Going back to the historical overview, with the introduction of labor laws, regulation of daily weekly working hours, as well as guaranteeing rights to breaks and vacations (1956), through the Nursing Service Organization Manual¹⁷, nursing professional sizing began to be discussed more explicitly, with the director being given the role of “[...] V - Developing the staffing table necessary for the service to function” and the head nurse being given the role of “[...] XI - Planning the distribution of staff with a view to maintaining continuing care to patients”^17:33-36.

In the international context, in 1961, Conner highlighted the need to consider the different degrees of complexity of patients in relation to care, and, consequently, measuring nursing intensity^18-19. In Brazil, in mid-1972, Dr. Circe de Melo Ribeiro, pioneer on the subject, presented the Patient Stratification System (PSS) with the thesis entitled “SCP como subsídio para o provimento de pessoal de enfermagem”²⁰. This was a historic milestone for the workload measurement systematization of Brazilian hospital nursing.

The 1990s saw a strong expansion in the national production of PSS instruments, emblematically Fugulin and Perroca, in line with current national recommendations¹². This continued into the 2000s, with several authors^21-23, adding other productions on how the time/intervention relationship constitutes a more accurate predictor than just the degree of dependence, in addition to advancing in terms of clinical specificities. In this regard, the cross-cultural adaptation of the Nursing Activities Score (NAS)²⁴ also stands out, to date not endorsed by the professional association in the current recommendation¹².

During this period, the method developed by Professor Raquel Rapone Gaidzinski in 1998 for performing nursing staff sizing advanced and enabled the identification and analysis of variables involved in the sizing process, contributing to the projection of staffing levels for health services. These variables include the unit’s average workload, the percentage distribution of nursing professionals, the technical safety index and the effective job tenure¹⁵. The method continues to be one of the most widely used in Brazilian study scenarios¹, and has also been the basis for COFEN resolutions on the subject.

Although the most comprehensive studies on nursing staff sizing began between the 1970s and 1980s, COFEN only addressed the topic for the first time in the 1990s. Considering the lack of regulation on minimum criteria for sizing nursing staff, COFEN established Resolution 189/1996 in 1996, providing the first parameters for sizing nursing professionals in health institutions²⁵. In 2004, improving the criteria for determining the quantity and quality of professionals required, COFEN issued Resolution n.º 293/2004²⁶, replacing the previous one. Subsequently, COFEN Resolutions n.º 527/2016²⁷ and n.º 543/2017¹⁰ revoked Resolution n.º 293/2004²⁶.

The incorporation of research results in different sectors of nursing activity stands out as a milestone and advancement of nursing in Resolution n.º 543/2017¹⁰. Areas such as Primary Health Care now incorporate a method adapted from a proposal by the World Health Organization, and sectors related to the Central Sterile Supply Department, Surgical Center, Radiology and Imaging also have their own parameters¹². Moreover, nursing hours for highly dependent patients are introduced, a step forward for hospital areas²⁸.

Recently, COFEN Resolution n.º 743 of March 12, 2024 revoked COFEN Resolution n.º 543 of April 18, 2017, publishing on March 15, 2024 Normative Opinion 1/2024/COFEN, recommending parameters for NWS planning by nurses^10-12. We believe that such a measure deserves to be problematized, considering the possible repercussions for planning the nursing force in Brazil.

Regulatory and legal barriers to nursing sizing

The technical, scientific and legal development of nursing sizing in Brazil has been a movement of resistance and persistence by the federal and regional nursing councils, researchers and many nurses who experience the challenges of professional practice. Furthermore, there is evidence of advances and setbacks in the planning of NWS worldwide that need to be considered in this discussion. This reflection begins with the diversity of methods used worldwide to size the nursing team.

A review study was carried out by English researchers²⁹ and identified, mainly, four methodological approaches, among them: 1) nurses’ judgment/perception of workload; 2) comparative assessment between units/services; 3) volume of activities represented by the proportion of patients per nurse/nursing professional; and 4) individual assessment of patient needs using stratification systems, indicators or timed tasks, among others. All methods aim at better working conditions and safe care; however, different approaches can generate different results and tools that assess a greater number of factors tend to estimate higher values ​​of nursing professionals needed for care²⁹. Thus, the methods complement each other and can be used in an integrated manner.

International^5,30-33 and national^9,34 research confirms, above all, the positive impacts for patients, professionals and health services when there is a greater proportion, better nursing staff perception or adequacy in relation to the volume, patients’needs or health care indicators. Determining this in “legal” terms is not a unanimous reality in the profession, nor is it an easy task. The resolutions defined by COFEN for staff sizing in Brazil have been increased over time with the diversity of methods accompanying scientific advances, especially in the national context, and the particularities of each service/place where nursing develops its work^10,11,25-27. Despite this, the enactment of resolutions has not been sufficient to verify, in practice, scenarios of qualitative and quantitative adequacy of NWS.

National publications demonstrate the leading role of nursing in the sizing theme, but there is still much to explore. Most studies focus on the forecast of professionals for certain units or services, especially in hospital settings, and do not consider the demands for staff to provide care considering the Health Care Network (RAS - Rede de Atenção à Saúde)¹. Regional differences also need to be analyzed and this issue is so important that it constitutes a limitation of this study, despite efforts to involve representatives from different regions of the country.

The dilemmas faced by nurse managers for the effective adaptation of NWS in the microcontext or in the RAS are not widely described. In other words, although it stands out in science, there are important gaps to be filled through multicenter studies that represent the services’ and health system’s needs in planning the Brazilian NWS. Moreover, it is undeniable that nurses suffer from the gap between available scientific evidence and decision-making for quantitative and qualitative conformation of nursing in health services.

In practice, the ethical and regulatory framework that should minimally support nursing professionals in Brazil in relation to quality and safety at work, instead of being recognized and implemented, tends to be neglected and repressed by political and economic forces. Nurses encounter difficulties in negotiating and complying with minimum parameters to ensure sufficient professionals for safe performance. This is a critical point of this reflection that is aggravated, in some scenarios, by the indifference and/or connivance of some leaders in health and nursing who assume the staff sizing proposed by COFEN as utopian given the institutions’ financial limitations and rely on divergences existing between national legislations to provide the smallest possible proportion of nursing professionals in health care units.

Despite advances, especially in the scientific field, regulatory and legal obstacles persist and have an impact on nursing professional practice. Therefore, it is more than necessary to look critically at this movement that suppresses COFEN Resolution n.º 543/2017 and “updates” nursing sizing through COFEN Resolution n.º 743/2024^10-11. The latter presents, among its considerations, Normative Opinion 01/2024 as a parameter for planning the nursing workforce by nurses, adopting it for all services/locations where nursing activities are carried out¹². It is worth highlighting that item I of this opinion comprises a report in which the justifications for the need for this document are presented and which originated as a result of clarifications requested by nursing professionals as well as COREN inspectors.

These clarifications led to the need to review and update the criteria, calculations and technical parameters that support the planning, control and regulation of nursing activities, considering the rapid technological transformations, but mainly due to the legal demands that oppose the standardization of the matter related to NWS.

The Official Note from COFEN³⁵ of March 18, 2024 makes this clear when describing that decisions such as those of the Federal Regional Court of the 4^th Region and the Federal Regional Courts of Goiás and the Federal District suspended the effects of Resolution n.º 543/2017¹⁰. According to these bodies, it is understood that CORENs cannot oblige health organizations, based on the parameters of the aforementioned administrative resolution, to serve the adequate number of nursing professionals, as actions of this nature can only be charged through Federal Law.

It is therefore pertinent to analyze the hierarchy of norms that prevails in the legal system. It basically corresponds to the position that the norms exercise, with a gradual superiority between them. Thus, laws are valid because they are subject to the control of the legislative process through the proposal of a bill, voting in the appropriate instances, approval and sanction by the legislative and executive powers, respectively³⁶. Considering this hierarchical arrangement of the rules, in analogy to a pyramid, at the top of the rules are the Federal Constitution and the Complementary Laws to the Constitution, preceded by Ordinary Laws, Delegated Laws, Provisional Measures, Legislative Decrees, Resolutions and Ordinances, and at the base of this pyramid are the contracts and sentences³⁷.

The Constitution is the supreme law, determined by the people by virtue of their sovereignty to guide their political organization, to address the methods of creating other laws and to decree the rights and duties of its members. Ordinary laws comprise the rules drawn up by the authority conferred by the legislative branch. The resolution, on the other hand, consists of an administrative act of a collegiate body, such as COFEN, which provides clarifications, solutions, deliberations, regulations or parameters on a given subject.

In view of these concepts, it is worth noting that Law 7498/86 does not have specific articles demonstrating the exact number of nursing professionals/bed or considering the characteristics of the activities/institutions that are carried out³⁸. This proposition is currently established by Resolution n.º 743/2024 and Normative Opinion 01/2024^11-12. These tools support the calculation of nursing professionals taking into account the type of client to be assisted, the characteristics of the activities and the organization, in addition to the number of nursing hours required for this care. However, it does not have the weight of a Law or regulatory force.

This aspect gives rise to a reflection on the counterpoint between the COFEN Resolutions and the Collegiate Board Resolutions (RDCs - Resoluções da Diretoria Colegiada) established by the Brazilian National Health Regulatory Agency (ANVISA - Agência Nacional de Vigilância Sanitária). Among the characteristics of the RDCs is the regulatory role, i.e., to establish the parameters and standardization of processes in health organizations, in order to be able to charge them through inspection, and, consequently, regulate their operation. These ANVISA documents describe the duties/activities of services as well as the provision of the necessary physical, material and human resources.

In order to exemplify the aforementioned contradiction, it is worth highlighting that according to RDC/ANVISA 7/2010³⁹, which provides for minimum requirements for the operation of Intensive Care Units (ICUs), amended by RDC 26/2012⁴⁰, it establishes the minimum number of 01 nurse for every 10 beds and fraction, in addition to 01 nursing technician for every 02 beds and fraction per shift. In other words, it “only” distributes the number of beds per professional, without considering the scientific evidence produced over the years that demonstrates the numerous variables that can influence staff sizing. Despite this possible weakness, the aforementioned RDC has regulatory weight for the operation of intensive care environments, and for this reason, it is frequently respected, unlike the COFEN Resolutions⁴¹.

It should be noted that resolutions are normative administrative acts that were established by higher authorities of a professional class (COFEN) or a regulatory body such as ANVISA, but not by the chief executive. Thus, resolutions regulate the matter under their specific jurisdiction. From this perspective, since nursing staff sizing is a specific matter for this area, it is up to the supervisory entity to regulate NWS, considering the specificities of the work process and Bill 1,091 of April 4, 2024, meets this premise and is under analysis in the Chamber of Deputies^37,42.

Supporting the analysis, two studies^41,43 assessed the use of RDC 26/2012 and the metrics established by COFEN. It is clear, in both articles, that the COFEN legislation is more appropriate in relation to nursing staff sizing in ICUs when compared to ANVISA regulations. Furthermore, when comparing the legal provisions and the implications for professional practice, it is observed that ANVISA does not consider that 52% of professionals in ICUs are composed of nurses, given the numerous activities exclusive to this professional in the care of critically ill patients.

Recent research⁴⁴ compared three metrics (COFEN Resolution n.º 543/2017, Nursing Activities Score and RDC 26/2012) to analyze nursing workload in calculating nursing staff sizing in children’s ICUs in hospitals in the state of Paraná. Among the results, the authors point out that the greatest contribution of the study was to demonstrate the discrepancy between the sizing required by different methodologies, such as that established by COFEN, and that recommended by ANVISA Resolution 26/2012, the most used in Brazilian ICUs.

Recalling international experiences for nurse managers of secondary and tertiary hospitals in China, in addition to recognizing the characteristics of patients, professionals and health units/services, the timely provision of NWS depends on policies with minimum parameters, financial incentives and mandatory legislation⁴⁵. There are a variety of policy measures, especially in high-income countries, to ensure a safe NWS. Although some laws are considered stricter, such as the state of California in the United States, all have shown positive results with more nurses at the bedside after being implemented⁴⁶.This means that legislation that makes nursing staff sizing compulsory makes it possible to dedicate more hours to caring for patients⁴⁷ and, consequently, shorter hospital stays, lower readmission rates and lower hospital mortality rates, resulting in savings for the health system^31,48.

Brazil has already made efforts towards a more robust political movement on nursing staffing, with three bills standing out: Senate Bill 448/2016 (archived); Chamber of Deputies Bill 930/2024; Chamber of Deputies Bill 2242/2021^49-51 that are being processed in the Chamber of Deputies and the Senate. These projects contribute to the fight for the incorporation of nursing staff sizing in Law 7,498 of June 25, 1986³⁸.

Considering the above, it is considered essential that nursing staff sizing be incorporated into the Professional Practice Law and/or specific Law, duly supported by the legal apparatus, in order to make the profession more socially recognized and valued, in addition to ensuring a practice with dignified and favorable conditions for safe care.

CONCLUSION

Nursing staff sizing standardization is marked by historical and scientific contributions, established through resolutions that propose methodological criteria and parameters to make this possible. It is important to recognize the progress of these standards with regard to scientificity and scope in professional practice scenarios. On the other hand, there is a divergence of regulations on nursing workforce planning, in addition to the lack of mandatory nature (and therefore no effective legal framework) of the resolutions that recommend the process of forecasting nursing staff in Brazil.

Criticism requires measures such as the revocation of COFEN Resolution n.º 543/2017, since even with the existence of an opinion from COFEN, nurse managers are still uncertain about which regulations to follow to promote effective coverage of the professional staff of their teams. In addition to this, there is a clear need for political progress in the weight and normative-legal respect of nursing staff sizing, since divergence of standards and absence of law implies non-adherence to the class entity recommendations.

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NOTES

• FUNDING INFORMATION
  This work was carried out with the support of the Coordination for the Improvement of Higher Education Personnel - Brazil (CAPES) - Financing Code 001.
• TRANSLATED BY
  Letícia Belasco.

Edited by

• EDITORS
  Associated Editors: Gisele Cristina Manfrini, Maria Lígia Bellaguarda.
  Editor-in-chief: Elisiane Lorenzini.

Publication Dates

• Publication in this collection
  13 Dec 2024
• Date of issue
  2024

History

• Received
  07 Aug 2024
• Accepted
  23 Sept 2024