NURSING WORK PROCESS IN THE CONTEXT OF THE INTERIORIZATION OF INTENSIVE CARE: A CONVERGENT CARE STUDYABSTRACT
Objective: To analyze the nursing work process in a newly implemented General Intensive Care Unit in an inland municipality in the post-COVID-19 context and, in a participatory manner, promote improvements in this process.
Method: Convergent Care Research conducted with 20 nursing workers from a newly implemented Intensive Care Unit in an inland region of Southern Brazil. Data were produced through non-participant observation, individual interviews, and a convergence group. The analysis followed the steps of the method: apprehension, synthesis, theorization, and transfer.
Results: The nursing work process was marked by the specificities of interiorization and weakened by managerial, structural, interpersonal, educational, and political barriers. Despite difficulties in engaging in the activity and understanding their own work process, the group demonstrated potential to reflect and propose feasible measures for its improvement.
Conclusion: Despite the barriers faced in the context of interiorization, it is possible to promote improvements in the nursing work process in Intensive Care through managerial, care-related, and collective engagement of workers in the change process.
DESCRIPTORS:
Nursing; Nursing staff; Intensive care units; Health work process; Philanthropic hospitals; Community-based participatory research
RESUMO
Objetivo: analisar o processo de trabalho de enfermagem em uma Unidade de Terapia Intensiva Geral recém-implantada em município interiorano no cenário pós COVID-19 e, de forma participativa, promover melhorias nesse processo.
Método: Pesquisa Convergente-Assistencial realizada com 20 trabalhadores de enfermagem de uma Unidade de Terapia Intensiva recém implantada no interior do Sul do Brasil. Os dados foram produzidos pela observação não participante, entrevistas individuais e grupo de convergência. A análise seguiu os passos do método: apreensão, síntese, teorização e transferência.
Resultados: o processo de trabalho de enfermagem era marcado pelas especificidades da interiorização e fragilizado por barreiras de natureza gerencial, estrutural, interpessoal, educativa e política. Apesar das dificuldades para engajar-se na atividade e compreender seu próprio processo de trabalho, o grupo demonstrou potencial para refletir e propor medidas factíveis para sua melhoria.
Conclusão: apesar das barreiras enfrentadas no contexto da interiorização, é possível promover melhorias no processo de trabalho de enfermagem em Terapia Intensiva a partir do engajamento gerencial, assistencial e coletivo dos trabalhadores no processo de mudança.
DESCRITORES:
Enfermagem; Equipe de enfermagem; Unidades de terapia intensiva; Processo de trabalho em saúde; Hospitais filantrópicos; Pesquisa participativa baseada na comunidade
RESUMEN
Objetivo: analizar el proceso de trabajo de enfermería en una Unidad de Cuidados Intensivos General recién implantada en un municipio del interior en el escenario pos-COVID-19 y, de manera participativa, promover mejoras en dicho proceso.
Método: Investigación Convergente-Asistencial realizada con 20 trabajadores de enfermería de una Unidad de Cuidados Intensivos recién implantada en el interior del sur de Brasil. Los datos fueron producidos mediante observación no participante, entrevistas individuales y un grupo de convergencia. El análisis siguió las etapas del método: aprehensión, síntesis, teorización y transferencia.
Resultados: el proceso de trabajo de enfermería estaba marcado por las especificidades de la interiorización y debilitado por barreras de naturaleza gerencial, estructural, interpersonal, educativa y política. A pesar de las dificultades para involucrarse en la actividad y comprender su propio proceso de trabajo, el grupo demostró potencial para reflexionar y proponer medidas factibles para su mejora.
Conclusión: a pesar de las barreras enfrentadas en el contexto de la interiorización, es posible promover mejoras en el proceso de trabajo de enfermería en Cuidados Intensivos a partir del compromiso gerencial, asistencial y colectivo de los trabajadores en el proceso de cambio.
DESCRIPTORES:
Enfermería; Personal de enfermería; Unidades de cuidados intensivos; Proceso de trabajo en salud; Hospitales filantrópicos; Investigación participativa basada en la comunidad
INTRODUCTION
The work process is defined as an activity through which human beings act to transform a given object, using work instruments and producing, as a result, products or services aimed at a specific purpose. The constituent elements of the work process are activity, object, instruments/means, objective/purpose, and workforce1. In nursing, the work process includes care, management, research, and education within care practices. It is influenced by working conditions and affects the quality of care2.
The Intensive Care Unit (ICU) is an important setting within the health system for caring for patients with acute organ dysfunction3. Nurses are the backbone of ICU care, and their competencies are essential for managing the work process4. The intensive nursing work process includes caring for people in critical life situations in coordination with a multidisciplinary team, through a set of skills and competencies encompassing care, management, and education3.
The nursing work process in ICUs was affected by the Coronavirus Disease 2019 (COVID-19) pandemic between 2020 and 2021. COVID-19 was characterized as a public health emergency that presented regional nuances associated with biopolitical, economic, and social aspects, deeply impacting health systems and intertwining with social inequalities5-6. COVID-19 especially affected the nursing work process in inland regions, since in Brazil there are inequalities in the distribution of public resources for these areas, particularly ICU beds, which are unevenly distributed7.
Inequality in access to ICU beds was one of the main challenges faced during the pandemic8. A study analyzed COVID-19 trends and incidence in Brazil between 2020 and 2021. The data showed that higher mortality rates were concentrated in regions characterized by a lack of health resources, including ICU beds9. To mitigate this fragility, the implementation of COVID-19 ICUs occurred especially in regions marked by a shortage of intensive care beds, including inland municipalities, enabling access to intensive care in these areas10.
After the most severe phases of the pandemic had passed, COVID-19 ICUs were closed. However, in regions where there had been a shortage of intensive care beds, these units were accredited as General ICUs. Thus emerged the process of interiorization of intensive care, in an attempt to mitigate a Brazilian hospital structure that is insufficient, geographically poorly distributed, unevenly integrated into local and regional systems, and severely weakened by chronic underfunding11.
The interiorization of intensive care is an emerging yet essential development in addressing serious public health problems9. However, it is possible to hypothesize that barriers are encountered due to geographic specificities, such as financial resources, hospital infrastructure, management, and coordination with the Health Care Network. Nevertheless, there is a lack of evidence in the literature regarding the work process in these sectors, especially from the perspective of nursing teams.
In addition, it is known that there is a gap in evidence concerning the post-pandemic context, which reinforces the relevance of this study12. Therefore, the present study aimed to analyze the nursing work process in a newly implemented General ICU in an inland municipality in the post-COVID-19 scenario and, in a participatory manner, promote improvements in this process.
METHOD
This is a qualitative study based on Convergent Care Research (CCR). CCR proposes the convergence between research actions and health care practices. Its purpose is to elucidate health needs and to plan/implement changes and innovations in care practice, especially in nursing13.
The study was conducted in a General ICU of a medium-sized philanthropic hospital located in an inland region of the state of Rio Grande do Sul, Brazil. The institution served as a reference for a population of 52,575 inhabitants, including small municipalities with rural lifestyles and work activities.
In 2021, the hospital submitted a request to the State Health Department of Rio Grande do Sul for the accreditation of an Adult General ICU, based on the former COVID-19 ICU. The unit had ten beds and a multidisciplinary team to care for critical/severe patients, who were admitted to the institution through the State Bed Regulation Center. Most admissions came from neighboring municipalities.
Data collection took place in May (observations and interviews) and September (convergence group) of 2023. During this period, 28 nursing workers were assigned to the ICU. The inclusion criteria were being a nursing worker with either technical or higher education and being assigned to the Adult ICU. Those who were on vacation, leave, or any type of functional absence during the period designated for observation and interviews (May 2023) were excluded.
One worker was excluded for being on vacation and another for being on leave. In addition, there were six refusals (five at the beginning of the study and one during the interview stage). Therefore, 20 workers participated in the study.
Data were collected by a nurse and master’s student, supervised by a nurse with a doctoral degree in nursing. The following techniques were used: structured participant observation; semi-structured interviews; and a convergence group.
Structured participant observation aims to document important phenomena that cannot be captured through questions or documents but must be observed in their real context14. Observations took place at the nursing station, in patients’ private areas, meeting rooms, medication rooms, material/equipment storage areas, and the decontamination room. A script developed by the researcher was used, focusing on the following elements: environment; team dynamics; task execution; professional interactions; problem-solving; and work instruments. Observations were conducted during morning, afternoon, and night shifts, totaling 32 hours, following the criterion of theoretical saturation. The information obtained was compiled into a field diary, later integrated into the analytical corpus.
The semi-structured interviews were conducted through invitations made in the workplace and scheduled individually with each participant. They were carried out individually, during the work shift, in an office located within the hospital facilities, and guided by a script developed by the researcher. First, sociodemographic and work-related data were collected (gender; age; professional category; academic background; length of time working in the unit; previous experience in Intensive Care). Next, the interview was guided by the following topics: perceptions about their work in the ICU; daily routines in the unit; conceptions about nursing practice in the ICU; weaknesses identified in the nursing work process in the ICU.
The average duration of the interviews was 30 minutes. A pilot interview was conducted to adjust the semi-structured script, and it was not included in the analysis. The interviews were audio-recorded with participants’ authorization and fully transcribed. The transcripts were offered to each participant in text format via a messaging application. They were given seven days for reading and suggestions. One interview and observation data were excluded from the records at the request of a participant.
After the transcription and validation of the interviews, the convergence group (CG) was organized, understood as a group technique that enables the triggering of care practice within CCR13. The institution’s and unit’s management suggested organizing three meetings, on different days and shifts, to allow greater participant adherence. The meetings were widely publicized in the ICU through invitations sent via messaging apps and posters in the break room; in addition, an individual invitation was delivered to each worker. The meetings were held in a hospital meeting room. On the first and last scheduled dates, no participants attended, while on the second date, four people were present.
The CG meeting was mediated by the principal researcher, assisted by two aides (undergraduate Nursing students previously trained in a research group that studies the relationship between work and nursing at a public university). Mediation was facilitated by a script developed for this study. Initially, participants were welcomed, followed by an introductory and integration activity. Next, a discussion was initiated in which participants were encouraged to identify the constituent elements of their work process. Afterwards, an activity using poster boards and markers was conducted to develop an improvement plan for the nursing work process in the General ICU through infographics. Finally, the improvement plan was discussed.
The meeting lasted one hour and thirty minutes. For data validation, a textual summary was prepared by an assistant and read at the end of the meeting. The content was validated by the participants. The discussions were recorded using digital devices, fully transcribed, and incorporated into the study corpus.
The qualitative dataset was subjected to the analytical procedures recommended by CCR: apprehension, synthesis, theorization, and transfer13. In the apprehension stage, the material relevant to the study objectives was organized and then thoroughly reviewed. The material was broken down into thematic units with the aid of NVivo software. In the synthesis stage, the thematic units were grouped according to semantic affinity, giving rise to analytical categories and subcategories, supported by conceptual maps created using CmapTools version 6.04.
In the theorization stage, the results were interpreted in light of the fundamental concepts of the work process as the theoretical-conceptual framework. In the final stage, transfer, once the consolidated results were obtained, an interlocution with similar studies was carried out to propose implications for practice13.
Excerpts from the field diary are presented in the results section with the acronym NO (“observation notes”), followed by the date on which they occurred. Excerpts from statements are also included, identified by the acronyms ENF (nurse), TE (nursing technician), a cardinal number according to the order of participation in the study, and an indication of whether the statement originated from an interview or the CG. The study was conducted in accordance with Resolutions No. 466/2012 and No. 510/2016. The project was approved by a local Research Ethics Committee. No Artificial Intelligence tools were used in the production of this study.
RESULTS
A total of 20 nursing workers participated in this study. Most were women (n=19), with ages ranging from 22 to 55 years. Six participants were between 22 and 28 years old; nine between 29 and 42 years old; and five between 49 and 55 years old.
Among the 20 participants, 15 were nursing technicians and five were nurses. Three had specialization or advanced training in Intensive Care. Three professionals had previous ICU experience before joining the institution. Most participants (n=13) had been working in the unit for more than one year; 12 had worked in the COVID-19 ICU.
Nursing work process in a general ICU: weakening factors identified after implementation
Figure 1 illustrates the synthesis of the weakening aspects of the nursing work process in the General ICU after implementation:
Conceptual map illustrating the synthesis of the weakening aspects of the nursing work process in an inland General ICU. Rio Grande do Sul, Brazil, 2023.
The weakening factors included the absence of managerial references for the night-shift teams, who at times felt unsupported during their shifts. In addition, the high turnover in the unit was notable due to the difficulty of finding workers in the municipality with an adequate profile to work in intensive care.
At night […] I think the presence of the supervisor is very lacking […] there are many things that I end up taking on myself […] because I don’t have a supervisor […] (ENF03-Interview).
[…] a lot of staff turnover. Some did not want to stay, they did not like the environment. Others did not work out, they did not adapt […] (ENF01-Interview).
Challenges related to the ICU bed regulation center and patient admissions in the inland region were also highlighted. Patients often arrived with clinical and care conditions different from those recorded in the regulation system.
Workers feel that, at times, hospitals exaggerate the severity of patients or omit details. I also observe inadequate patient management until arrival at the ICU: without IV access, with low oxygen saturation, accompanied only by a nursing technician who sometimes has no information about the case to pass on to the ICU team […] (NO, 05/05/2023).
[…] they say a very sick patient is coming, needing ventilation. The patient arrives breathing room air, stable. […] Sometimes I think they want to transfer because they lack resources in the municipality […] Sometimes they say the patient is fine, and the patient arrives here almost dead, in shock, in cardiac arrest, with nothing we can do […] (TE08-Interview).
From a structural standpoint, difficulties were noted in discharging patients from the General ICU to the hospital’s inpatient units, due to the lack of human resources and infrastructure capable of meeting semi-intensive care demands.
[…] patients stay here [ICU] for a long time, they are long-stay patients. Hospitals have semi-intensive units; we do not. We have Unit 1 [inpatient unit]. To transfer a patient there, they must be 100%. If they still have a central line, it is already a “seven-headed beast” for them […] (ENF01-Interview).
Physical limitations of the environment also compromised the work process, burdened workers, and hindered the care provided.
[…] The patient was in bed 1, had a wound, and needed daily dressings. In bed 1 the space is small. We had to go in with several people, and we would leave feeling unwell, it was very stuffy (TE01-Interview).
[…] when she [the patient] was in another bed, bath time lasted half an hour; after she moved to bed 1, the time doubled (TE09-Interview).
In the interpersonal dimension, communication breakdowns and interpersonal problems were prominent. There were disagreements during task division, shift handovers, and fulfillment of demands.
I notice numerous conflicts among shift colleagues and unit colleagues. Some professionals who have fewer demands do not help the rest of the team. There are conflicts regarding breaks and going to assist in other units. Nurses complain about colleagues who do not hand over the shift as expected (NO, 05/05/2023).
In the educational dimension, workers recognized that they felt insufficiently trained to work in Intensive Care and therefore emphasized the importance of more educational actions, both technically and regarding mental health.
Our problem is the ventilators. We cannot operate them […] Care with tubes: I see many mistakes with gastric tubes. […] mechanical ventilation training, tracheostomy care […] (TE04-Interview).
[…] something very important to work on: the psychological well-being of those who work here [ICU] […] I think many people do not have the psychological readiness to work in the ICU […] (TE08-Interview).
Finally, the interference of political and economic dynamics in the ICU nursing work process became evident. During data collection, rumors multiplied about a possible closure of the ICU for economic reasons, which generated concern among nursing workers. Participants expressed indignation, lamented the potential loss of all the work built so far, and feared the repercussions for the institution, the municipality, and the region.
One of the professionals expresses concern regarding political issues surrounding the monthly cost of maintaining the ICU. Municipal representatives consider the unit unsustainable […] (NO, 03/05/2023).
[…] I saw on social media that the city administration says the ICU does not generate profit. That it only generates losses, so it should be closed (TE04-Interview).
Politics […] it was a struggle for the General ICU to operate. […] They think it is unnecessary unless a family member of theirs is here. Until then, it is just an expense! […] (TE06-Interview).
Convergent-care proposal for improving the nursing work process in a general ICU
Three CG meetings were organized, in different shifts, with an open invitation extended to all nursing workers. In one of the meetings, four participants attended (one nurse and three nursing technicians).
Understanding the nursing work process to develop the improvement plan
To develop the improvement plan, participants were initially encouraged to identify the constituent elements of their work process. For some, the term was not clear, and they associated it with the nursing process. Other participants described attributes such as affection and compassion, comparing their professional practice to that of a psychologist.
The anamnesis, physical examination, nursing progress notes. The records that the whole team makes (ENF05-CG).
[…] sometimes we play the role of a psychologist. When they [patients] are recovering, when they are extubated, they become somewhat delirious, so you have to engage in their conversation so they can adapt […] I have this habit of giving patients nicknames […] (TE01-CG).
To advance these discussions, the mediator helped participants identify that the work process is composed of five elements: activity; object/subject; instruments; objectives/purposes; and workforce. From this starting point, they were encouraged to identify the characteristics of these elements within nursing practice. Chart 1 summarizes what participants constructed during the discussion:
Subsequently, participants were divided into pairs and, using poster boards and markers, developed proposals for the improvement plan. They later presented their proposals, which are summarized in Chart 2:
Non-adherence to the convergence group: analysis beyond the limitations
The low participation of workers in the CG will be discussed within the study’s limitations; however, it can also be analyzed in light of the research findings. During the interviews, participants mentioned low recognition and devaluation. The political movement toward closing the ICU, cited in the previous category, was interpreted by some as a reflection of the financial pressure caused by the imminent approval of the National Nursing Wage Floor Law.
Fatigue. The lack of recognition, of decent pay. Having to find side jobs to pay the bills […] our profession is disunited. Before, it was applause and banging pots, and now it feels like everyone is wearing a clown nose, being made a fool of! […] the pandemic ended and here we are, cleaning patients (TE10‑Interview).
[regarding the ICU closure] I think this is to put pressure because of the wage floor. They want to scare us. “If the wage floor is approved, we will close the ICU, we will have to lay off staff” (TE14‑Interview).
Finally, during the CG, one of the participants pointed out that, despite the absence of the teams in the meetings and training sessions, there had been intense participation in an event related to the Wage Floor Law, suggesting that professional demands were considered more urgent at that moment.
[…] Participation is low. On the day of the meeting about the wage floor, there was no more space in this room for people to come in […] (TE14‑NC).
DISCUSSION
The analyses were guided by an examination of the new challenges faced in the nursing work process within a recently accredited inland ICU after COVID-19, revealing macro-structural aspects that influence nursing work, particularly political, economic, and managerial factors. Structural, interpersonal, and educational dimensions were also confirmed as elements that weaken the work process. Within the convergence group, it became evident that promoting improvements in this setting requires profound transformations involving ethical strengthening, professional engagement, a sense of belonging, and valuing the nursing profession.
The lack of administrative references for night-shift teams aligns with the managerial dimension and may be related to the particularities of nursing work performed at night, which includes reduced presence of managers and administrative structures15. The presence of management is not always perceived as effective; however, this perception of support is essential for nursing workers to find satisfaction and motivation in their work12.
Turnover was also mentioned and may be related to the context of inland services, given the challenge of selecting human resources with an ICU profile in a municipality that previously did not have such a structure. Nonetheless, the shortage of nursing professionals for intensive care has been described in the literature and is also associated with other factors, such as excessive workload, moral distress, and burnout16.
The managerial dimension was also marked by difficulties in patient admissions, especially within the context of the state-level regulation of intensive care beds, as the General ICU often received patients from small municipalities whose clinical conditions differed from what was expected. This difficulty may be related to the fact that an inland ICU serves as a reference for small towns with limited health resources for more complex care.
In the Serviço Único de Saúde (SUS, Brazilian National Health System), expanding the availability of ICU beds is essential to enhance access to high-technology care. However, this requires adequate regulation of these beds. Hospital beds are high-cost resources; therefore, efficient management directly impacts the financial sustainability of hospitals and the optimization of their service capacity. Managing beds with appropriate admission and discharge criteria reduces waiting times, ensures user accessibility, and leads to improvements across the healthcare network. Nevertheless, bed management is challenging, as the processes of hospitalization and discharge are complex and involve multiple factors, including fragmentation among teams17.
Structural weaknesses were also identified, such as the absence of a step-down unit (SDU), which compromised the continuity of patient care. A study conducted in 12 inland SDUs showed lower mortality rates compared to inpatient units; only 3.9% of patients returned to the ICU, and 31% were discharged home. The study suggests that the existence of such units strengthens the care pathway for critically ill patients18. However, it is important to consider the reality of small hospitals, which face budgetary and structural challenges that hinder the implementation of these units.
This reflection can be extended to the issue of ICU infrastructure. It is known that strengthening the nursing work process depends on adequate working conditions, including comfortable and safe work environments2. The availability of ICUs with good resources is associated with reduced morbidity and mortality3. A cross-sectional study conducted in 30 U.S. ICUs showed that only 30% of them met guidelines related to physical space19.
Communication breakdowns and interpersonal problems also emerged as factors that weaken the work process. Cross-sectional Iranian studies with ICU nursing teams showed that better levels of teamwork (including leadership, mutual support, and communication) were associated with lower levels of missed care, suggesting their importance for care quality20-21.
Educational weaknesses included the need for in-service training and capacity-building. Among the competencies of the nursing work process is teaching, which involves educational actions aimed at preparing nursing professionals for comprehensive care2.
ICU nursing workers must receive work-related education throughout their careers. Beyond strengthening the quality of care provided in these units, education consolidates the professional identity of intensive care nursing. Establishing minimum criteria for training and qualification creates a foundation capable of reducing turnover and ensuring a critical professional workforce prepared to face future health challenges22.
Demands for actions promoting mental health in the workplace were also mentioned by participants. Occupational risks are present in the nursing work process, with psychosocial risks being particularly significant2. ICU nursing workers carry the memory of suffering experienced during COVID-19, due to the daily exposure to death and the emotional burden of coping with it23. Even after this phase, stressful experiences persist, related to patient morbidity and mortality, the technical demands of the sector, precarious working conditions, and stress24, reinforcing the need for a sensitive and attentive approach to these workers.
The political dimension also emerged as a factor weakening the work process, due to the interference of municipal political and financial issues in the functioning of the ICU. It is estimated that more than half of the world’s population does not trust the governance of state institutions to resolve health demands. Supporting this reality, a study conducted in an African country revealed that political interference influenced health governance practices25.
In the context of expanding intensive care services to small municipalities, political and economic tensions may take on unique proportions and be intensified by the reduction of public resources allocated to health. However, in the health sector, it is essential to combine efforts to strengthen governance, including improving management systems through shared responsibility between local and central governments25.
In the second analytical category, the development of the convergent-care proposal aimed at improving the nursing work process in the ICU was presented. Participants in the CG had difficulty identifying the constituent elements of their work process, tending to associate attributes of affection and compassion with the nature of their profession
Compassion, affection, and bonding are important elements in the relationship that nursing workers establish with their patients26. However, when these qualifiers of care occupy the center of professional identity, this may indicate the influence of gender stereotypes, which attribute these qualities to women and reduce nursing to these attributes. This occurs because sex differences generate an unconscious yet collective symbolic order that influences the roles and careers of nursing workers. It shapes behaviors that become incorporated into daily routines and institutionalize organizational processes. Therefore, these aspects must be problematized and re-signified collectively27.
Despite these difficulties, the process of problematization proved effective in prompting workers toward a new reflection on the work process. This aligns with a study conducted with Angolan nurses, which demonstrated the potential for professional engagement regarding their work process28.
Based on this experience, it was possible to encourage participants to construct an improvement plan that summarized their aspirations for change as well as their perception of commitment to the work process. Strengthening the professional profile of intensive care nursing is necessary, fostering teamwork and the development of problem-solving skills29.
Lastly, the low participation of workers in the CG extended beyond being an important limitation and can also be discussed as a reflection of the moment experienced by the team: the strain caused by the municipal ICU management policy and the anticipation surrounding the approval of the National Nursing Wage Floor Law. It is essential to understand the silence behavior of nursing workers in the workplace, as the inability or unwillingness to express themselves and participate in collective processes may indicate job dissatisfaction or low productivity. Silence behavior in nursing can be influenced by cultural aspects, organizational practices, and economic issues, which aligns with the findings of this study. When nursing workers feel unable to express their ideas or participate in decision-making processes, their sense of purpose and motivation may be compromised, weakening engagement and commitment to the profession30.
Finally, the nursing work process in the ICU was shaped by the characteristics of inland services, which influenced financial, organizational, and hospital dynamics. The care practice enabled the construction of a productive moment that proved important for promoting improvements through managerial, care-related, and collective engagement in the process of change. Further studies focusing on the nursing work process in inland ICUs are recommended, in order to shed light on scientific evidence regarding the particularities experienced in these regions.
It is recommended that new studies be conducted focusing on the nursing work process in inland ICUs, illuminating scientific evidence about their specificities. Analyzing the work process, the challenges in training and retaining qualified professionals, and the effects of local management and healthcare network infrastructure on intensive care delivery in these regions may provide valuable insights for formulating more effective public policies adapted to the specific needs of these localities
CONCLUSION
The analysis of the nursing work process in the newly implemented inland ICU revealed professional, managerial, and political barriers faced within the context of healthcare interiorization. The findings add economic and political dimensions to the discussion on the work process, exposing deep obstacles to opening intensive care beds in inland municipalities.
However, the participatory action demonstrated that it is possible to improvements in the nursing work process in ICUs through managerial, care-related, and collective engagement of workers in the change process. It is suggested, however, that such improvements must be accompanied by fair compensation, recognition, safety, and appreciation of the profession.
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