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Este documento pretende fazer um relato sustentado e reflexivo do trabalho realizado no estágio, dividido em três módulos, desenvolvidos no Curso de Mestrado de Natureza Profissionalizante (2009-2011), com vista ao desenvolvimento de competências de Enfermeira Especialista em Enfermagem Comunitária.
O módulo I, realizado na Unidade de Saúde Santa Casa Castelo, tendo sido feito o diagnóstico de situação e identificadas duas áreas problemáticas, passíveis de intervenção: a Gestão de Materiais provenientes da farmácia e do armazém, e gestão da Diabetes – Empowerment. Foi ainda elaborado um projecto de reestruturação da gestão de materiais da Unidade de Saúde, de acordo com necessidades institucionais.
No módulo II, foi desenvolvido um projecto para a criação e estruturação da Consulta de Enfermagem à pessoa com Diabetes na Unidade de Saúde, com vista à melhoria da oferta de Cuidados de Enfermagem e de saúde à população e igualmente no sentido da autonomia e afirmação da profissão.
No módulo III, foi diagnosticada a necessidade de estabelecimento de parcerias entre a Equipa de Cuidados Domiciliários do Centro Hospitalar de Lisboa Central, EPE e os recursos comunitários, tendo incidido sobre a articulação com um Centro de Saúde da área de abrangência do hospital e uma Unidade de Saúde Santa Casa – para tornar a transição hospital-casa num processo facilitado e apoiado, envolvendo desde logo o doente e família.
Na gestão, conseguiu-se responder às necessidades expressadas e diagnosticadas. Respondendo a obrigações éticas e de cidadania, bem como desenvolvendo competências de Enfermeiro Especialista, nomeadamente de gestão e liderança de equipas e processos de mudança, bem como o recurso e mobilização de conhecimentos - tendo por base a experiência profissional e de vida, bem como orientações técnicas especializadas.
De salientar em relação à gestão de materiais que o trabalho realizado, deixa o caminho facilitado para os gestores, nomeadamente, o Enfermeiro Coordenador da Unidade de Saúde, rentabilizarem os recursos e diminuirem o desperdício. Bem como, o envolvimento da equipa de Enfermagem, delegando responsabilidades de previsão, gestão e registo de gastos de materiais nos Enfermeiros de cada programa da Unidade de Saúde - deixando o Enfermeiro Coordenador com maior disponibilidade para investir noutras áreas.
Os Enfermeiros estão estrategicamente colocados no seio da equipa multidisciplinar, como elementos privilegiados no acompanhamento à pessoa diabética e família em todo o seu processo terapêutico. Torna-se então clara a importância de cada vez melhor dirigir e aperfeiçoar a abordagem do Enfermeiro aos doentes diabéticos seguidos em consulta de Enfermagem – de inequívoca importância e relevância para o controlo desta pandemia.
O conceito de parcerias é actual, responde às necessidades identificadas da Equipa de Cuidados Domiciliários hospitalar, no sentido de mobilizar recursos e articular-se de forma eficaz com os Centros de Saúde e as Unidades de Saúde da Santa Casa da Misericórdia de Lisboa – considerados um recurso comunitário de saúde. Fazendo todo o sentido, neste percurso desenvolvido, da comunidade para o hospital, ser explorado no sentido da intervenção em Enfermagem Comunitária.
This document is intended to present a sustained, insightful report of the work performed during training, divided into three modules, which was developed within the Professional Master’s Course (2009-2011) in order to develop Community Nursing Specialist skills. In module I, we performed a situation diagnosis of Santa Casa Castelo Healthcare Unit (USSCC) and identified two problematic areas susceptible to intervention: pharmacy and warehouse Material Management, and Diabetes Management – Empowerment. Additionally, we elaborated a restructuring plan for the healthcare unit material management in accordance to institutional needs. In module II, we developed a plan to create and structure Nursing Visits to patients with diabetes at USSCC in order to improve health and nursing care supply to the population and to turn the professionals more autonomous and prominent. In module III, we diagnosed the need for establishing partnerships between the Central Lisbon Hospital Centre’s Home Based Care Team and the community resources. This focused on articulating a Healthcare Centre from the hospital’s influence area with a Santa Casa Healthcare Unit. In this case, the transition from hospital to home would become an easier, better supported process which would immediately involve the patient and his/her family. Regarding management, we were able to respond to all explicit and diagnosed needs, whether by following ethical and citizenship duties or by developing Nursing Specialist skills, namely team management and leadership, change process management and leadership, and knowledge resource and mobilization based on professional and life experience and specialized technical guidelines. We would like to highlight that the work performed regarding materials management renders future management efforts, especially those of the Healthcare Unit Coordinating Nurse, easier to improve resource efficiency and decrease waste. Also, by involving the nursing team and delegating materials forecasting, management and spending responsibilities to its members, within the Healthcare Unit, would enable the Coordinating Nurse to be more available to invest in other areas. Nurses are in a strategic and privileged position regarding the multidisciplinary team that follows the diabetic patient and his/her family throughout the entire therapeutic process. It is at this moment that the relevance of managing and perfecting the Nurse’s approach to diabetic patients during Nursing Visits becomes clear and unequivocally important for the control of this pandemic. The concept of partnerships is up-to-date and it responds to the identified needs of the Hospital’s home based care team as it mobilizes resources and it articulates itself effectively with Healthcare Centers and Santa Casa da Misericórdia de Lisboa (SCML) Healthcare Units (it is deemed a community health resource). As so, it is senseful, following this developed pathway from the community to the hospital, to explore this concept regarding Community Nursing intervention.
This document is intended to present a sustained, insightful report of the work performed during training, divided into three modules, which was developed within the Professional Master’s Course (2009-2011) in order to develop Community Nursing Specialist skills. In module I, we performed a situation diagnosis of Santa Casa Castelo Healthcare Unit (USSCC) and identified two problematic areas susceptible to intervention: pharmacy and warehouse Material Management, and Diabetes Management – Empowerment. Additionally, we elaborated a restructuring plan for the healthcare unit material management in accordance to institutional needs. In module II, we developed a plan to create and structure Nursing Visits to patients with diabetes at USSCC in order to improve health and nursing care supply to the population and to turn the professionals more autonomous and prominent. In module III, we diagnosed the need for establishing partnerships between the Central Lisbon Hospital Centre’s Home Based Care Team and the community resources. This focused on articulating a Healthcare Centre from the hospital’s influence area with a Santa Casa Healthcare Unit. In this case, the transition from hospital to home would become an easier, better supported process which would immediately involve the patient and his/her family. Regarding management, we were able to respond to all explicit and diagnosed needs, whether by following ethical and citizenship duties or by developing Nursing Specialist skills, namely team management and leadership, change process management and leadership, and knowledge resource and mobilization based on professional and life experience and specialized technical guidelines. We would like to highlight that the work performed regarding materials management renders future management efforts, especially those of the Healthcare Unit Coordinating Nurse, easier to improve resource efficiency and decrease waste. Also, by involving the nursing team and delegating materials forecasting, management and spending responsibilities to its members, within the Healthcare Unit, would enable the Coordinating Nurse to be more available to invest in other areas. Nurses are in a strategic and privileged position regarding the multidisciplinary team that follows the diabetic patient and his/her family throughout the entire therapeutic process. It is at this moment that the relevance of managing and perfecting the Nurse’s approach to diabetic patients during Nursing Visits becomes clear and unequivocally important for the control of this pandemic. The concept of partnerships is up-to-date and it responds to the identified needs of the Hospital’s home based care team as it mobilizes resources and it articulates itself effectively with Healthcare Centers and Santa Casa da Misericórdia de Lisboa (SCML) Healthcare Units (it is deemed a community health resource). As so, it is senseful, following this developed pathway from the community to the hospital, to explore this concept regarding Community Nursing intervention.
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Enfermagem Enfermagem comunitária Gestão de materiais Educação terapêutica na diabetes Gestão da diabetes (empowerment) Parcerias Parcerias comunitárias Community nursing Nursing Material management Diabetes therapeutic education Diabetes management (empowerment) Partnerships Community partnerships