Abstract
BACKGROUND:
Risk management analysis at work makes it possible to find individual and collective experiences of recognition and hierarchization of risks in view of the specificities of labor situations and the complex and contradictory application of the right to refuse in health work, whose space and technique are still in a deep structural transformation.
OBJECTIVE:
To investigate how work organization impacts on the daily life of nursing care, in a general hospital surgical center, (un)enabling individual and collective risk management strategies in the context analyzed and how the right to refuse can be appropriate as a condition and strategy for work management.
METHODS:
Ergonomics (Work Ergonomic Analysis) was used to bring about the actual work activity and Ergology for epistemological deepening, whose research approach took place in a surgical center with four registered nurses.
RESULTS:
The results reveal that nursing work is invisible and that individual and collective strategies are used to manage the variability and constraints of the environment. The right to refuse is one of the competencies universe strategies conceived and built at work that ensure the realization of the results found.
CONCLUSIONS:
The right to refuse is full of meanings. Refusing does not mean “not doing”, but also to do otherwise, by other means. It is beyond health and security and can be linked to other variables such as quality, environment, social responsibility.
Introduction
The right to refuse dangerous work/serious and imminent risks is one of the most complex topics on occupational prevention and management. It preserves a potential to be understood and energized both by the academic perspective and by the bias of work management practices within the scope of organizations. It is presented by Regulatory Standards (RS; NR in Portuguese) related to occupational safety and medicine in Brazil, as an instrument that ensures the worker to interrupt his/her activities if he/she considers that they involve serious and imminent risk to his/her health and safety (or that of third parties) [1].
In the world, several studies show the mobilizations of the various social actors on the subject and their consequences, reinforcing that any worker who is in a work situation that compromises his/her individual, collective and even environmental health can validate and exercise his/her right to refuse, also called by right of withdrawal [2–4].
The theme is addressed in the United States of America (USA) by the Occupational Safety and Health Administration–Departament of Labor [5], by CGTLABORIT–General Confederation of Labour, France [6], by Canada Labour Code [7], by the Guide to the Occupational Health and Safety Act [8], by Duties and Rights of Workers [9], by Health and Safety Executive [10], by Guia Laboral–La Prevencíon de Riesgos Laborales [11], not limited to those destinations.
According to Amorim Junior [12] the principle of the worker right to refuse to the legal system for the protection of workers’ health and safety in Brazil is important. This principle is a relevant instrument for the protection of workers, and that, the economic inferiority of workers before capital, should not be an impediment to an articulation of mutual interests between safety and production.
According to Hilgert [13] the study of refusal is a study of the challenge, which maintains its importance while recognized and neglected. It is a right that arises associated with the health and safety of people, which refers to other important reflections on the potential that the right to refuse can offer. Why can’t the right to refuse be triggered also to reject activities that could compromise the management of the environment and/or the quality of the products and processes developed by the organization?
After all, thinking prevention strategies implies understanding the multiple variables of work contexts that simultaneously articulate aspects of health and safety, quality of processes and products, the environment and social responsibility [14].
In this context, the article aims to investigate how work organization impacts on the daily care of a general hospital (un)enabling individual and collective risk management strategies in the context analyzed. And considering its complexities and contradictions, how the right to refuse can be appropriate as a condition and strategy for job management, contributing (or not) to this approach.
Methodology
This is a qualitative study, with theoretical and methodological foundation based on Ergonomics (Work Ergonomic Analysis–in Portuguese AET) [15] and Ergology [16]. Through activity analysis, a dialogue centered on the observation and action of the subjects in real and concrete means of work is established, with theoretical and practical determinations that offer resources to understand and solve the real questions found.
It privileges a perspective that focuses on knowledge about the real work situations, the subjects’ conditions under analysis presented and represented in their dynamics, actions, conflicts and decisions. The centrality of human intervention is the factor that allows regular, anticipating or correcting the course of work situations, providing that the results proposed and expected by the organization are effectively realized [17].
The worker is at the center of discussions as a primary element of the identifications of existing problems and as a facilitating and purposeful agent of the solutions of those problems and deviations, based on his/her knowledge, his/her knowledge and doing, on his/her experiences, competencies and skills [18].
Data collection procedure
The research field is the surgical center of a regional hospital located in a city in the interior of the state of Minas Gerais, Brazil, which is a microregional reference in several medical specialties, serving a population estimated at approximately 300,000 inhabitants.
Initially, all the characteristics of the research were agreed with the technical director of the hospital, as well as the details about technical visits and posture and confidentiality criteria. Subsequently, a meeting was held with the technical responsible for the sector, in which it was presented to her and soon after to the collaborators, the Informed Consent Form, ensuring the full knowledge and willingness of those involved. Only after this initial stage the hospital allowed the entrance and data collection. In addition, the study was approved in 2 research ethics committees (tenderer and co-participant), through certificates of Approval and Ethical Appreciation (CAAE 75205517.5.0000.5559 and 75205517.5.3001.5110, res-pectively).
Soon after all the formalization of the technical part, systematic observations were made through the daily follow-up of the hospital sectors, thus knowing the entire work process, service flow and characteristics of the environments in order to define the search site.
The collections occurred between March and September 2018, a total of 120 hours. Through a descriptive and exploratory study, it was possible to understand the various situations experienced in the environment, since data collection occurred in the natural environment, through the monitoring of daily work (field notebook and recordings in transcription of the verbalizations of the workers involved, simultaneous confrontation in certain issues and, later, ordering and study of the points that presented greater relevance.
Posteriori, after a series of visits and contact with the employees, questions focused on the work routine were made, trying to understand the flow of the process and the basis of the places’ routines.
From the entrance into the field, several areas were recognized and understood, considering their aspects and importance for the functioning of the institution as a whole. There is no more or less important area. Various sectors are interconnected and have their importance for the functioning and realization of the desired general results.
The approach developed by identifying the characteristics of the field, in meetings with people in their diverse areas and work shifts, using some guiding questions: What do you do here? How long do you work here? How long do you work as a nurse? What are the relations of this sector with the general organization of the work? What are the prescriptions for the job? How is the work done? What are your difficulties? What kind of adjustments do you have to do? What do you need the most? What do you consider the worst thing in your routine?
The writing of the observations assumed an anthropological bias (privileging the meanings, positions, social roles, culture, meanings of symbols and objects), materialized in a plan of observation (script and field notebook) with annotations of ideas containing the perceptions of the research field triggered by the researcher, associated with the normative perspectives of the institution.
Within the anthropological perspective [19], culture can be read and interpreted from the ethnographic narratives that reveal the meanings of the actions and the actors involved themselves. Thus, a dense description of everything that was observed was promoted, interpreting the discourses of the operators and their meanings. What do people realize at work? What are the daily work discourses? What are your perceptions of work activities? What is most valued? What is less valued (individually and collectively)? What is understood by hazards and risks (threats/opportunities)?
The surgical center is the hospital unit where the surgical interventions of the hospital are performed. Its area consists of rooms, equipment, materials used by the surgery team, with the support of other teams that contribute to the proper functioning of the sector (e.g.: general services, cleaning and hygiene of rooms and throughout the surgical center).
Due to the following criteria, the surgical center was chosen as an area to be researched: a) complexity and interaction with several important areas of the hospital. It is an area that represents centrality in the hospital (sector with higher hospital profit and interfaces with the various other sectors with upstream and downstream impact on the regulations established for necessary health care); b) it associates objective and subjective dimensions on the perception of risks at work.
Within the surgical center, it was chosen for the development of the research, to monitor the activities of the registered nurses–they are on the front line of the surgical center, responsible for all operational part of the sector, which includes the organization of work processes. The participation of the registered nurses in the study took place voluntarily, through each consent and approval, with consequent signature of the Free and Informed Consent Form (in Portuguese - TCLE). General and systematized observations were made at the local level, with the construction of preliminary guiding hypotheses of the subsequent cutouts assumed.
The reasons that determined this choice are the importance of the position for the effective management and outcome of the sector for the hospital analyzed. This position is occupied by four nurses (research population), graduated in Nursing, dividing their activities in the sector on a work shift basis (12×36 hours). Two professionals took turns on a fixed day shift and the other two in fixed night shift.
Regarding the sampling of the research subjects, given the nature of the study, there was a focused concern in the sense of deepening and understanding about the object, understood as an adequate number of observations and interviews capable of reflecting the totality in their dimensions.
Thus, the saturation criterion was observed, in which four registered nurses were observed and interviewed (individually and in groups), who comprised the total population of the analyzed environment, a number, which portrayed the moment when observed the exhaustion of categories in the interviewees’ statements.
Results
In the hospital, the work activity of registered nurses is invisible and complex, with exposure to the various occupational risk conditions. However, there is a centrality of verbalizations in relation to psychosocial risks, that is, the constraints that the current organization of work processes offers, directly impacts on the health and safety of those workers.
This condition causes more than the materialization of occupational accidents, but, daily, silently, those professionals are exposed to events and requirements that can trigger diseases and disorders to their health. The results will be presented by categories a-f.
a) The complexity and invisibility of nursing work
The registered nurses are the professionals responsible for the management, operation and functioning of the surgical center performing the interface with the entire hospital. There are four professionals, women, graduated in Nursing, aged between 25 and 35 years, who take turns, with professional experience and time of work in the hospital over five years.
The routines of the shifts are passed on in the exchange of service (shift exchange), when all occurrences that involved and characterized the work shift are discussed. The night shift activities of the registered nurses include and accumulate responsibilities that are beyond the limits of the surgical center, extending to the management of maternity and pediatrics UMI (Child Maternity Unit), which includes nursery (and children aged up to 13 years).
This night shift routine also involves an administrative part of conference documents completed including by other teams, such as: verification of operating room controls, reports and documents about the surgeries performed, which inform about equipment and materials used; verification of the type of procedures performed and medical reports; analysis of the safe room check-list; verification of the anesthesia sheet; verification of the patient’s hospitalization guide copy; analysis of patient guides (internal and external); verification of the protocol notebook of entry/exit of equipment of the surgical center; verification of intercurrence reports; analysis and review of death records.
The registered nurses routine of the day shift also begins with the exchange between shifts (night and daytime) when all situations and eventualities occurred on the shift are discussed. A series of activities are developed, among which stand out: verification of the case book; beginning of the “Daily Agenda”, when the operating rooms and patients who will enter surgical procedures are organized; completion of the “Sheet of Indicators of Room Occupancy Time”, where the following items of the surgeries that identify characteristics such as the number of the room, the patient, the surgeon responsible, the type of surgery (urgency/emergency), entry time of the patient, arrival time of the surgeon, time of anesthesia application, time of the surgery beginning, time of surgery end, time of anesthesia release, if there was any delay, the reasons for the delay, in addition to a field for presentation general observations.
In addition to those tasks, the registered nurse during the day shift should also carry out the inspection of the various equipment of the surgical center that includes the emergency cart test, the verification of the “almotolia” (plastic container, used in the health area to store alcohol in the asepsis), the operation verification of the “Baby Puff” (neonatal resuscitation apparatus), inspection of the portable charger of the oximeter, verification of the hospital’s video key, verification of the equipment cabinet key, temperature sensor verification, in addition to administering other situations about the surgical center operation.
b) The anticipated advances needed for future malfunction management
The surgery scheduling system determines that the secretary of the surgical center or the physicians concerned should schedule the surgeries directly with the technical responsible nurse of the sector (the manager of the surgical center) or with one of the registered nurses (which become effective responsible for the task).
This process should be carried out using the surgical center’s information technology system. Even if work organization determines that the schedules of the surgeries should be made by the computerized system available, the registered nurses are routinely busy, and cannot interrupt their activities, which end up using the “WhatsApp” app as a management strategy and work organization to schedule surgeries.
All information arrives by “WhatsApp, and this instrument has become a “facilitator”, an ally, a refuge, “freezing” information about scheduling (and even other requests) that will only be accessed when the context of the work situation allow the appointments of surgeries to perform.
c) Standardized security and self-managed security
There is a discourse in the management model and safety of the institution’s work that aims to meet all normative criteria, but there is no formal device that presents the right to refuse as an available management tool so that the worker can formally trigger it.
In the surgical center, safety choices take place in practice (self-managed safety in action), in the actual work activity, more than in the descriptions of procedures and standards. Refusing or not a certain work situation began to be perceived and understood in the analysis and judgment of workers in the face of real work situations.
Opinions and decisions at work circulated through “clandestine” circuits, on the fringes of “official” aspects, but which helped through those margins of maneuvers, build and maintain health at work in addition to obtaining the desired production results.
One patient was sent by the High Complexity Clinic (in Portuguese - CCS) without any information on the characteristics of his/her condition. Even in the face of this situation, he was accepted. This trial took place through the individual and collective competencies of the surgical center team, which defined the choice and path to be followed in that situation.
The registered nurse and her team identified that it was a case of a bacterium that the antibiotic did not fight and that the patient needed a contact isolation. Thus, the specific actions for the situation were provided, combining the prioritization of the collective safety of the surgical center and its other patients, with safety, service and individual care for that individual patient who needed specific care.
d) The risks of work in the surgical center
The risks in the surgical center are associated with the category of biological, chemical, physical, mechanical and ergonomic risks.
But the way the current conceptions of work process organizations (communication, organizational culture, work shifts, team training are willing), directly impact decision-making processes, performance, mental burden, reliability, and in individual and collective stress to which workers in that sector are exposed.
The threats are far beyond the ergonomic aspects associated only with the perspective of biomechanics (excessive physical exertion, inadequate posture, physical arrangements, etc.). It is observed that the greatest threat is linked to psychosocial risks, characterized by working conditions that impact on professionals’ health, causing psychological, physical and social damage, due to the daily tensions experienced.
e) Know/power: Conflict of relations
The surgical center presents some very important peculiarities: it is based on the relationship of care (person-person interface), highly specialized services, use of high technology, diverse dimensions and roles (social, economic, political and scientific).
The surgical center includes several professionals (physicians, nurses, nutritionists, pharmacists, administrators, maintenance technicians, cleaning team, etc.), multiple services and specialties, technological development. In this context, the almost absolute power of the medical body is integrated, which has effective control of activities purposes, power and authority are not governed only by rules, but because specific technical knowledge.
The tensions of a group and professional nature that occurred in the surgical center involve the doctors themselves who become difficult professionals to work with. Due to their training that involves decisions about life and death, they have difficulty dividing power, listening to recommendations and suggestions, and even dealing with disciplinary regulations and rules. There are tensions related to the conflicts between the power of physicians and individual interest stemming from other actors working in the sector.
f) Cooperation and trust
However, even in the face of some stress frameworks involving part of the actors working in the surgical center, there are also social relationships between other team members who are centered on collective solid bases of cooperation and trust responsible for positive results in the work processes.
The commitments between workers, mutual care, collective arrangements, are the elements that integrate solidarity between operators and their working groups. An example of this mobilization and collective cooperation was revealed in the process of releasing a post-surgery room that would receive a new surgery in sequence.
The surgery patient who was in finalization was directed to the post-surgical recovery room, the materials used were collected and disposed of appropriately. Cleaning and hygiene were performed, the pharmacy staff collected the materials and resubmitted a new pharmacy according to the future surgery that would be performed. The scrub nurse removed only the material that was used, led to the purge and reputed the necessary materials for the new surgery.
The entire team (cleaning, pharmacy, scrub nurses, nurse assitants, nurses) organized and prepared the room, and, in 15 minutes, was ready, prepared and made available.
Discussion
Nursing work is full of complexities, often invisible and misunderstood by those who organize work processes. This invisibility is mainly due if the perspective of work organization considers only the approach of previous planning of the task, which preconditions the means and results intended, disregarding the variability that the environment and the work activity itself offer.
The work planning however best it is elaborated, cannot recognize and anticipate all variations, unforeseen events, events and real-time situations that occur within the dynamics of work activity. Therefore, the importance of workers who become agents capable of regulating those differences by providing the effectiveness of the desired results [20].
Those elements not always predictable in their entirety require interventions and follow up by registered nurses to be administered and resolved. There is a distance, a gap between what is planned by the organization and administration of work (task) and the effective demands found in the actual work situations (activity) [21].
Unforeseen situations, events, breakdown of planning, require interventions, to make use of themselves to regulate constraints at work. This in turn produces new events and consequences that transform relations with the means of work and social relations between people again. It is necessary to know those constraints that plague daily workers lives, understand them, and thus elaborate new forms of management and organization of work that favor workers actions [22].
According to Mullen, Gillen, Kools and Blanc [23] the perspectives of nurses with work-related injuries, obstacles and motivations for return to work, the consequences of injuries and the impacts produced in their lives are influenced by personal conditions, costs and losses, impacts on workers’ pay. Those considerations and knowledge can help hospital management promote a more effective return of workers and develop prevention strategies for accident reduction.
In the surgical center, registered nurses are exposed to various types of risks, but the psychosocial risk category is central in the daily lives of those professionals. Working conditions, relationships between workers, relationships between workers and users, daily tensions experienced, constraints, organization and work management, all this can cause significant psychological, physical and social damage [24].
In this context, there is not necessarily the materialization of accidents, but there is illness. Occupational diseases caused according to this organizational arrangement may manifest themselves in the present or future of the life of that worker who is in daily business. The impossibility of saying “no” harms health. The risk of not saying “no” is sick. The impossibility of not having leeway to manage the work, acting, deciding, improvising, can produce illness [25].
Workers promote the necessary anticipations, manage the malfunctions of the system, act within the possibilities and compatibilities of the present moment. The question that presents itself here is not to state that the registered nurse has failed to comply with a work procedure, that her action refers to error or guilt. The premise of Ergology and Ergonomics are associated with the commitment to understand the real work situations, identifying their gaps and proposing their transformation in order to continuously adapt and improve conditions and outcomes [26].
The operating in activity constantly performs arbitrations through more or less conscious, individual and/or collective criteria, which allow simultaneously to obey and transgress a work procedure.
They are micro choices made in work activity in the dramatic use of themselves [27].
What is perceived is a work organization model that does not understand the existence of some limitations in its current stage. Those days, the use of “WhatsApp” as a work tool is a reality in many locations. But some conditions need to be recognized: the “WhatsApp” that registered nurses use are of personal use, privately owned, which allows several reflections on this situation. Work invades the privacy of those professionals, who, committed to their performance and results, start to develop strategies that occupy part of their personal lives.
A model of surgery scheduling management system is offered by the hospital. However, work daily business, the system appropriation is not enough to help manage all the dynamics that context and reality offer. In the absence of a work organization that understands the characteristic dynamism that the actual work activity of registered nurses faces, it is necessary to develop alternative strategies produced by those who experience daily work [28].
The refusal in this case was revealed not to fully use the operational system of scheduling surgeries offered by the hospital, in doing differently than is offered, than is official, because this model limits the actions and consequently the results in the work of the registered nurses. For this reason, the use of “WhatsApp” has become an important tool capable of assisting in job management and problem solving.
Innovative work organization models simultaneously combine normative aspects with practical elements linked to workers’ experiences and knowledge. Combining those two perspectives between Normative Security and Self-Managed Security (or safety in action) is a fundamental prerogative for advances in several work-associated variables [29].
The conceptions of work organization in the hospital, especially linked to the surgical center, can unite those two premises. Some gaps linked to regulatory aspects on work management and workers’ health and safety were identified. Some basic aspects involving mandatory normative items can be reviewed or implemented in the hospital sectors, contributing to alignment and compliance with mandatory regulatory requirements [30].
The right to refuse dangerous work/serious and imminent risks should be more than a mandatory regulatory requirement but a strategy for managing and organizing work processes. In terms of prevention, it is necessary to meet the normative requirements, but it is necessary to go further, taking advantage of the opportunity that the knowledge of the experience of workers provide producing more significant positive results in the most diverse aspects of the work [31].
Nordlöf, Wiitavaara, Winblad, Wijk and Westerling [32] investigated crop and risk safety in Sweden using interviews in worker focus groups with their experiences and perceptions about risks and safety in the steel manufacturing industry. The results highlighted that it is necessary to accept the risks at work; whereas there is an individual liability for risk; there is a conflict of interest between production and security; good communication is fundamental to the results; daily situations, occurrences, unforeseen events affect the development of work.
According to Kristina, Mikael and Teresia [33] the duties of risk assessment in Ergonomics have a reactive bias and that interventions are rarely evaluated. There is a lack of systematic approaches in risk assessment in Ergonomics, with reduced rates of use and knowledge of those risk assessment tools.
The current conception of work organization in the hospital can benefit from the association between the perspectives of standardized safety and self-managed safety. It is necessary to improve the normative requirements met and adapt those that are pending, always considering the articulation of the knowledge of norms with the knowledge of the experience [34].
In the surgical center, psychosocial risks assume a central meaning, because they are characterized by working conditions (relationships between workers, organization and work management) that impact the professionals health, can cause psychological, physical and social damage, due to the daily tensions experienced. For the understanding of those contexts, it is important to associate approaches that favor the analysis of subjective and mental elements, elements capable of offering an understanding of the real constraints that work activity offers [35].
Stress, tiredness, depression, difficulty concentrating, lack of motivation, are associated with this type of risk that should not be ignored by those who are responsible for organizing work processes. How this impacts the personal and professional lives of workers who are in those contexts is one of the central challenges for the management of risks at work [36].
According to Frögli, Rudman, Lovgren and Gustavsson [37] the relationship between the problems of tasks domain, social acceptance and the clarity of roles, are elements that explain the symptoms of wear of nurses during the first years of profession. An intervention designed to support the development of socialization processes can be effective in preventing burnout symptoms among new nurses.
The materialization of this risk in workers’ health may be beyond the materialization of an accident. For example, due to the tiredness caused by the work routine, a nurse can get hurt with a piercing-cutting and characterize a classic work accident. But it is also necessary to consider that a poorly crafted work process organization can require a lot from the worker, putting him/her on the limit of his/her abilities, and over time, this will have a negative effect that can become an occupational disease [38].
Life inside and outside work is now achieved. Social, personal, family, professional relationships are exposed to the effects of those contexts. The health professional in his/her activity begins to compose strategies that simultaneously meet the desired productive results, having as main objective to maintain, care and build patients health under their responsibility and also their health that should be conserved in the exercise of their profession [39].
The strategies (individual and collective) necessary to ensure patients’ health, ensure the health and safety of the professionals work in health services, produce results in the quality of products and processes, neutralize negative environmental impacts, and in order to maintain the ability to continuously improve the organization of work processes are elements that circulate through the work universe, which are inserted in models of work organization with characteristics capable of contributing for the suffering of workers [40].
Although technology has significant importance within the hospital context, it is in the relationship between human beings that the dynamicity of the whole system is effective, it is being besieged by a mosaic of fiefdoms [41] - each compartmentalized/segmented knowledge in its space - however, that it is shared by a common relevance, such as assistance to a patient who requires collective action [42].
The doctor has effective control of the organization’s activities [43, 44]. The tensions of a group and professional nature that occurred in the hospital involve the doctors themselves who become difficult professionals to work with. Due to their training that involves decisions about life and death, they have difficulty dividing power, listening to recommendations and suggestions, in dealing with disciplinary regulations and rules [45].
Even with the evolution of hospital organizations, the power of the doctor still prevails, whether in relations with other health professionals, or in relationships with hospital administrators (including medical owners), causing conflicting relationships between those involved. The main characteristic of conflicts refers to the perception of the superiority of physicians in relation to other professionals [46].
The registered nurses established a relationship of trust with their teams, regardless of the hierarchy. The committed team is fundamental to achieving the expected results, and without this relationship of trust and cooperation this would not be possible. They are relationships built based on respect, consideration, overlapping the relationship between leadership and subordinate.
There is a collective of work based on the good relationship between teams, with implicit rules, codes and reasons, with strategies of anticipation of problems, mediated by interventions that regulate the asymmetries of work processes, neutralizing the effectiveness of unwanted events. This collective is governed by individual and collective competencies, which add competence ingredients, factors responsible for the good results produced [47].
During the preparation activity of the surgical center, the ingredients of competence at work are now constituted. Those ingredients align with characteristics that include the broad dominance of teams over work protocols, the relative incorporation of the work situation history, the ability to manage the unique dimension of those situations, in the relationship between the person and the means of work in which they must act, in the debate of existing individual and collective standards and values, thus promoting a synergy of skills in working situations [48].
Working as a team is summarized in the understanding that all people have different stories that need to be respected, understood, and articulated with each other. Collective work supposes a synergy between those different ingredients, linking people with different profiles and stories, working together, without artificial hierarchies [49].
Solidarity develops through collective knowledge built at work. Sharing difficulties, sorrows, joys, choices, values, solutions, all of this underpins the consolidation of an effective collective of work, centered on trust, dialogue and frankness. Harmony, balance and respect provide the basis of good relationships, capable of managing difficulties at work. With rules, codes and reasons of their own and implied, anticipations, interventions, solutions and administration of the entire work process is incorporating into the daily lives of those workers, and offering the possible exits to their problems [50].
Conclusions
The results proved the existence of a certain degree of invisibility and lack of knowledge on the part of work organization about the real work of registered nurses and teams, characterized by a serious number of requirements and constraints which challenge health professionals on a daily basis.
For this reason, individual and collective strategies that are beyond the operational work procedures are built and developed by those professionals who incessantly seek to solve their daily challenges. Among the strategies conceived, we highlight the right to refuse as an instrument and perspective capable of assisting the administration of the variability of work processes, managing health and safety risks, promoting the quality of products and processes, and, preserving the environment.
The right to refuse appears as a polysemic expression, composed of many senses, variable in intensity and use in the various areas of knowledge. Refusal is also associated with the quality of a work provided, ensuring that positive results linked to other work variables are obtained. Refusing does not mean “not doing”, but also doing otherwise, otherwise, by other paths, sometimes distinct from the previously determined guidelines, but always with the commitment to realize the expectations of the various variables that composes the perspective of production and organization of work.
Conflict of interest
None to report.