Changes In Nursing

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					                                                                                                                            Short communication

A comparative analysis of the changes in
nursing practice related to health sector
reform in five countries of the Americas
Edilma B. Guevara1 and Elnora P. Mendias1

                                       ABSTRACT           Objective. To identify changes in nursing practice and the nursing-practice environment that
                                                          have occurred with implementation of health sector reform in five countries in the Americas.
                                                          Methods. An exploratory study of selected settings in Argentina, Brazil, Colombia, Mex-
                                                          ico, and the United States of America was conducted between 1997 and 1999 to collect narra-
                                                          tive data from 125 professional nurses about their perceptions of nursing practice and changes
                                                          in work environments. Descriptions of characteristics and trends in nursing practice in the
                                                          study sites were also obtained.
                                                          Results. Reorganization of health services has occurred in all five of the countries, respond-
                                                          ing to health sector reform initiatives and affecting nursing practice in each country. Respon-
                                                          dents from all five countries mentioned an emphasis on private enterprise, changes in payment
                                                          systems for patients and providers, redistributions in the nursing workforce, changes in the
                                                          personnel mix and nursing-practice functions, work shifting from the hospital to the commu-
                                                          nity, and greater emphasis on cost control and prevention in practice settings.
                                                          Conclusions. The study provides initial information about current nursing issues that
                                                          have arisen as a result of health care reform initiatives. Regardless of differences in service
                                                          models or phases of health sector reform implementation, in all the countries the participating
                                                          nurses identified many common themes, trends, and changes in nursing practice. The driving
                                                          forces for change and their intensity have been different in the five countries. Nurses maintain
                                                          their core values despite increased work stress and greater patient care needs in all the coun-
                                                          tries as well as economic crises in the Latin American countries.

                                       Key words          Health care reform, nursing, hospitals, health manpower, delivery of health care.

  Improvements in the health status                       tion health status influences the devel-                This perspective has served as the
of a population are affected by social                    opment of maximum human capacity                      basis for market-driven health sector
and economic factors and by develop-                      and productivity. Therefore, the provi-               reform. However, this philosophical
ment in areas such as urbanization,                       sion of health services may be consid-                shift and its focus on market concerns
employment, nutrition, education, and                     ered an investment in human capital                   has resulted in limited consideration
environment (1). Moreover, popula-                        and a crucial factor for countries’ be-               of other aspects such as the needs for a
                                                          coming and remaining competitive in                   socio-environmental framework for
1   The University of Texas Medical Branch, School of     a global economy, according to a con-                 analyzing health status and for hu-
    Nursing, Galveston, Texas, United States of Amer-     ference paper by Barillas.2                           manistic approaches to empowering
    ica. Send correspondence to: Edilma B. Guevara,
    University of Texas Medical Branch, School of                                                               both health care providers and health-
    Nursing, 301 University Boulevard, Galveston,         2   Barillas E. Health care reform: global economic   system clients.
    Texas 77555-1029, United States of America; tele-         and social trends [conference paper]. The Third
    phone: (409) 772-5029; fax: (409) 772-5864; e-mail:       Millennium Conference, 16 May 1996, Galveston,
                                                                                                                  Health sector reform, in various                                         Texas.                                            forms, has affected all aspects of health

Rev Panam Salud Publica/Pan Am J Public Health 12(5), 2002                                                                                            347
care delivery: objectives, administra-        ticipating countries. Additional data                addition, health service reorganization
tion, organization, outcome measure-          on external factors (country character-              was characterized using the health
ment, and payment systems. Nursing            istics) and internal factors (site charac-           care reform indicators in the Barillas
personnel and nursing services have           teristics) were used to assess the com-              conference paper mentioned earlier.
been considered the target and means          parability of the study sites.
both for cost containment and for                After study approval by the Institu-
quality improvement (2). Nursing per-         tional Research Board at the Univer-                 Data analysis
sonnel comprise a large percentage of         sity of Texas Medical Branch and insti-
health care personnel, and changes in         tutional review committees at each                      The research team in each country
health care organization have altered         participating institution, researchers               was responsible for the analysis of
nurses’ practice and work environ-            used a purposive sample approach to                  its own data, using the standardized
ments. Nurses have had limited partic-        obtain a sample of at least 10 profes-               protocol. Data analysis techniques
ipation in the decision-making on the         sional nurses working at participating               included content analysis, constant
reorganization of their services. Thus,       institutions in each country. (Purpo-                comparison, and unitization and cate-
it is vital to obtain more information        sive sampling is commonly used in                    gorization of emerging themes as a
about how health sector changes are           qualitative research and involves se-                means to define category labels and
influencing nursing practice, decision-       lecting subjects considered typical of               generate each country’s definition of
making, and regulatory mechanisms.            the study population (12)). After ob-                nursing practice.
   Although much has been written             taining informed consent, researchers                   According to Lincoln and Guba (13),
about health care reform, little is           interviewed participating nurses in                  evaluation of the trustworthiness of
known about how nurses’ practice and          depth at least once to obtain narrative              qualitative findings may be conducted
work environment have changed since           data on their perceptions of nurses’                 using four indicators: credibility,
the reorganization of health care sys-        practice and work environments as                    transferability, dependability, and
tems in the 1990s. One urgent need is         well as descriptions of nursing-prac-                confirmability. Credibility was ad-
the identification of relevant concepts       tice characteristics and trends. Inter-              dressed through peer debriefings in
and variables related to current nurs-        views took place in private in the facil-            two ways: 1) frequent researcher con-
ing practice and work environments,           ities where the nurses were working.                 sultations with the project’s principal
as an initial step in the description of      Researchers used a standardized pro-                 investigator and 2) two researchers’
the nature, extent, and magnitude of          tocol to apply a structured interview                meetings. Transferability or generaliz-
these changes. In addition, there is a        guide. The interview guide included                  ability of findings was achieved by
need to develop cross-cultural instru-        questions related to 11 areas, including             identifying rich segments of data com-
ments to study current nursing issues.        participants’ perceptions about defini-              mon to all the countries and establish-
To address these needs, an exploratory        tions of nursing practice and the social             ing inter-country agreements about
qualitative study was designed to ob-         value of nursing, nursing functions                  themes. Dependability (stability of
tain a current cross-cultural view of         and roles, recent changes in nursing                 findings) and confirmability (neutral-
nursing in selected health settings in        practice and the practice of other                   ity) were achieved by using an audit
five countries of the Americas and to         health care workers, reasons for recent              trail. To ensure consistency of method-
provide information about current             changes, the effect of those changes on              ology and confirmability of narrative
trends in nursing practice, education,        nursing practice and patient care,                   data, a sample of transcripts (trans-
and regulation. This paper presents a         nursing decision-making, and the fu-                 lated into English) was reviewed by an
cross-country summary of findings             ture of nursing. Interviews were au-                 expert in qualitative data analysis.
reported by researchers in each of the        diotaped, then transcribed verbatim.
five participating countries: Argentina,         Naturalistic inquiry methodology
Brazil, Colombia, Mexico, and the             (13) was used to collect and analyze                 RESULTS
United States of America. The study           the narrative data in each country. The
framework (3, 4) and the individual           goal of naturalistic inquiry is not to               Study population
country studies (5–11) have been pub-         generalize findings but to present a
lished elsewhere.                             view of the phenomenon as perceived                     The study population included a
                                              by participants and researchers.                     total of 125 practicing professional
                                                 Goins’ Paradigm of Dynamic Inter-                 nurses as well as other health profes-
MATERIALS AND METHODS                         action (3) was used as the framework                 sionals, who were interviewed at se-
                                              to characterize the study sites’ internal            lected institutions. Included here are
   This multicenter study used a quali-       environment (money, manpower, ma-                    results from 20 nurses from Córdoba,
tative approach to identify changes in        terials, facilities, and equipment) and              Argentina; 42 from Ribeirão Preto,
nursing practice and the nursing-prac-        external environment (social, techno-                Brazil; 10 from Antioquia, Colombia;
tice environment since implementa-            logical, economic, ethical, political,               20 from the state of Mexico, Mexico,
tion of health sector reform in the par-      legal, and environmental aspects). In                and 16 from the state of Nuevo León,

348                              Guevara and Mendias • Changes in nursing practice related to health sector reform in five countries of the Americas
Mexico; and 17 from the state of Texas,               maintained. Varying degrees of tech-         specific basic package but has imple-
United States. The researchers in each                nology were found in public hospitals,       mented a number of health programs
country described the characteristics                 ranging from state-of-the-art technol-       with similarities to basic packages, in
of the nurses whom they interviewed.                  ogy in the United States to limited          that comparable services and popula-
                                                      technology in the other four countries.      tions are identified.3 The trend in all
                                                      Private facilities were well equipped,       the countries was to encourage pre-
Structural characteristics                            including with equipment for high-           ventive and health promotion services.
                                                      tech procedures.                                Targeted populations in all the coun-
   Structural characteristics are sum-                                                             tries have included the indigent and
marized using Goins’ Paradigm of Dy-                                                               uninsured. Women and children have
namic Interaction (3), which includes                 Reorganization of health services            been considered high-risk groups in
such institutional resources as man-                                                               Argentina (5), Brazil (14), Colombia (7),
power, money, materials, facilities,                     Health services had been reorga-          Mexico (15), and the United States.3
and equipment. Researchers in all the                 nized in all five countries in response to   The elderly have been targeted in
countries had difficulty obtaining spe-               health care reform initiatives. Those re-    Brazil (6), Colombia (14), Mexico (15),
cific information about financial and                 form initiatives are summarized below,       and the United States (16). Specific ser-
material resources at the study sites. A              using Barillas’ health care reform indi-     vices have been targeted to indigenous
mix of private and public funding ex-                 cators, which include decentralization,      groups in Brazil (17), Mexico (15), and
isted in all the study sites. In all five             self-initiatives, changes in private and     the United States (18).
countries, federal, state, and municipal              public funding, basic health packages,          In summary, the study sites ap-
governments funded public hospitals                   and target populations (4).                  peared to differ in the characteristics of
and clinics. Private services used insur-                Decentralization has occurred in all      the populations served and the extent
ance, prepaid, or fee-for-services plans.             five countries, with a shifting of con-      of health care reorganization. These
   Reflecting regional trends, with the               trol from federal to state and local lev-    facts were considered in interpreting
exception of the United States, most of               els (5–11).                                  and comparing the study findings.
the study sites had a low percentage of                  Self-initiatives are efforts directed
nurses as compared to nurse auxil-                    toward increasing management capa-
iaries or nurse’s aides. The proportion               bility and decision-making at the state      Changes in nursing practice
of nurses with a baccalaureate degree,                and local levels (4). Self-initiatives fo-
which requires four to five years of                  cusing heavily on institutional financ-         The study’s data analysis included
full-time university education, was                   ing have been a by-product of compe-         identifying major thematic areas re-
low in all the countries except the                   tition between the public and private        lated to changing nursing work en-
United States. In the four Latin Ameri-               sectors in efforts to control costs or       vironments and responsibilities. Even
can countries, public institutions re-                to subsidize health services for the         though the characteristics varied
ported a higher percentage of bac-                    underserved. In all the countries, self-     among the study sites, we identified
calaureate-prepared nurses than did                   management has allowed public                several common categories of recent
private facilities. One reported trend                health institutions to charge for health     changes in nursing practice.
was a decreasing number of nursing                    care services that they provide to the
personnel. Another trend was short-                   members of private health care plans         More work in less time with fewer
term contracting of nursing personnel                 or of other plans.                           staff. Some nurses mentioned a de-
to work in specific programs or proj-                    A mix of private and public funding       crease in the nursing workforce, differ-
ects, instead of hiring them for stable               for health care existed in all the study     ent duties, extended use of auxiliary
full-time positions. Salaries had been                sites, with private financing exceeding      personnel, or reductions in other job
diminished or frozen in Argentina and                 public financing. The level of private       positions that impact nursing tasks.
Colombia.                                             financing ranged from 53% in Mexico          Specific comments included: “There is
   Although there were some varia-                    (8) to 70% in Colombia (7).                  an immense accumulation of work,”
tions and some missing data across the                   Basic health packages are selected        “There is more pressure on everybody
countries, in comparing private and                   health services that are designated          to do more with less,” and “There
public settings, the study found that                 as the minimal health services for a         seems to be less time and less staff. My
public sites were more likely than pri-               targeted population. The four Latin          workload is greatly increased, and
vate sites to report insufficient materi-             American countries had identified            there is no one to help me.”
als and supplies. The renovation and                  basic packages, which usually in-
maintenance of public hospitals varied                cluded preventive health and health
within all the countries, but it tended               promotion services for vulnerable
to have decreased in all the countries                populations such as women and chil-          3   Goins PN. US STEEPLE framework. Paper pre-
                                                                                                       sented at Pan American Health Organization Re-
except the United States. Private sites               dren, the elderly, and the poor (5–10).          searcher Group, University of Texas Medical
were reported to be adequate and well                 The United States has not designated a           Branch, March 1998, Galveston, Texas.

Rev Panam Salud Publica/Pan Am J Public Health 12(5), 2002                                                                                       349
More paperwork. Nurses reported               ing education and to be up to date in all            work, administrative duties, and fewer
having to do large amounts of paper-          theoretical and practice aspects; [every-            nursing personnel.
work as well as performing responsi-          thing is] an innovation.”                               In Mexico the themes included
bilities once assigned to others. One                                                              decreased time for care, heavy work-
nurse commented, “No one has picked           Clients who are more informed, edu-                  loads, low salaries, increased respon-
up any of my responsibilities.” An-           cated, and demanding. Nurses ex-                     sibilities, too few nurses to meet in-
other nurse said, “We have picked up          pressed the need to be more knowl-                   creased service demands, increased
more of what different people used to         edgeable about disease processes and                 paperwork, and more technology.
do.” In addition, the amount of paper-        about sophisticated technology, to re-                  The themes in the United States in-
work requested from the clients has           spond to both market demands and                     cluded doing more with less, heavy
complicated the health care system, in-       population characteristics. One nurse                paperwork, more time spent manag-
cluding the delivery of nursing care.         said: “People are starting to under-                 ing and less time spent providing di-
                                              stand their values and needs. They are               rect care, more time directing the work
Less direct patient care. Nurses men-         more demanding. He [the patient]                     of unskilled staff, insufficient supplies,
tioned increased workloads affecting          knows what he wants and can get.                     and managed care. Nurses indicated
their practice, including reduced time        More access to information is making                 that managed care dictated reim-
for direct patient care despite in-           an internal revolution.”                             bursable services, which increased
creased patient acuity. For example,                                                               nurses’ time spent in completing pa-
one nurse said, “Now we have fewer                                                                 perwork and in documenting clients’
nurses to take care of an increasing          Changes in the nursing work                          health needs, which were needed to
number of patients who are coming in          environment                                          ensure reimbursement. Also, restric-
worse conditions, poorer, and with                                                                 tions on reimbursement for supplies
more serious deterioration in their per-      Dominant themes in each of the                       and equipment affected client care.
sonal appearance and nutrition.”              countries. The study identified domi-
                                              nant themes in work environment
More administrative duties. Nurses            changes in each country.                             Common categories of factors
cited increased administrative respon-           In Argentina these themes included                affecting nursing work environments
sibilities. “There is a big change,” one      increased workloads, decreased job
nurse said, “and responsibility has in-       security, insufficient supplies, low                   The study also identified common
creased. You have to supervise several        salaries, increased demand for techno-               categories of factors affecting nursing
workers now.” The need for self-              logical knowledge, and the need for                  work environment across the countries.
financing also affects nursing and            nurses to hold two jobs in order to
nurses’ administrative duties. One            support their families.                              Insufficient resources. Nurses men-
nurse reported, “We have to imple-               Themes in Brazil included redirec-                tioned insufficient resources for ade-
ment a billing system for the commu-          tion of resources, supplies, and tech-               quate patient services. One nurse said:
nity activities in order to obtain finan-     nology from hospital to ambulatory                   “Materials are much scarcer. They de-
cial resources.”                              care; the need for a more cohesive                   mand a series of things, but the ele-
                                              workforce, in which interaction and                  ments are not provided to accomplish
Increased demand for technological            communication among various disci-                   them. The only thing that this creates
knowledge. Nurses in all five countries       plines are facilitated; increased service            is chaos within personnel of the entire
felt a demand for knowledge based on          demands, with greater client needs                   health team.” Another nurse said:
technological advances and new work           and fewer nursing personnel available                “Sometimes we do not have anything
settings, as well as administrative ex-       to meet those needs; increased work-                 to work with. There are no disposable
pectations for continuing professional        loads; job dissatisfaction among hospi-              materials, clothing, medicines, but
growth. Some nurses mentioned the             tal nurses; low salaries; the need to                they put in the latest-generation de-
impact of computers. One nurse com-           hold two jobs; more paperwork in pri-                vices.” Nurses in some countries com-
mented, “Doctors and nurses are using         vate institutions; and reduced supplies              mented that patients are expected to
Windows 95 [computer operating sys-           and equipment in public hospitals.                   provide their own syringes or other
tem], and we have to get into the com-           Among the themes in Colombia                      supplies, occasionally resulting in a
puter all the time, to check out orders       were increased workload, fragmented                  crisis. According to one nurse, “There
and do chart checks that way.” An-            services that decrease health care                   was a period of big crisis when a
other nurse commented, “You have to           continuity, insufficient numbers of                  mother gave birth to a baby without
keep up with computers and the other          nurses, poor work conditions, low                    anything in which to dress the baby.”
changes that are occurring in medi-           salaries, and job dissatisfaction. An-
cine.” Nurses also mentioned educa-           other theme was having less time                     Lack of service availability. Restric-
tional expectations. One nurse said,          to spend providing nursing care to                   tions in service provision were also felt
“They are pushing us to have continu-         clients, due to such reasons as paper-               to be a problem. One nurse said,

350                              Guevara and Mendias • Changes in nursing practice related to health sector reform in five countries of the Americas
“Sometimes it is hard to explain [to pa-              tions. In the United States, nurses            agement] responsibilities delegated to
tients] that there are no openings that               mentioned concerns related to unli-            us; they take up a lot more time.” An-
day for them to be seen.” Another                     censed or uncertified personnel, who           other nurse said: “We’re doing more
nurse said: “[At night] the medical                   needed more supervision and training           paperwork and a lot less patient care. I
clinic is closed, and no patients can be              to ensure nursing quality. “More pa-           don’t enjoy it like I used to.”
accepted. Where do these patients                     tients come in,” said one nurse, “and
go?” A third nurse commented, “There                  we are not hiring any more nurses.”            Malpractice concerns. Legal and ethi-
are times when we cannot accept more                                                                 cal concerns are reflected in nurses’
people, as we are full.”                              Inter-institutional migration or per-          comments about new or strengthened
                                                      sonnel transfers. Nurses moving from           malpractice worries. Said one nurse:
Stressful conditions or work-related                  one institution to another, due to             “The voluminous load of paperwork
stress. This lack of service availability             increases in salary and improvement in         takes you from the patient. You can’t
created stress for both nurses and pa-                working conditions at the community            get to the patient. We who are the best
tients. One nurse said: “People are                   level, was observed in Brazil. In              prepared for patient contact have the
being turned away and they don’t even                 Colombia, inter-institutional migration        least patient contact.” Nurses in Co-
have access to the care of the nurses                 was generated by the creation of empre-        lombia reported practicing “defen-
or physicians because they can’t access               sas sociales del Estado (State social enter-   sive care” because clients are more
us. Once they do get through, they                    prises), a kind of third-party system.         demanding and can more easily sue.
are angry.” Another nurse reported:                   Personnel in Colombia were also being
“Sometimes the patient says he is going               transferred from community settings            Changes in practice settings. Nurses
to a radio station to complain [about                 to tertiary care institutions. Personnel       discussed a number of changes in their
lack of service], and they really call the            transfers also occurred in Argentina           practice settings or work environ-
radio stations! This is really stressful.”            and in the United States, with nurses’         ments. In Colombia, there was de-
One nurse said that patients may feel                 work environments increasingly shift-          creased emphasis on disease preven-
that “we really don’t care that much                  ing from inpatient to outpatient or            tion and health promotion programs,
about them, because we just don’t take                community settings. In Argentina, new          increased emphasis on hospital care,
enough time to spend with them and                    legislation has allowed the transfer of        and decreased emphasis on working
really know what is going on.”                        health workers from provinces to mu-           in the community. In contrast, disease
                                                      nicipalities, with a decreased number          prevention programs have been ex-
Job dissatisfaction. Some nurses re-                  of work hours and lower salaries (5).          panded in Brazil, with increasing em-
ported conditions leading to job dis-                                                                phasis on community work and de-
satisfaction, such as with salaries not               Flexible employment contracts.                 creasing emphasis on hospital care.
being paid. “Some think,” said one                    Nurses noted changes in employment             Home care has increased in the United
nurse, “that because they make less                   contracts and job stability, including an      States and in Brazil.
money, they should not work as hard.                  increased number of nursing person-               Other changes in nurses’ work en-
[Delayed worker payment has created                   nel without a definite contract, with a        vironments included organizations
conditions where] several workers on                  part-time contract, or contracted by           shifting their mission from service to
the nursing and medical staff wanted                  projects or programs. A decrease in            enterprise due to serious financial
to stop working. This interferes with                 employee benefits was also reported.           problems, changing emphasis from an
our routine and harms the patient.”                                                                  individual model to a family-based
                                                      Discrepancies among educational                model, emphasis on prevention or ter-
                                                      preparation, job titles, and work roles.       tiary care, and stressful work environ-
Changes in the labor market                           Some nurses reported administrative            ments. With the exception of Colombia,
                                                      reorganization and changes in job titles.      health services have moved from insti-
   The study also identified common                   Some nurses mentioned reporting to a           tutional to community settings. Coun-
trends in the labor market of the par-                non-nurse. One nurse said, “Now we             tries have experienced increased acuity
ticipating countries.                                 have an administrator with no nursing          in hospitalized patients and increased
                                                      background, just in administration-            service demand due to coverage ex-
Changes in the nursing workforce.                     level management.” Reductions in cler-         pansion (because of universal coverage
Nurses mentioned fewer nurses em-                     ical positions and in other staff resulted     in Latin American countries), along
ployed, different duties, the extended                in nurses adding duties previously             with greater emphasis on cost control.
use of auxiliary personnel, and reduc-                done by others, such as making ap-             Payment systems for patients and
tions in other job positions that impact              pointments and referrals, receiving            providers have changed, with empha-
nursing tasks and job security. In Ar-                linens, and managing patient trans-            sis on reimbursement, stricter reim-
gentina, Brazil, and Colombia, con-                   portation. In the United States, nurses        bursement requirements, and strate-
cerns were related to reductions or                   reported increased job responsibilities.       gies such as managed care. Short
freezes in the number of nursing posi-                One nurse said, “We have more [man-            hospital stays are common. In addition,

Rev Panam Salud Publica/Pan Am J Public Health 12(5), 2002                                                                                351
administrative changes have included                   to new varieties of health personnel,                vided by nurses, and how this is affect-
the use of organizational matrices, in                 and become more flexible regarding                   ing care of the population. Given factors
which nurses appear to report to more                  organizational changes.                              such as the aging of the nursing work-
than one supervisor or to have respon-                    The nursing labor market reflects eco-            force in most of the countries studied,
sibilities for more than one area; redis-              nomic trends across the countries to                 the insufficient resources, and the job
tribution of nursing resources; and                    varying degrees. Nurses in the four                  stress and dissatisfaction, there is a need
focus on interdisciplinary teams.                      Latin American countries reported their              to study nurses’ working environment.
                                                       practice was affected by changes in labor            Educational issues warranting future
                                                       contracts. The influence of the economic             research include the need for initial and
CONCLUSIONS                                            crisis on health service was more evident            continuing education and for retraining,
                                                       in Argentina than in any other country,              in order to deal with changes in health
   Although health care reform has                     and Argentine nurses reported the need               knowledge and technology, nursing
been implemented in the four Latin                     to hold two or three jobs in order to sup-           roles, nursing-practice sites, and ethical
American countries included in this                    port their families. This trend was also             and legal concerns. Further study is
study and, to a certain degree, in the                 present in Brazil, Colombia, and Mexico,             needed to update information about
United States, reform modalities and                   although to a lesser extent.                         nursing-practice regulation. These stud-
the extent of reorganization have var-                    In summary, nurses report changes                 ies would provide vital information for
ied greatly. Our study results are con-                in their practice and work environ-                  planning nursing systems adjustments
sistent with other current knowledge                   ments as well as in health service or-               that best meet population needs and
about health care reform in the study                  ganization, population characteristics               health service reorganization demands.
countries. Nevertheless, the intensity                 and needs, and structural characteris-
of changes has varied among the coun-                  tics. Current nursing practice is chang-               Acknowledgements. We extend
tries, as have some of the driving                     ing as the work environment is chang-                our thanks to these individuals at the
forces for change.                                     ing, making us wonder: Where do we                   following institutions: Pan American
   In relationship to nursing practice,                go from here? From a larger perspec-                 Health Organization (PAHO): Maricel
the study identified a large number of                 tive, does the market-driven reorgani-               Manfredi, Pedro Brito, Sandra Land,
common themes and trends shared by                     zation of health services conflict with              and Edgar Barillas (PAHO consul-
the five countries. In general, nurses                 the essence of nursing, which is car-                tant); the University of Texas Medical
report their practice has been influ-                  ing? How do we harmonize the oppo-                   Branch, School of Nursing: Mary Fen-
enced by altered personnel mixes or                    sites? How do we protect both service                ton, Elizabeth T. Anderson, Judith C.
decreases in the nursing workforce,                    providers and clients? How do we reg-                Drew, and Phyllis N. Goins (retired);
stricter reimbursement mechanisms,                     ulate an unregulated market?                         Universidad de Buenos Aires, Escuela
health service restraints brought on by                   To answer these questions, additional             de Enfermería: Ana María Heredia;
economic limitations, new organiza-                    studies are needed. A study to explore               Universidad Nacional de Córdoba, Es-
tional structures, and a changing de-                  whether the views expressed in this                  cuela de Enfermería: Stella Felizzia;
mographic and health profile for the                   study reflect general nursing views—                 Universidade de São Paulo, Escola
populations served. The nurses de-                     and are still current—would be useful.               de Enfermagem de Ribeirão Preto:
scribe doing more work in less time                    Given the increased workload and the                 Clarice Aparecida Ferraz and Silvana
with fewer staff, with sicker popula-                  smaller numbers of nursing personnel                 M. Mishima; Universidad de Antio-
tions, and with more restrictions in                   reported at the study sites, future quan-            quia, Escuela de Enfermería: Consuelo
supplies, equipment, and services.                     titative studies could examine factors af-           Castrillón, Silvia Orrego Sierra, and
   In nurses’ work environments, pro-                  fecting nursing availability and utiliza-            María Elena Ceballos Velásquez; Uni-
fessional practice arenas have diversi-                tion. Studies could further explore                  versidad Autónoma de Nuevo León,
fied, moving from hospitals to com-                    nurses’ perceptions that recent health               Escuela de Enfermería: María de los
munity settings such as clients’ homes,                service reorganization measures focus-               Ángeles Paz Morales; and Universi-
businesses, or schools. As the health                  ing on cost control may be negatively                dad Juárez del Estado de Durango, Es-
care environment has become more                       influencing both the quality and the                 cuela de Enfermería: María Elena
complex and sophisticated, nurses                      quantity of health service. A specific               Valdez Martínez. This project was
have had to learn new technologies,                    need exists to examine who is now pro-               funded by PAHO and by the partici-
work in interdisciplinary teams, adjust                viding the direct care formerly pro-                 pating institutions in each country.


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                                        RESUMEN          Objetivos. Identificar los cambios en la práctica de la enfermería y en el medio
                                                         donde se ejerce que han tenido lugar con la puesta en marcha de la reforma del sec-
                                                         tor de la salud (RSS) en cinco países americanos.
          Análisis comparativo                           Métodos. Entre 1997 y 1999 se realizó en Argentina, Brasil, Colombia, México y los
 de los cambios en la práctica                           Estados Unidos de América un estudio exploratorio para obtener los datos narrados
                                                         por 125 profesionales de la enfermería acerca de sus percepciones de la práctica de la
 de la enfermería relacionados                           profesión y de los cambios en su ambiente de trabajo. También se obtuvieron de-
      con la reforma del sector                          scripciones de las características y de las tendencias de la práctica de la profesión en
   de la salud en cinco países                           los lugares de trabajo estudiados.
                    americanos                           Resultados. En el contexto de la RSS, los cinco países han sufrido una reorganización
                                                         de los servicios de salud que ha afectado a la práctica de la enfermería. Los participantes
                                                         de los cinco países mencionaron el aumento de la importancia de la empresa privada;
                                                         los cambios en el sistema de pago, tanto para los pacientes como para los proveedores;
                                                         la redistribución de la fuerza de trabajo de los profesionales de la enfermería; los cam-
                                                         bios en la composición del personal y en las funciones prácticas de estos profesionales;
                                                         el cambio del trabajo en el hospital hacia el trabajo en la comunidad, y la mayor impor-
                                                         tancia prestada en el campo práctico a la prevención y al control de los costos.
                                                         Conclusiones. El estudio proporciona información inicial sobre los problemas ac-
                                                         tuales de la enfermería que han aparecido a consecuencia de las iniciativas de RSS. Los
                                                         participantes de los cinco países identificaron muchos temas, tendencias y cambios co-
                                                         munes en la práctica de la enfermería, independientemente de las diferencias en los
                                                         tipos de servicios de enfermería y de la fase de implementación de la RSS en cada país.
                                                         Las fuerzas que llevaron al cambio y la intensidad de este han sido muy diferentes en
                                                         los cinco países. Los profesionales de la enfermería siguen manteniendo sus valores es-
                                                         enciales a pesar del mayor estrés laboral, de las mayores necesidades asistenciales de
                                                         los pacientes y, en los países de América Latina, a pesar de la crisis económica.

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