The nurse ’ s visibility in intensive care units : perceptions of workers A visibilidade do enfermeiro em unidades de terapia intensiva : percepções de trabalhadores

We aimed to understand health worker’s perceptions about the nurse’s visibility who works at an intensive care unit. An exploratory descriptive and qualitative research conducted in a large size hospital in the South of Brazil. Participants were physicians, physiotherapists, secretaries and cleaning workers from intensive care units. Data were collected through semi-structured interview and submitted to content analysis, thematic modality. The nurse’s visibility is recognized by articulation in assistive process, subsidized by scientific knowledge and management capability. The lack of institutional support and work overload were pointed by other professionals as limits. The great responsibility given to nurses and overload are unfavorable factors to visibility, yet, scientific knowledge linked to their actions, gives them visibility, credibility, trust and respect from the team. Descriptors: Nurses; Nurse's Role; Intensive Care Units. RESUMO Objetivou-se conhecer as percepções de trabalhadores da área da saúde sobre a visibilidade do enfermeiro atuante em unidade de terapia intensiva. Pesquisa exploratória, descritiva, de abordagem qualitativa, realizada em um hospital de grande porte do Sul do Brasil. Os participantes foram médicos, fisioterapeutas, secretárias e serventes de limpeza atuantes nas unidades de terapia intensiva. Os dados foram coletados por meio de entrevista semiestruturada e submetidos à análise de conteúdo, modalidade temática. A visibilidade do enfermeiro é reconhecida pela sua articulação do processo assistencial, subsidiada pelo conhecimento científico e capacidade gerencial. A falta de apoio institucional e a sobrecarga de trabalho foram apontadas pelos outros profissionais como limites. A grande responsabilidade imputada ao enfermeiro e a sobrecarga são fatores desfavoráveis a visibilidade, já o conhecimento científico aliado ao fazer do enfermeiro, lhe dá visibilidade, credibilidade, confiança e respeito por parte da equipe. Descritores: Enfermeiros; Papel do profissional de Enfermagem; Unidades de Terapia Intensiva. Frota LA, Camponogara S, Arboit EL, Tolfo F, Beck CLC, Freitas EO. Rev. Eletr. Enf. [Internet]. 2015 jul./set.;17(3). Available from: http://dx.doi.org/10.5216/ree.v17i3.31608. 2 INTRODUCTION The visibility building process requires responsibilities and engagement from professionals, in the sense of searching for constant depth in the theory-practice knowledge field, as well as in the improvement of intergroup relationships. In this context, nurses have been looking for visibility and recognition while professionals, as through their practice, care is a central element; being it on individual, family or community level. However, this theme is complex, as professional visibility is related to many factors. The nurse’s action is valuable and recognized when it allows: respect between health professionals and team trust; understanding of needs and problem solving by clients; and, specifically from the institutional point of view, when it has social and financial return from a rational and efficient professional performance. On the other hand, recognition of the nurse’s work stimulates and mobilizes the professional and at the same time, it incentivizes his actions. Thus, realization and satisfaction feelings at work contribute effectively to professional development and they feel stimulated to grow professionally. In this perspective, a study found the nurse recognized by other health professionals as an articulator professional who integrates different knowledge, especially due to the constant presence patients and for detecting easier alterations happening throughout the day. In some care settings, this theme can have different characteristics. In intensive care units (ICU), professional visibility is allied with assistencial and complex management activities, requiring technical and scientific competency, whose decision making and safe conducts adoption are directly related to life and death of people. Nursing assistance is characterized by the need of a direct care to the patient, whose severity and acuteness of clinical conditions also requires the nurse to act in direct interface with technological instruments and with different workers of the assistance team. The management process focuses in organizing assistance, directing actions towards the organization of human and material resources. Facing the exposed, the nurse has a relevant role in these sectors that can favor a greater visibility within other workers. Nursing visibility translates emancipation of attitudes and actions in their intervention field and implicates competencies articulation with technical, scientific and relational evidence. The professional status is built through individual actions forming the collective, and they are reflected in a broader social level. Thus, we consider appropriate to investigate perceptions of different workers regarding the nurse’s visibility in the intensive care unit setting, trying to offer subsides to give opportunities for reflections about the theme. At the same time that it increases the knowledge construction about it, it can collaborate with the strengthening of their professional identity. The importance of this debate is supported by the unknown, undervaluing, and in (visibility) of nurses, by other health professionals, which can cause suffering to nurses, making their relationship difficult with the multiprofessional team and the nursing autonomy exercise. Besides, it is noticed that regarding its importance, this theme has been shown as a gap in national and international scientific production. Thus, this study aims to understand perceptions of workers from the multiprofessional team about the nurse’s visibility, who is active in intensive care units. METHODS We conducted an exploratory study, with a descriptive qualitative design, conducted in a large hospital in the South of Brazil. Subjects were of different careers who worked in adult, pediatric, neonatal and cardiologic intensive care units. Inclusion criteria were defined as: to be a worker linked to the adult, pediatric, neonatal and cardiologic intensive care units; to work for at least three months in the sector. Exclusion criteria were: workers on vacations or license from any nature during data collection. Frota LA, Camponogara S, Arboit EL, Tolfo F, Beck CLC, Freitas EO. Rev. Eletr. Enf. [Internet]. 2015 jul./set.;17(3). Available from: http://dx.doi.org/10.5216/ree.v17i3.31608. 3 Data collection was conducted during October and November of 2013, by semi-structured interviews including open and close ended questions. Sociodemographic data was in the first part and questions regarding the nurse’s visibility at intensive care units in the second part. The number of subjects interviewed was defined from the adherence of subjects in the study, by intentional choice, obeying to data saturation criteria. We included three physicians, three physiotherapists, two secretaries and four cleaning servants, totalizing 12 workers. We considered the proportionality between different segments of workers participating in the study. Interviews were recorded, guaranteeing a rich and reliable material that was transcribed and identified by letters and numbers. For data analysis, we used the content analysis technique that is constituted by the following steps: organization of the material and pre-analysis; organization of analysis categories and interpretative analysis. We respected the ethical aspects of the research, approved by the Ethics in Research Committee with the CAAE number: 18933613.0.0000.5346. We identified participants by a code relative to their initial letter of profession category and sequentially numerated, as shown in the example: P1 – physician 1 (“médico”); F2 – Physiotherapist 1 (“fisioterapeuta”); S3 – Secretary 3; SL4 – cleaning servant (“servente de limpeza”) 4. RESULTS AND DISCUSSION Regarding participants’ characteristics, from 12 workers, eight were female, between 27 and 58 years old, and four were men varying from 45 to 55 years old. Within these participants, six completed superior education, one had incomplete superior education, one completed technical course, three completed high school and one had incomplete middle school. Time of service in the sector varied from four months to 18 years. Information obtained from participants was pooled in two thematic categories related to “the nurse’s work visibility: assistance and management activities” and “factors influencing the nurse’s visibility in the intensive care unit”. The nurse’s work visibility: assistance and management activities In the intensive care environment, the nurse’s work is to articulate diverse ways of work from the health and nursing team, as well as to provide direct care of higher complexity to the patient. In a first moment, data emerged about the importance of the nurse’s work in intensive care units. [...] you see that person was born to do that, from the time she arrives until the time she leaves, she does everything for the unit to work, nobody stay still, everyone works, you feel that things flow. (SL1) The nurse’s work is really important. Without the nurse, there was no unit. (F2) A fundamental job. Without the nurse, there is no ICU and I think that here at the unit, the nurses are really well adapted to intensive care particularities. (M3) Testimonials show the recognition of the work importance of the ICU nurse and perception of the unit’s good flow being related to the presence of this professional. This perception is from workers of different career categories, so it can be inferred the nurse’s visibility being present and noticeable among ICU workers. Nowadays, to health professionals, the nurse’s social practice is highlighted by his actions as articulator and integrator of health actions. This articulation ability have been recognized by other health professionals, particularly, due to the nurse’s ca


INTRODUCTION
The visibility building process requires responsibilities and engagement from professionals, in the sense of searching for constant depth in the theory-practice knowledge field, as well as in the improvement of intergroup relationships.In this context, nurses have been looking for visibility and recognition while professionals, as through their practice, care is a central element; being it on individual, family or community level (1) .
However, this theme is complex, as professional visibility is related to many factors.The nurse's action is valuable and recognized when it allows: respect between health professionals and team trust; understanding of needs and problem solving by clients; and, specifically from the institutional point of view, when it has social and financial return from a rational and efficient professional performance (2) .
On the other hand, recognition of the nurse's work stimulates and mobilizes the professional and at the same time, it incentivizes his actions.Thus, realization and satisfaction feelings at work contribute effectively to professional development and they feel stimulated to grow professionally (3) .In this perspective, a study (4) found the nurse recognized by other health professionals as an articulator professional who integrates different knowledge, especially due to the constant presence patients and for detecting easier alterations happening throughout the day.
In some care settings, this theme can have different characteristics.In intensive care units (ICU), professional visibility is allied with assistencial and complex management activities, requiring technical and scientific competency, whose decision making and safe conducts adoption are directly related to life and death of people.
Nursing assistance is characterized by the need of a direct care to the patient, whose severity and acuteness of clinical conditions also requires the nurse to act in direct interface with technological instruments and with different workers of the assistance team.The management process focuses in organizing assistance, directing actions towards the organization of human and material resources (5) .
Facing the exposed, the nurse has a relevant role in these sectors that can favor a greater visibility within other workers.Nursing visibility translates emancipation of attitudes and actions in their intervention field and implicates competencies articulation with technical, scientific and relational evidence.The professional status is built through individual actions forming the collective, and they are reflected in a broader social level (6) .
Thus, we consider appropriate to investigate perceptions of different workers regarding the nurse's visibility in the intensive care unit setting, trying to offer subsides to give opportunities for reflections about the theme.At the same time that it increases the knowledge construction about it, it can collaborate with the strengthening of their professional identity.The importance of this debate is supported by the unknown, undervaluing, and in (visibility) of nurses, by other health professionals, which can cause suffering to nurses, making their relationship difficult with the multiprofessional team and the nursing autonomy exercise (7) .
Besides, it is noticed that regarding its importance, this theme has been shown as a gap in national and international scientific production.Thus, this study aims to understand perceptions of workers from the multiprofessional team about the nurse's visibility, who is active in intensive care units.

METHODS
We The number of subjects interviewed was defined from the adherence of subjects in the study, by intentional choice, obeying to data saturation criteria (8) .
We included three physicians, three physiotherapists, two secretaries and four cleaning servants, totalizing 12 workers.
We considered the proportionality between different segments of workers participating in the study.Interviews were recorded, guaranteeing a rich and reliable material that was transcribed and identified by letters and numbers.
For data analysis, we used the content analysis technique that is constituted by the following steps: organization of the material and pre-analysis; organization of analysis categories and interpretative analysis (9) .We respected the ethical aspects of the research, approved by the Ethics in Research Committee with the CAAE number: 18933613.0.0000.5346.We identified participants by a code relative to their initial letter of profession category and sequentially numerated, as shown in the example: P1 -physician 1 ("médico"); F2 -Physiotherapist 1 ("fisioterapeuta"); S3 -Secretary 3; SL4 -cleaning servant ("servente de limpeza") 4.

RESULTS AND DISCUSSION
Regarding participants' characteristics, from 12 workers, eight were female, between 27 and 58 years old, and four were men varying from 45 to 55 years old.
Within these participants, six completed superior education, one had incomplete superior education, one completed technical course, three completed high school and one had incomplete middle school.Time of service in the sector varied from four months to 18 years.
Information obtained from participants was pooled in two thematic categories related to "the nurse's work visibility: assistance and management activities" and "factors influencing the nurse's visibility in the intensive care unit".

The nurse's work visibility: assistance and management activities
In the intensive care environment, the nurse's work is to articulate diverse ways of work from the health and nursing team, as well as to provide direct care of higher complexity to the patient (5) .In a first moment, data emerged about the importance of the nurse's work in intensive care units.Nowadays, to health professionals, the nurse's social practice is highlighted by his actions as articulator and integrator of health actions.This articulation ability have been recognized by other health professionals, particularly, due to the nurse's capacity to comprehend the social context more broadly, to receive and be identified with user's needs and expectations, directly interacting with the user, family and community; as well as to promote the interaction of those with the health team (10) .
Obviously, for that, the nurse needs knowledge, planning, communication, efficacy, quickness and constant updates.In the ICUs' specific context, besides coordinating the labor dynamic, the nurse assumes the role of link between patient and multi-professional team, mediating interpersonal relationships in the work environment, requiring theoretical fundaments, leadership, initiative, maturity and emotional stability, within others (6) .
These characteristics allow offering support to professional practice as a whole, sets up strategy for professional improvement.
Although these characteristics are relevant in any environment, in the ICU context, they are even more needed, considering the patient care involving a complex network of relationships and communication between professionals, patients and family (11) .
An investigation reveals the nurse considered fundamental in the nursing team, being respected by other professionals, giving them a big responsibility, once they are seen as coordinators of the ICU work process (12) .
Thus, the nurse is pointed out as a leader in the multiprofessional team, being noticed by the decision making actions, with the attribution to manage the patient care, becoming the bond within the whole team.In accordance with the testimonials, we notice the nurse being recognized through some characteristics, considered essential by other workers, as: leadership, communication ability and decision making capacity.In general, the nurse, when aggregating these characteristics, qualifies his performance as a health team manager (13) .
The complexity and work demand imposed to the ICU nurse, managing and guiding care actions and practices, reinforce the need of leadership development.A study reveals that in these environments, the nurse has the opportunity to develop and practice leadership, especially because situations experienced are real and compelling, requiring compromise, responsibility, empathy, ability for decision making, communication and management in an effective and efficacious way (5) .In this direction, an investigation conducted in Japan with nurses from an oncology unit, found the leadership exercise being essential to improve nurse's visibility in multidisciplinary environments (14) .
In an intensive care environment, interactivity and agility are needed, once decisions need to be fast and assertive.However, this can be seen as an authoritarian posture in many times, but it also results in the nurse' visibility, whose shall be regarded as a boss.The nurse, in this context, should adapt the leadership style, recognizing each team member's value, aiming to establish responsible leadership, where confidence and continuous search of knowledge prevail (15) .
However, results points that management and leadership are not characteristics that can be generalized for all nurses but can be individually developed, over the daily work.Thus, it emerges this as a process where each professional builds over time, in the measure that aggregates peculiar characteristics and develops his own leadership style.These styles seem to influence the work team perception about the nurse's visibility.
The leader nurse tries to reach common objectives easily implementing actions discussed with other multiprofessional team members.In this case, good relationship and feedback within members allow a more full-bodied and political relationship, with better guarantees of objectives resolution (16) .
The team also related nurse's visibility to assistance direct to the patient: As the nurse is always closer to the patient, he ends being the unit professional who is seen more.His presence with the patient is superior to the doctors.(M3) I think he is that "grabs" closely, knows more the patient

[...] has more experience. (F1)
As mentioned in one of the testimonials, the nurse is the professional who acts closer to the patient, in a constant and continuous care process, which makes him more visible.The nurse professional, when appropriating himself of the needs and clinical conditions of patients admitted to intensive care units, with the intention to perform the care plan and guide the nursing team actions, acquires a highlight position in his professional performance.
When providing nursing care to high complexity patients, the nurse gets involved, feels accomplished, learn to exercise his commitment favoring the strict relationship with the patient and, consequently, contributing with quality assistance.Therefore, in this environment, the nurse job is not resumed to articulate diverse ways of work from the nursing and health team, but also, in the direct care of higher complexity to the patient (5) .
This The continuous improvement is ruling for the meaning that will be attributed to the ICU nurse, constituted in a value that is once linked to the importance given to the professional in this sector (17) .The ICU work is characterized by the increase of nurses' selfesteem, considering the culture instituted in the profession that these workers have a different profile, as they dominate the hard technology, deal with variability, make decisions fast and have high capacity (18) .
The work recognition by the health team and society allows the professional to understand his importance as a working citizen, when his labor activity has its value recognized (16) .Obviously, development of bonds with patients and families are essential for professional visibility.A study points the invisibility of nursing professionals acting in intensive care in face of family members, resulting of questions related to lack of bond and infrastructure (19) .Therefore, we highlight the nurse's visibility could be linked to many factors, that can influence their performance in these sectors.

Factors influencing the nurse's visibility in the intensive care unit
Workers pointed positive and negative factors that influence the nurse's visibility.Some adversities related to the institution are present in their work routine and can negatively influence his visibility.
[...] one thing that I notice is that sometimes the nurse has good will to work, he is a hardworking person.But sometimes, the difficulty found is the hospital system, that does not depend only on his will Beyond the commitment with the user assistance, the nurse is compromised with the institution where he works and, thus, can be distant from providing direct assistance to users, being delegated to team professionals, due to function overload (20) .
The nurse job in health services sometimes is presented with many facets, dividing and submitted a variety of positions which sometimes generate attrition (21) .This can be even more evident when considering ICU, as the work load and stress are even greater than in other hospital units, considering the clinical condition severity of patients and the needed therapeutic complexity.Studies (22)(23) show stress present in intensive care nurses, demanding health institutions to establish measures guided to minimize the work overload and optimize the work process.
Besides, many times there is transferring of many tasks to nurses, without support from other workers or, even so, from the work institution.The need to recognize nurses as important members in the health team is essential, especially regarding the caring aspects, leading to think about the value given to pairs and other team members.Thus, it is understood visibility consisting of search for new partnerships, in the strengthening of it, through recognition and in the sharing of responsibilities and tasks (24) .
Regarding the recognition of the nurse work in intensive care, workers found scientific knowledge, allied with care practice, as main element of credibility and respect, in front of other team workers.
The work routine of the nurse in intensive care units is characterized by activities related to assistance and management itself, which are complex and require technical and scientific competencies.In this context, decision making and adoption of conducts are fundamental to quality assistance provided to patients, also directly related to patient's life and death (5) .
Nursing, within the health working team, has care as its essence as singularity, being considered as science and art, reflecting specific character in its practice, allowing different expression in the health team.Thus, to be science, for Nursing involves working with a cumulative body of scientific knowledge, derived from physics, biological and behavioral sciences, therefore constituting a branch of the knowledge body that differs from other disciplines (25) .
The nurse's knowledge is in the exercise of activities, in which professionals should relate conceptual knowledge acquired with problems and events found in concrete situations in their daily work.Thus, the nurse will be critically acting, breaking limits imposed by the system and making their competencies visible.

FINAL CONSIDERATIONS
The investigation allowed us to find that within workers from a multi-professional team, the nurse's work Given the importance of the theme, we suggest new investigations addressing the subject, particularly directed to nurse's visibility caring for critical patients.We also suggest studies pointing out strategies that could be used to amplify the nurse's visibility, in the professional practice as well as in the training process.
[...] you see that person was born to do that, from the time she arrives until the time she leaves, she does everything for the unit to work, nobody stay still, everyone works, you feel that things flow.(SL1) The nurse's work is really important.Without the nurse, there was no unit.(F2) A fundamental job.Without the nurse, there is no ICU and I think that here at the unit, the nurses are really well adapted to intensive care particularities.(M3) Testimonials show the recognition of the work importance of the ICU nurse and perception of the unit's good flow being related to the presence of this professional.This perception is from workers of different career categories, so it can be inferred the nurse's visibility being present and noticeable among ICU workers.
more constant and closer care to the patient implicates in the need of constant search for improvement of scientific knowledge, proactivity, and effective leadership exercise of the team.Besides, requires development of abilities as: observation, interpersonal relationship and, work process organization abilities.Obviously, these attributes facilitate the nurse recognition as key-figure inside the multi-professional team and in the health assistance process.
[...] cannot do it alone.(SL1) I see this way [...] lots of work and, many times, he is too stressed [...] sometimes, is lacking personnel [...] too much requests or excess of responsibility and I think that they are a little stressed because of too much work leave, many absences.(SL3) The fact of nurses being involved in direct care to patients can result in work and, especially, administrative activities.Work overload is one of the limiting factors to the implementation of work process with management, assistencial and educational articulations.Management activities performed by the nurse have been standing out in the nursing work process.
in intensive care is visible.This visibility is essentially linked to the fact of being considered an articulator in care processes.Constant and responsible acting in this sector and to provide direct care to inpatients collaborate with visibility, allied to management practice and team leadership exercise.The action supported by scientific knowledge was also shown as propulsive element of the nurse's visibility.There are many factors influencing nurse's visibility during their work in intensive care.The major responsibility given to the nurse and the stress generated are unfavorable factors when building this worker's visibility, allied to the lack of institutional support.In counterpart, dedication and leadership capacity even between difficulties found throughout the work process, are highlighted as favorable points to professional visibility.It is still noteworthy, the importance attributed by participants to scientific knowledge linked to the nurse's actions, considered essential to professional visibility, credibility, trust and respect from the team.
think it is of leadership, the nurse role is of total person who is there to request, to give orders, I see thisway.(SL1)The nurse is the bond in all units [...] So the connection exists within all there, because he is indispensable [...] the nurse, the physiotherapist, the doctor, now there are audiologists, everything rotates, most of the team communication rotates around the nurse.(F3) ...] the work, because it doesn't matter anything if you boss and not know how to do, in first place you have to know how to do and then you can boss, because it doesn't matter if I get here and send this person there, because she/he has to do a certain activity [...] you have to know how to do so then you know how to boss, I believe in this.