In addition to appreciation and opportunities for career growth, doctors as well as nurses at HS express that they feel they have the opportunity to practice what they have studied given the resources available to them at HS. A physician shared:
You have both technological and human support for you to be able to practice cutting edge medicine. Even though a SUS hospital, you can do a very good job. This is what motivates
me to continue [here]… [Here] I am able to practice everything I learned during my residence and more. This is what motivates me. In other hospitals you have the normal SUS difficulties;
sometimes you don't have material, sometimes it takes a little longer to receive the test results (Physician, Interview, October 2018).
A nurse at HS who also held a position at a public institution described her frustration with regards to her experience at the public institution and all the undermining efforts she has experienced to secure resources for her patients:
… They [some medical professionals in the public sector] think they have no individual obligation [when the material they need is not there]. They [think they] have the obligation to do
[a procedure] if they have the material it but if they don't have the material, they don't [see it as their responsibility to] have to look for what is needed. Available resources [to perform your job] have to be present [as the bare minimum]. For me it was a professional commitment and a personal responsibility [to do my job] so I left my house on Saturday or Sunday morning to go to the other sectors [at the public hospital], call the other coordinators and ask for 20 syringes.
Because I had patients in the pediatric line who needed that material [the next day]. And it frustrates you, it undermines you as a professional, it wears you out. After two and a half years I
asked to leave (Nurse, Interview, February 2020).
Another nurse at HS who holds a position at a public hospital different to the nurse above shared:
There is a lot of bureaucracy. To give you an idea, to get a plastic box like that one [showing the box] at the public hospital [I work at] takes several requests. The system is not even computerized. It takes several written requests. I experienced it myself. My coordination [at the public hospital] was trying to put together surgery kits with boxes like those there [showing the box again]. It has been 14 years that I am there. My coordinator got the boxes 5 or 6 years after
requesting. Here [at HS], if I place an order today, the purchase will be made and the next scheduled delivery, I will have it…
… the tenders [in public hospitals] are slow, time consuming. Buying equipment is very difficult.
If an equipment were to break today, there would be a bid and at least 3 companies will need to bid. When we receive the material, it might be 2 years later. It is possible when the obsolete equipment arrives, it already needs updating. There will be the need to open a bid again to buy the system update. For example, monitors were bought at the public hospital where I work. When
they arrived they needed a module with a system update to work… (Nurse, Interview, January 2020)
The state of radiology sectors in public hospitals was further described as precarious with respect to outdated x-ray and CT equipment and maintenance. CT scanners in different public hospitals in the state of Bahia were reported to be out of service for 2-6 months either due to the need of an x-ray tube, software configuration or fuse replacement. At the same time, it took hospitalized patients up to 20-30 days to perform CT or MRI exams, while reports took 7-10 days to be released, with some hospitals only having reports for 10-20% of the diagnostic exams performed (Technical Officer, personal communication, April 2019).
In addition to material resources, participants refer to organizational structures in place that allow them to practice their profession. One of the starkest conversations I experienced was with a nurse at HS who also worked at another public institution. She expressed confusion, anger, anxiety and burnout at the practices, structures of work, availability of health personnel and materials available at the other institution. At the same time, she repeatedly used the word
“smooth/unconcerned” (tranquilo) throughout the interview to describe her shift at HS even though an emergency department is not a typical “smooth” or “unconcerned” work environment.
She explained that because of inadequate coordination structures, she does not feel sure that she is doing what she should be doing at the public institution. On the contrary, she expressed great admiration for her coordinator at HS and the structures in place which create a sense of safety for her to practice her profession, even in an environment of emergency crisis (Nurse, Interview, January 2020). Furthermore, another study participant mentioned that the structures build at HS and the resulting high level of communication do not permit that a problem of communication remains as such for a long time (HS Management Team Member, Interview, January 2020).
Furthermore, participants talked about the importance of the existence of protocols and conducting their job with less fear because of the existence of protocols. Even though protocols
could be considered technical tools that serve to bring about organized and homogeneous practices in health organizations, a study participant referred to protocols as tools that could represent the use of a common language that unites and serves as a means of better
communication but also as a psychological tool that provides professionals with a sense of safety at HS:
That's the point about the protocol, the language is universal, everyone will speak the same language. Another thing about the protocol is the security it brings to the patient and the professional (Nurse, interview, January 2020)
Theme 3: Empowerment