AÇÕES GERENCIAIS DE ENFERMAGEM NOS SERVIÇOS DE REFERÊNCIA EM CARDIOLOGIA MANAGED NURSING ACTIONS IN CARDIOLOGY REFERENCE SERVICES

Cardiology services are critical sectors due to the unpredictability of occurrences and highly accelerated rhythms. Therefore, nursing management is essential and has a direct influence on the quality of care. This is an integrative literature review, which aimed to learn about nursing publications and the impacts of their managerial actions for the qualification of cardiology services. 10 articles from the LILACS, PubMed and SciELO databases were used. The descriptors "Health Management", "Nursing", "Hospital Services" and "Cardiology" were used crosswise. The selection of articles was carried out in the months of October and November 2018. The inclusion criteria were: articles produced by nurses; published in the period 2009-2018; in Portuguese, Spanish and English; and available electronically in full. The data were organized and tabulated for analysis. The results found that most of the articles that comprised this review were of a qualitative nature and published in national nursing journals. Managerial practices stood out as practices of decision making, leadership, communication, training, qualification, allocation of human and material resources. The work of nurses in public cardiology units represents a challenge, which reinforces the need for studies that prove their relevance for promoting continuous improvements in care.


INTRODUCTION
Cardiovascular Diseases (CVD) are among the major public health problems worldwide, due to their high incidence that causes 17.9 million deaths every year, of which 7.4 million (13%) are caused by coronary heart disease and 6.7 million (12%) by stroke (1)(2) .
According to the American Heart Association, in 2017 CVD was the underlying cause of nearly 801,000 deaths in the United States (3) . Similarly in Brazil, 383,961 deaths were estimated, 28% of the total, being the second cause of death in young adults and the first in people over 60 years old, which generated costs of more than 37 billion to the health system in 2015 (4-5-6) .
This epidemiological configuration, associated with the evolution of technology, public policies and health services, has been instigating nursing researchers, especially regarding the dynamics of work, resource mobilization, process management to achieve the goals and consequently proposals for service qualification (7)(8) .
In this context, among the health sectors, the cardiovascular units represent one of the most critical services in relation to quality of care, and must be provided with the human and material resources necessary for the implementation of effective assistance, considering the specificity of the patients treated, requiring from the multidisciplinary team scientific improvement, development of skills and dynamization of care (9) .
The nurse, as a manager or team leader, needs theoretical and practical knowledge that can support and enable the development of activities of greater complexity, which involve training, updating, revitalizing or recognizing the skills and developing the potential of nursing workers as a practice that emerges from work to promote better care actions in the institutional context (10)(11) .
However, management is often seen by nurses as a bureaucratic activity disconnected from the production of care, which is characterized by work fragmentation with separation between conception and execution, managerial control of the production process associated with rigid hierarchy, rationalization of the administrative structure, impersonality in interpersonal relationships, and emphasis on systems of procedures and routines (12)(13) .
Therefore, the relevance of this research is Thus, this research aimed to know the nurse's managerial actions in cardiology referral services and to highlight the nurse's work as a cardiovascular unit manager.

METHOD
An integrative review was used as a methodological resource, which is an important tool for analyzing the evidence in the literature in a broad and systematic way to disseminate the results of the studies, contributing to point out problems that can be solved with evidence discovered in other research (14) .
The construction of this review was structured based on the following steps: identification of the theme, formulation of the guiding question; establishment of eligibility criteria; survey of studies in the databases; assessment and critical analysis of the selected studies; categorization, evaluation and interpretation of results and presentation of the synthesis in the integrative review (15) .
In this perspective, the question that To operationalize this research we used the PRISMA recommendation -Main Items for Reporting Systematic Reviews and Meta-Analyses (16) , according to the flowchart in figure   1. The search strategy was ("health management" AND "nursing" AND "cardiology" OR "health management" AND "hospital services" AND "nursing") and ("health management" AND "nursing" AND "cardiology" OR "health management" AND "hospital services" AND "nursing"). Regarding the origin of the studies, seven articles were published in Brazil, in nursing or interdisciplinary journals (7,17-19,22-24,) . United States, Australia and Italy contributed one study each (20)(21)25) .
In  Studies were identified in which seven nurses participated (7,19) , however La-Sala et al.
(2017) (25)  This research evidenced that the nurse managers were aged between 23 and 62, predominantly female, with more than five years of education, postgraduate degrees, not necessarily in cardiology, but in urgency and emergency, ICU and management (17)(18)20,24) .
It was also observed the lack of nurse managers specialized in cardiology, which demonstrates the need for qualification of these professionals for high complexity cardiovascular care, due to the demands that the sector requires in the actions of training and qualification of the nursing staff, organization and development of work processes in the sector, care support activities, such as risk management, patient safety and total quality management (20)(21) .

DISCUSSION
The management of cardiology services has as its main focus the organization of integral care, that is, the planning of shared actions so that the nursing team, under the leadership of the nurse, develops the work process with efficiency and quality, in order to satisfy the needs of safety and welfare of the assisted patient (22) .
Thus, for the authors, the essential managerial actions for the work of the nurse manager of a cardiovascular unit are related to decision making, communication, leadership, provision of material resources, dimensioning of human resources, supervision, elaboration of protocols, continuing education, among others (7,(17)(18)20) .
Regarding service management, a study conducted with seven nurses who work in a reference state government institution in the cardiovascular area refers that planning and decision making, as functions attributed to nurses, help in the development of service management (7) , because of this, it promotes the appropriate use of equipment, ensuring the effectiveness and cost in the process of selection and training of the workforce and in the performance of highly complex procedures and practices (18)(19) .
Communication directly influences the effectiveness of institutional protocols, supervision and the leadership process, since it allows nurses to transfer and receive information and knowledge, organize their service and outline objectives with their team. Thus, the success of the leader is related to the ability to communicate, which is essential to reduce adverse events and ensure safe care, and facilitate the achievement of previously established goals (20,22) .
Thus, it can be seen that leadership is an important action in the work of the nurse manager of cardiology services, because it is a tool for promoting improvements in care, which assists in the evaluation, planning and communication of the work processes of the sector.
Regarding the dimensioning of human resources, Kobayashi, Silva and Ayoub (2010) (7) point out that this action makes it possible to provide the necessary personnel to meet the demands of customer care. It also makes it possible to evaluate the workload in the unit and thus plan the ideal number of nursing workers to provide care, making this activity an essential requirement to measure the quality of care provided.
Likewise, the management of material resources in the cardiology unit is an effective practice in quality control and waste, due to the high cost of these materials and the difficulty of replacement (22)(23) , especially in public institutions where resources are scarce. Therefore, the use of technology and innovation of equipment are essential for assistance, because obsolete inputs and equipment increase the possibility of errors, health risks to the worker and misfortunes to patient safety (18)(19) .
As a consequence of these facts, there is a need for the nurse manager to participate in the purchase and distribution of materials, intermediating the contacts between the institutional levels and the responsible sectors, this aspect being one of the fundamental aspects of the nurse's work that guarantees the continuous improvements of the assistance and the management for total quality.
In the context of cardiology services, it was unanimous in the studies the conception that the lack of training impairs assistance. Due to this circumstance, it is essential that the nurse manager assumes the challenge of planning continuing education training, through the implementation of specific programs that address practical knowledge about the handling of equipment used in procedures, the conduct required in everyday situations, as well as the achievement of established goals (18,23,25) .
In this sense, the implementation of continuing education in cardiology services, under the perspective of nursing management, provides opportunities for professionals to experience learning, according to the reality of the sector and the daily activities, contributing to the qualification of these services.

CONCLUSION
From an integrative review, we sought to know the managerial actions of nursing in cardiology services. Therefore, the study proved to be effective to provide support in building the profile of the nurse manager, i.e., they are professionals capable of driving and mobilizing care practices in the context of these services.