Quality of maternal-child health care at a University Hospital , according to the nurses' perspective

Abstracts

O objetivo deste estudo foi analisar a qualidade assistencial na Divisão de Enfermagem Materno-Infantil do Hospital Universitário da USP, fundamentado no modelo Donabediano. Os dados foram obtidos em agosto de 2006, empregando-se um questionário, respondido por 55 sujeitos. A análise dos dados ocorreu segundo índices percentuais e testes específicos. O Alpha de Cronbach do instrumento foi 0,71, demonstrando confiabilidade. Na dimensão de estrutura, 98,2% dos enfermeiros consideraram adequado o local do carro de emergência e 63,6% apontaram dificuldades em participar das atividades educacionais. Em processo, 96,4% concordaram que o SAE é um instrumento de melhoria da qualidade, e 72,7% apontaram dificuldades na comunicação com os profissionais de saúde. Para resultado, 72,7% indicaram que a prescrição de enfermagem atende às necessidades dos usuários. A dimensão de estrutura obteve o pior escore, média de 38,5. Acredita-se que este estudo subsidie ações de melhoria da qualidade nas três dimensões, sobretudo, na de estrutura.

Enfermagem materno-infantil; Cuidados de enfermagem; Qualidade da assistência à saúde; Avaliação em saúde

ORIGINAL ARTICLE

Natalia Eiro Yuri^I; Daisy Maria Rizatto Tronchin^II

^INurse, graduated by School of Nursing, University of São Paulo. Nurse at Nove de Julho Hospital. São Paulo, SP, Brazil. [e-mail]

^IINurse. Ph.D. Professor of the Department of Professional Guidance at School of Nursing, University of São Paulo. São Paulo, SP, Brazil [e-mail]

Correspondence addressed to

ABSTRACT

The objective of the present study was to analyze the quality of health care at the Maternal-Child Division of a Hospital of University of São Paulo, based on the Donabedian model. Data collection was performed in August of the year 2006, using a questionnaire that was answered by 55 subjects. Data analysis was performed by means of percentage rates and specific tests. A Cronbach's Alpha of 0.71 was found for the instrument, thus showing reliability. As for structure, 98.2% of nurses considered the emergency car location appropriate, and 63.6% reported difficulties in participating in educational activities. As for process, 96.4% consider that the SAE is an instrument that improves quality, and 72.7% stated having communication difficulties with health care professionals. As for the results, 72.7% reported that the nursing prescription meets the users' needs. Structure was the aspect with the worst score, a mean of 38.5. This study supports actions to improve quality in the three domains, particularly structure.

Key words: Maternal-child nursing. Nursing care. Quality of health care. Health evaluation. Nursing.

RESUMEN

El objetivo de este estudio fue examinar la calidad asistencial en la División de Enfermería Materno Infantil del Hospital Universitario de la USP de acuerdo con el modelo de Donabedian. Los datos fueron obtenidos en agosto de 2006, empleándose un cuestionario que fue respondido por 55 sujetos. El análisis de los datos se efectuó a través de índices porcentuales y tests específicos. El Alpha de Cronbach del instrumento fue de 0,71, lo que demuestra la fiabilidad del estudio. En la dimensión de estructura 98,2% de los enfermeros consideró adecuada la localización de la ambulancia de Emergencias, y 63,6% mencionaron tener dificultades para participar de las actividades educativas. En proceso, el 96,4% estuvo de acuerdo en que el SAE es una herramienta para el mejoramiento de la calidad y el 72,7% se refirió a las dificultades en la comunicación con los profesionales de la salud. Para el resultado, 72,7% indicó que las indicaciones de enfermería responden a las necesidades de los usuarios. La dimensión de la estructura obtuvo la peor puntuación, con un promedio de 38,5. Se cree que el estudio contribuya a trazar líneas de acción para el mejoramiento de calidad en las tres dimensiones estudiadas, particularmente en la estructura.

Descriptores: Enfermería maternoinfantil. Atención de enfermería. Calidad de la atención de salud. Evaluación en salud.

INTRODUCTION

Nursing Services, which are part of complex institutions, face the great challenge of guaranteeing health care quality, to effectively meet the needs of both internal and external clients.

Today it is observed that the awareness regarding the need to provide quality health care is no longer an isolated attitude; it has become a technical and social imperative, due to multiple reasons, particularly the increase in health care demands; on one hand, the growing costs of maintaining the service; and on the other hand, the limited resources and the fact that users have become more and more demanding and aware about their rights, in addition to the claims from health care professionals, who yearn for proper and ethical work conditions, and public administrators, who are responsible for guaranteeing funding for the health system^(1-2).

In terms of evaluating quality in health, one of the frameworks widely used by researchers and government organizations is the Donabedian Model, which comprises the analysis of a three-component approach: structure-process-outcome. In this model, the item structure corresponds to the relatively stable characteristics of institutions: physical area, human, material and financial resources, as well as the organizational model. The process item refers to a set of activities developed in the general production, in the health sector, through the relationships established between professionals and service users - from the search for the service to diagnosis and treatment. Finally, the outcome item concerns the characteristics of the products or services, whose quality translates into the effects on the health of the clients and population⁽³⁾.

It is observed, however, that regardless of the quality programs and evaluation models, it is fundamental that the nursing team never loses sight of their commitment with service quality, respecting that commitment, as it has a direct impact on the outcomes.

Therefore, it becomes mandatory to obtain data regarding the perception of the nurses involved in the service, considering that the program or actions that aim at improving quality require changes in the service, which, in turn, depend considerably on the compromise and commitment of the professionals to make them effective, and, later, evaluate them.

Perception is understood as the process by which people organize and interpret their own sensory impressions, with the purpose of assigning a meaning to the environment they are in. This is important because their behavior reflects the perceived reality⁽⁴⁾. The author of the aforementioned statement considers that several factors occur to shape or distort perception. The main features of the observer are the attitudes or motivations, and the expectations. The object is represented by the setting, movements or sounds. Finally, in the context of the situation, the main factor is the working or social environment itself.

The perceptions also integrate specific contexts, and include a side set of codes, world views and representations that guide practices, values, beliefs and attitudes of individuals and of the group⁽⁵⁾.

This study is, therefore, grounded on the premise that knowing the nurses' perception about the real conditions of the service being delivered may contribute to establishing the situational diagnosis, identifying limits and possibilities to monitor and guarantee the quality of health care.

OBJECTIVE

To analyze the nurses' perception about the quality of the nursing care that is delivered at the Maternal Child Division (DEMI, abbreviation in Portuguese for Divisão Materno Infantil) at the University Hospital - University of São Paulo (HU-USP), in terms of the structure, process and outcome components of the Donabedian model.

METHOD

This exploratory-descriptive study was performed at the DEMI of the HU-USP, a public teaching institution located in the Municipality of São Paulo.

The DEMI comprises the following Sections: Obstetric Center (OC), with 8 pre-delivery beds, and 4 delivery rooms; Rooming-in Care (RC), with 53 beds; Nursery (NUR), with 24 beds; Pediatric/Neonatal Intensive Care Unit (P/NICU), with 16 beds; and Pediatrics (PED), with 36 beds.

During this study, the Division was composed by 61 nurses. Nevertheless, the target-population consisted of 56 nurses, who met the eligibility criteria: inclusion (work at the institution for at least six months) and exclusion (nurses who were in a management position, on vacation or on a sick leave during the data collection period). Fifty-five nurses (98.2%) responded the instrument, and were thus the subjects of the present study.

Data collection was performed in August 2006, after the study was approved by the Commission for Teaching and Research and the Research Ethics Committee at the referred Hospital.

The instrument consisted of a two-part questionnaire. The first part included the socio-demographic data of the subjects; the second comprised 36 statements (22 affirmative and 14 negative), 12 of which addressed the structure dimension, 12 the process and 12 the outcome, which were randomly distributed. To answer the affirmative items, a Likert scale was used with the purpose of measuring attitudes, opinions, perceptions or feelings, with two fields of variation, one for agreement and one for disagreement ⁽⁶⁾. The scale had the following five degrees: Totally disagree (TD), Partially disagree (PD), Neither agree nor disagree (N), Partially agree (PA) and Totally agree (TA).

The statements were created based on literature review, emphasizing on service quality, health service evaluation, on the Donabedian model, and on national government organizations - the National Health Surveillance Agency (ANVISA, abbreviation in Portuguese for Agência Nacional de Vigilância Sanitária) and the Accreditation Manual of the National Organization on Accreditation (ONA, abbreviation in Portuguese for Organização Nacional de Acreditação).

The statements addressing the structure concerned the physical and material resources, nursing staff, furniture and infrastructure; process statements address the group of activities performed by nurses, including interpersonal relationships, professional training and healthcare model used. Finally, the items addressing the outcome concerned the desirable characteristics of the service, highlighting the effects of service and the professional satisfaction towards the care that was delivered, as well as the changes regarding knowledge and people's behavior.

In compliance with literature recommendations, in terms of trustworthiness, the questionnaire was submitted to validation considering the criteria for internal consistency and content. For content analysis, the instrument was evaluated by seven judges, who were experts in issues regarding health service quality and evaluation or in methodology. All of the seven judges (100%) requested some of the statements to be rewritten.

The questionnaire was then submitted to a pretest, and was distributed to the study subjects. A 20-day period was established for subjects to return the questionnaires.

To test the reliability of the instrument, Cronbach's Alpha was used, which represents the correlation among the items on the scale and all other possibilities, containing a same number of items, constructed from the universe of potential questions that measure the factor of the basic concept^(6-7). An Alpha of 0.71 was found for the questionnaire, and the value 0.60 was used as reference⁽⁷⁾.

The data were stored on an Excel® electronic spreadsheet and analyzed based on descriptive statistics and considering a favorability score for each dimension. Friedman's non-parametric test was used to compare the structure-process-outcome scores. Hence, the maximum value to be found for each dimension was 60 and the minimum was 12. The level of significance used for the tests was 5%.

RESULTS

Of all participants, 54 (98.2%) were women. The average age was 37.4 years (sd+7.4). The average time since graduation was 13.9 years (sd+7.0), and of work at the HU-USP was 11.1 years (sd+6.4) and in the job position for 10.4 years (sd+5.7). Of the 55 nurses, 9% had a leading position and 91% were assistive staff.

As for their education, 61.8% had a specialization degree. Most nurses specialized in Obstetrical Nursing (52.9%), Pediatric Nursing, 17.6%; Neonatal, 14.7%; and Management, 11.7%. Of all nurses, 18.2% also had a master's degree.

The results with relative frequencies expressing the responses of the participants are presented in tables 1, 2 and 3. The statements were ordered in the tables from the higher to lower percentages obtained in the agreement and disagreement scores. Table 4 indicates the favorability score of the three evaluated dimensions.

In terms of the structure dimension (Table 1), it was found that, regarding the location of the emergency vehicle, 98.2% (sum of partially and totally agree responses) believe it was located in a place of easy accessibility. However, before the statement that there were insufficient supplies, 89.1% disagreed, 69.1% totally and 20% partially.

Another aspect of this dimension, analyzed positively by nurses, refers to the equipment in the emergency vehicle. Of all interviewees, 87.3% (adding 80% of total and 7.3% partial) disagreed with the statement that they did not work. As for vacuum system functioning, 83.6% (14.5% partially and 69.1% totally) consider it adequate.

Most professionals (70.9% - 40% partial and 30.9% total) agreed that the Educational Support Service promotes educational activities, at least as often as every six months. Nevertheless, 63.6% (partial and total together) reported they found some difficulty to participate in educational activities. Another record of an unfavorable perception by the professionals who participated in the study was the need to update the routine manual. Only 49.1% agreed, and only partially, with the statement that the manual was up to date. The nurses, in 50.5% of cases (45.5% total and 5% partial), concluded that there is insufficient clothing, an important element for them to provide good care.

There was no consensus among the subjects in terms of the number of professionals available. Most, 54.6% (considering total and partial), agreed that the quantity was sufficient. On the other hand, 40% (total and partial) reported the contrary.

Table 2 lists the findings regarding the process dimension. The study shows that 96.4% of professionals believe that the Nursing Service System (SAE, abbreviation in Portuguese for Sistema de Assistência de Enfermagem) is an instrument that is likely to improve nursing service (76.4% of total agreement and 20% partial).

In 94.6% of cases, partial and total responses together, the nurses reported that, in the case of an iatrogenic occurrence in nursing service, they develop actions so that the event does not occur again. Another 78.2% of nurses report that they register the occurrences on the users' records. This item had the highest percentage of total agreements: 49.1%.

Also in this dimension, it was observed that 87.3% (30.9% in the degree of partial agreement and 56.4% for total agreement) of nurses have invested in their personal technical-scientific knowledge. Of all participants, 76.4% (36.4% total and 40% partial) considered that their pairs make the same investments and disagree from the negative statement.

For 85.5% of professionals, the health care activity records are fully registered, as they disagree from the negative statement (65.5% totally and 20% partially). As for the managerial activities, there was 80% of agreement, though a high number of professionals agreed only partially: 52.7%.

The study found that the communication problems of the nursing team with other health professionals reduce the quality of the service. Of all nurses, 72.7% agree with the negative statement - 49.1% totally agree. There was no consensus, however, regarding the fact that communication problems among members of the nursing team could reduce the quality of the service delivered. Of the nurses, 41.9% agreed and 52.7% disagreed.

As for the outcomes dimension, in Table 3, 98.2% (72.7% totally and 25.5% partially) of the study subjects stated that the nursing prescription indicates actions related to the users' needs, and that 94.5% (72.7% total agreement and 21.8% partial agreement) valued the opinions of users /companions in the service process. The nurses that considered it necessary to know the opinion of users regarding the nursing service, 89.1% (78.2 totally and 10.9 partially) disagree with the negative statement.

Most subjects (92.8%, total and partial disagreements together) disagreed with the fact that the orientation given at the moment of discharge from hospital did not meet the needs and expectations of the users/companions.

In certain statements, despite the high percentage of agreement that was found, the partiality degree prevailed. Therefore, 70.9% of nurses reported being satisfied with the service provided by the team. Nevertheless, 63.6% consider that the study results could help change nursing practice. Another 58% report the fact that users rated the service as excellent, and 40% refer there is a need for the team to improve the relationship they establish with users.

Furthermore, in the outcomes dimension, 87.2% stated that iatrogenic occurrences related to the nursing service are discussed among their superiors (54.5% totally).

Table 4 shows the comparability of the favorability score of the three dimensions. The average favorability score of nurses, regarding the process dimension was 44.27 (sd±4.70), superior to those of structure and outcomes. The comparison between the three dimensions and that of structure presented less favorability, with a statistically significant difference, p<0.001.

DISCUSSION

In terms of the do questionnaire of the present study, it was found that the internal consistency in the three dimensions was satisfactory, as the Alpha value was above 0.60⁽⁷⁾.

There was a considerable proportion of female nurses, which is expected, since nursing is a profession that is considered mostly feminine. The study involved adult professionals, with wide experience, considering the time since their graduation and of work at the institution. All professionals entered the work market at the moment of complete technical-scientific preparation. Therefore, they have the necessary knowledge to perceive and analyze service quality with time.

In Brazil, studies about health care workers revealed that women occupy 73% o the work slots and that public institutions generate 47.8% of the nurse positions. As for their age, the average was 37 years, and the professionals stay in the same institution for an average of six years. In the Southeast region, female participation is 88.5%, with an average age of 36 years, and an average 5 years time at the institution⁽⁸⁾.

The nurses from the HU-USP, therefore, surpassed the average age and time of permanence at the institution compared to the results of the abovementioned study.

In this study, it was verified there is a considerable proportion of master and doctorate graduates, especially in obstetrical nursing, which is a specialty required for job positions at RC and OC. Some nurses have completed service management courses, pediatrics and neonatology, which meets the needs of the clientele of the institution. There is also a reasonable number of professionals with a master degree, with is positive considering that the quality of the service depends on highly qualified professionals, who commit to their work⁽⁹⁾.

As for the evaluation of the structure dimension, it was found that the best agreement rates comprised the items: location, adequate functioning of the emergency vehicle and material supplies.

The location and functioning of the emergency vehicle have a close relationship with service quality, as the equipment is used in situations in which lives are at risk. Therefore, they are determining factors in how the image of the health facility is developed and projected. Hospitals that are applying for an evaluation by the National Organization on Accreditation to achieve a level 1 (accreditation), must prioritize institution structure and safety, level 2 (full accreditation), describe and register the process, and at level 3 (accreditation with excellence), focus on the processes linked to the strategy and continuing improvement of quality⁽¹⁰⁾.

Material supplies are meant to meet the material and equipment needs of those who develop and provide products; i.e., health care professionals. In this sense, the selection of products is determined by the health care professionals, who should work with criticism and responsibility, observing the care in the operation, which is always the central objective of quality actions⁽¹¹⁾.

In the study, the update degree of the routine manual was the item that obtained the highest rate of partial agreement among the nurses. Therefore, it should be the focus of a project for improvement. The same should apply to the adequacy of professional clothing.

It should be considered that, in everyday practice, routine manuals are administrative instruments that have the purpose of facilitating the work dynamics and nursing practice. Hence they are tools for the compilation, aggregation, and consolidation of norms and rules, administrative or operational techniques, permitting to unify terms. They also act as organizational catalysts, permitting workers to use the same concepts in any area of the organization. Therefore, it is essential for the manuals to be always be updated and to reflect, objectively, the guidelines and norms, accompanying the growth and development of the institution⁽¹²⁾.

The number of clothes is influenced by a series of variables, whose management often does not concern Nursing, especially in cases of outsourced service - which is the case of the referred institution.

There was no consensus among the respondents regarding the fact that the hospital had adequate nursing staff to provide quality service. The distribution of human resources in organizations has been a target of attention and reason for conflicts between nurses and health service administrators, as it interferes directly on the quality and operational cost. Hence, it becomes imperative that nurses with the appropriate ethical, technical and political preparation clarify the real situation of the service, use specific methodology to measure personnel with the power of argumentation and persuasion, when the proposition is to apply for adequate staff, capable of guaranteeing efficient and safe service⁽¹³⁾.

As for professional training, the study subjects reported that they have invested in their technical-scientific knowledge. Nevertheless, they experience difficulties to participate in educational activities. The survival of organizations depends, unquestionably, on the investment on training and developing their professionals, with the purpose of improving their theoretical-practical knowledge, favor self-development and encourage their participating in educational processes, to meet the needs and expectations of users, who are becoming more and more demanding, seeking quality services⁽¹⁴⁾.

Furthermore, it is recommended that the educational process reaches nurses of the Continuing Education Service and those working in the field of practice, because the observation of reality together with practice helps create updated program content, compatible with the needs of the service and management⁽¹⁵⁾.

It was observed that the nurses of the DEMI were concerned about providing qualified service, as they registered, on the patient records, the iatrogenic occurrences related to the service and, in this respect, they develop nursing action to avoid any recurrence. This attitude reveals an ethical commitment with the quality of care, free of risks and failures, and this fact is possible based on monitoring and the use of actions so the event will not be repeated⁽¹⁶⁾.

The health care model - Nursing Service System (SAE) used at the HU-USP, as of 1981, was emphasized in the process and outcomes dimensions as a facilitator for developing quality practice. The model permits to identify the users' needs, the planning and effective implementation of care, in addition to visualizing the evolution and evaluation of the service, thus favoring quality control. As to nursing prescription, this is one of the phases of the SAE, in which the nurse decides about the conducts that will be implemented, monitoring and documenting the actions for a further evaluation of the outcomes⁽¹⁷⁾.

Another interesting finding of the study was high percentage of nurses who value the opinion of users/companions during the service. The polysemic character of quality demands recognizing the symbolic processes and discursive practices of the people involved, particularly users, imposing the valorization of their perceptions, understanding them not as decontextualized subjectivities, but as signs of experiences materialized in the relationships established through health practices⁽¹⁸⁾.

It was observed that items that addressed the registers of nursing service activities are performed more comprehensively, when compared to managerial activities. That reality was confirmed by authors⁽¹⁹⁾, who analyzed the records of users of a university hospital and found high rates of incomplete or fragmented nursing notes, which made it impossible to identify minimal conduct aspects.

Considering that, by means of nursing records it is possible to, indirectly, measure service quality as they are technical and legal documents in the juridical and ethical scopes, it is imperative to build awareness, sensitization and make efforts for the nursing team to make appropriate registers of service as well as managerial activities.

It was observed that certain aspects regarding the communication among professionals need to be improved, as there was agreement that this type of problem has reduced the quality of the service. This problematic may be related with the culture of the organization, the works methods or to personnel preparation.

Communication is understood as a process to performing strategies, improving and integrating elements in the structures of the organization. Many inter and intrapersonal barriers explain the inefficacy of the communication; the main ones are selective perception, information overload, emotion, language, and cultural aspects⁽²⁰⁾.

Most nurses totally agreed that the iatrogenic occurrence in nursing service is discussed among superiors. In the Donabedian model, this situation is understood as a complex problem that depends on the infrastructure and process, in which the activities associated with the service are developed. In this aspect, a contextual analysis of the problem is essential to, in addition to identifying the culprits, for their punishment, it is necessary to diagnose the existing weaknesses and adopt proactive measures to prevent risks⁽¹⁶⁾.

By measuring the level of satisfaction that the nurses attributed to the quality of the service delivered by the nursing team it was found that most agreed partially, denoting certain dissatisfaction. It is acknowledged that the concept of satisfaction is multidimensional, as it encompasses numerous factors such as: the way of living, experiences learned, expectations and values, for the individual and for the society⁽⁴⁾.

In the comparative analysis of the structure-process-outcome aspects, the dimension with the best evaluation was the process, corresponding to the activities developed in the relationships established by health professionals among themselves and with users, including ethical aspects and all actions involving the therapy and the diagnosis of users⁽³⁾.

CONCLUSION

Considering the importance of knowing and analyzing the nurses' perception in terms of the quality of the service delivered at the DEMI, this study permitted to establish and identify the vulnerable points that should be reconstructed in the three evaluated dimensions and detect those that strengthen the quality attribute at the referred Division.

The structure dimension obtained the worst evaluations, involving the services of logistics support and organizational infrastructure. Also regarding this dimension, the responses evidenced that there is a tendency towards agreement or partial disagreement in terms of the items: difficulty to participate in professional training courses, manual updating, and quantity of clothing. There was no consensus regarding the number of nursing professionals, which points at the need for further studies.

The process dimension received the best evaluation from nurses, especially regarding the items related to the implementation of the SAE, services registers and performing actions so that iatrogenic occurrences are not repeated.

The communication between the nursing team and other health care professionals appears as a factor capable of compromising service quality. Although communication is seen as a complex element in the organizations and in human relationships, it is indispensible that nursing professionals acknowledge the problem and be willing to face it, searching for effective strategies, with a view to minimizing the negative consequences - losing service quality.

In the outcomes dimension, although the iatrogenic occurrences are registered on the users' records, the nurses stated that, in most cases, those events are discussed exclusively among their superiors. This fact deserves attention from managers, who should find administration models that are more flexible and that decentralize decisions and promote the effective participation of workers to take on responsibilities, promoting effective team work.

It should be emphasized that with the purpose of continuously improving quality, using the Donabedian triad, it is fundamental to identify the problems, aiming at implementing effective actions, monitoring the process each of those action, thus favoring service evaluation to achieve the ideal standard of quality excellence.

In conclusion, quality administration demands several strategies and tools. Most of all, however, it is necessary to count on the participation and commitment of those involved. After all, workers are the ones directly involved in the flux and dynamic of work, representing the potential of the group.

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Quality of maternal-child health care at a university hospital, according to the nurses' perspective

Calidad asistencial en la división de enfermería materno infantil de un hospital universitario, según la óptica de los enfermeros

Publication Dates

• Publication in this collection
  01 July 2010
• Date of issue
  June 2010

History

• Accepted
  15 Apr 2009
• Received
  23 Jan 2008