Validation of the process criteria for assessment of a hospital nursing service

Feldman, Liliane Bauer; Cunha, Isabel Cristina Kowal Olm; D'Innocenzo, Maria

doi:10.1590/S0104-11692013000400003

Acessibilidade / Reportar erro

Brasil

Revista Latino-Americana de Enfermagem

Español English

Brasil

Español English

sumário « anterior atual seguinte »

Sumário

Original Articles • Rev. Latino-Am. Enfermagem 21 (4) • Jul-Aug 2013 • https://doi.org/10.1590/S0104-11692013000400003 copy

Validation of the process criteria for assessment of a hospital nursing service ¹ 1 Paper extracted from doctoral dissertation “Validação dos critérios de avaliação do serviço de enfermagem no programa de acreditação”, presented to Escola Paulista de Enfermagem, Universidade Federal de São Paulo, SP, Brazil.

Authorship SCIMAGO INSTITUTIONS RANKINGS

OBJECTIVE:

to validate an instrument containing process criteria for assessment of a hospital nursing service based on the National Accreditation Organization program.

METHOD:

a descriptive, quantitative methodological study performed in stages. An instrument constructed with 69 process criteria was assessed by 49 nurses from accredited hospitals in 2009, according to a Likert scale, and validated by 16 judges through Delphi rounds in 2010.

RESULT:

the original instrument assessed by nurses with 69 process criteria was judged by the degree of importance, and changed to 39 criteria. In the first Delphi round, the 39 criteria reached consensus among the 19 judges, with a medium reliability by Cronbach's alpha. In the second round, 40 converging criteria were validated by 16 judges, with high reliability. The criteria addressed management, costs, teaching, education, indicators, protocols, human resources, communication, among others.

CONCLUSION:

the 40 process criteria formed a validated instrument to assess the hospital nursing service which, when measured, can better direct interventions by nurses in reaching and strengthening outcomes.

Nursing Evaluation Research; Quality Assurance, Health Care; Outcome and Process Assessment (Health Care); Evaluation Studies; Accreditation; Safety Management

	Not important		A little important		Relative importance		Important		Very important
	n	%	n	%	n	%	n	%	n	%
1 - The Standard Operating Procedures (SOPs) and/or Normative Instructions (NIs) are updated all over the institution							10	20.4	39	79.6
2 - Nursing SOPs and/or NIs are distributed among workers							10	20.4	39	79.6
3 - There is a formal description of SOPs, NIs and/or nursing protocols in the Nursing Manual							6	12.2	43	87.8
4 - There is a Nursing Manual available and easily accessible for consultation by the team.							8	16.3	41	83.7
5 - Nursing SOPs and/or NIs are validated by the quality area					4	8.3	15	31.3	29	60.4
6 - Nursing SOPs and/or NIs are periodically reviewed							13	26.5	36	73.5
7 - The assessment phase of the Nursing Process is applied							11	22.4	38	77.6
8 - The diagnostic phase of the Nursing Process is applied					2	4.2	17	35.4	29	60.4
9 - The care planning phase of the Nursing Process is applied					1	2.0	10	20.4	38	77.6
10 - The evaluation phase of the Nursing Process is applied							10	20.4	39	79.6
11 - The phases or model of the Nursing Process are applied in critical areas such as the ICU							7	14.3	42	85.7
12 - The phases or model of the Nursing Process are applied all over the institution					4	8.2	16	32.7	29	59.2
13 - Information from the Nursing Process is used by the multidisciplinary team					4	8.2	12	24.5	33	67.3
14 - There is evidence of the utilization of information from the Nursing Process in the prescription of other professionals					7	14.3	21	42.9	21	42.9
15 - The use of the Nursing Process is articulated as a form of continuity of care					2	4.3	10	21.3	35	74.5
16 - Nurses are responsible for their own practice and care coordination					2	4.2	10	20.8	36	75.0
17 - Nursing administration and management is visible in the institution					1	2.0	8	16.3	40	81.6
18 - The nurse specialist participates in the selection and acquisition of hospital technology (equipment) for the workplace			1	2.0	2	4.1	13	26.5	33	67.3
19 - There is evidence of assessment by the nurse manager for the technology to be acquired in the institution			2	4.1	2	4.1	16	32.7	29	59.2
20 - There is at least one nursing work group to improve processes and institutional interaction.					2	4.1	14	28.6	33	67.3
21 - Nurses participate in working groups (committees or commissions) in general in the institution					1	2.0	10	20.4	38	77.6
22 - Nursing administration or management is available					1	2.1	6	12.5	41	85.4
23 - There is active participation (involvement and commitment) of the nurse manager and nurse leaders in nursing administration					4	8.2	4	8.2	41	83.7
24 - The nurse manager is autonomous to make decisions about the work processes					3	6.1	6	12.2	40	81.6
25 - The care processes that involve nursing are often analyzed and improved					2	4.1	4	8.2	43	87.8
26 - The critical analysis and improvement of processes (e.g. non-compliance and risk) identified by nursing are treated with a deadline					3	6.1	10	20.4	36	73.5
27 - Formal periodic meetings are held for the analysis of nursing work processes					2	4.3	10	21.7	34	73.9
28 - Nurses use indicators to measure the quality of care					2	4.1	6	12.2	41	83.7
29 - The indicators of quality of nursing care are used to outline action plans and improvement of processes					2	4.2	6	12.5	40	83.3
30 - The participation of the nursing team is encouraged to establish actions and assess the outcomes.					4	8.2	12	24.5	33	67.3
31 - The nursing team is aware of who its customers and suppliers are					2	4.2	18	37.5	28	58.3
32 - There is a systematic and periodic update and/or improvement program for the nursing team					1	2.0	9	18.4	39	79.6
33 - The nurse manager has the autonomy to hire nursing workers	1	2.1			5	10.6	9	19.1	32	68.1
34 - Nurses have the autonomy to fire nursing workers	1	2.1			6	12.8	7	14.9	33	70.2
35 - There is a formal program to integrate the new employee (nursing professional) into the institutional service			1	2.0	1	2.0	12	24.5	35	71.4
36 - Patient's rights and privacy are respected in all hospital environments by nursing, according to law							7	14.3	42	85.7
37 - Nurses participate or act in the inpatient information system with other professionals							15	31.3	33	68.8
38 - The day/night cycle of inpatients is preserved by nursing					2	4.2	21	43.8	25	52.1
39 - There is evidence that communication is effective in nursing					2	4.2	15	31.3	31	64.6
40 - Nurses know the most prevalent nosocomial profile in the institution					5	10.4	21	43.8	22	45.8
41 - The institution has (multidisciplinary) clinical protocols used by nursing based on evidence and on the nosocomial profile			1	2.1	3	6.3	13	27.1	31	64.6
42 - Newborns are distributed according to severity by nursing.					2	4.3	10	21.7	34	73.9
43 - The nurse who is member of the hospital risk management committee or group participates in decision making					1	2.1	15	31.9	31	66.0
44 - There is a system implemented for the management of adverse events	1	2.1			1	2.1	6	12.8	39	83.0
45 - Nursing implements actions against adverse events					2	4.2	6	12.5	40	83.3
46 - Nursing counts on safety and/or controlled access and/or continuous surveillance in Pediatrics, Neonatal and Psychiatry areas			1	2.1	4	8.3	14	29.2	29	60.4
47 - There is a system implemented for the management of infection risks					1	2.1	8	16.7	39	81.3
48 - Nursing acts in partnership with the Commission for Infection Control in epidemiological surveillance of infections							9	18.4	40	81.6
49 - Nursing implements action against infection-related adverse events					1	2.0	11	22.4	37	75.5
50 - Nursing implements action against adverse events with blood components					2	4.1	13	26.5	34	69.4
51 - Nursing implements action against adverse events with equipment					5	10.2	15	30.6	29	59.2
52 - Nurses control psychotropic drugs in the nursing unit					3	6.3	11	22.9	34	70.8
53 - Nursing implements action against adverse events with drugs					3	6.1	8	16.3	38	77.6
54 - There is validation by nursing related to sterilization processes in the Material and Central Sterilization							5	10.2	44	89.8
55 - There is a thermometer for temperature and humidity measurement by nursing in the arsenal of the Material and Central Sterilization by nursing					2	4.1	8	16.3	39	79.6
56 - Nursing implements action in the absence of any instrument after surgery in the operating room					1	2.0	15	30.6	33	67.3
57 - There is a system implemented for the management of environmental risks in the institution			1	2.1	4	8.5	23	48.9	19	40.4
58 - The pieces in the institution are comprehensively identified and its outflow is registered and controlled by nursing					1	2.0	9	18.4	39	79.6
59 - Nursing follows the destiny of body parts to the environment, with other areas	1	2.1	2	4.2	14	29.2	19	39.6	12	25.0
60 - Nursing implements actions against adverse events with waste					3	6.1	6	12.2	40	81.6
61 - There is an institutional system implemented for the management of civil nursing responsibility risks	1	2.1			2	4.3	16	34.0	28	59.6
62 - There is a contingency plan for unforeseen or unexpected events in Nursing	1	2.1			6	12.8	18	38.3	22	46.8
63 - Nursing implements action when there are contingent events	2	4.1			1	2.0	17	34.7	29	59.2
64 - In the refrigerators of the nursing unit, there is complete identification of what is stored	1	2.1			1	2.1	9	18.8	37	77.1
65 - There is systematic control of the refrigerator temperature in the nursing units					1	2.1	10	20.8	37	77.1
66 - There is a systematic routine of cleaning and hygiene of refrigerators used by nursing					4	8.7	15	32.6	27	58.7
67 - Nursing management receives and analyzes customer assessments					1	2.0	14	28.6	34	69.4
68 - Nursing management uses customer assessments to propose improvements in processes					1	2.1	14	29.2	33	68.8
69 - There is articulation between the Hospital and the Nursing School or College evidenced in care	2	4.3	1	2.1	9	19.1	22	46.8	13	27.7

Escola de Enfermagem de Ribeirão Preto / Universidade de São Paulo Av. Bandeirantes, 3900, 14040-902 Ribeirão Preto SP Brazil, Tel.: +55 (16) 3315-3451 / 3315-4407 - Ribeirão Preto - SP - Brazil
E-mail: rlae@eerp.usp.br

Acompanhe os números deste periódico no seu leitor de RSS

[1] Corresponding Author: Liliane Bauer Feldman Rua Traipu, 704 Bairro: Pacaembu CEP: 01235-000, São Paulo, SP, Brasil E-mail: lilianedoutora@gmail.com