The reasons of the nursing staff to notify adverse events 1

OBJECTIVE: this research aimed to understand the motivation for reporting adverse events from the perspective of nursing staff in the work environment. METHOD: qualitative study that used the phenomenology of Alfred Schutz for reference, which offers a systematic approach to understand the social aspects of human action. Data were collected by open interviews with 17 nurses and 14 technicians/assistant nurses in a university hospital. RESULTS: motivation was revealed through six categories: all types of occurrences must be reported; the incident report is an auxiliary instrument to health care provision management; the culture of punishment in transition; nurses as the agents responsible for voluntary reporting; sharing problems with higher management and achieving quality in the work process. DISCUSSION: it was unveiled that, when reporting adverse events, team members perceived themselves to be in a collaborative relationship with the institution and trusted that they would receive administrative support and professional security, which encouraged them to continue reporting. Reporting allows health care professionals to share responsibilities with managers and encourages corrective actions. FINAL CONSIDERATIONS: the study revealed the nursing staff's motivation for adverse event reporting, contributing to reflections on institutional policies aimed at patient safety in health care.


Introduction
In the last few years, the voluntary reporting of adverse events has become an important instrument to improve quality in health care systems worldwide.
The reporting system consists of interconnected actions aimed at detecting and analyzing adverse events (AE) and risk situations, so that professionals can learn from such events and improve patient safety during hospitalization (1) . However, studies show that, due to underreporting, this type of system does not capture the total number of AEs occurring in institutions (2)(3) .
Research in Brazil found that 76.8% of individuals never filled a notification and, internationally, over 40% of them never utilized this procedure and 25% did not know the reporting system (4)(5) . Among the factors that interfere with underreporting are cultural and organizational aspects, practical health care structure, security systems and work regulations and processes (6) .
The Hospital Survey on Patient Safety Culture indicates that the aspects that need to be improved in institutions, in relation to notification systems, are non-punitive responses to error and the number of reported events (7) .
In view of the statements above, the questions that prompted this study were: what motivates the nursing staff to report AEs and what has their experience with a reporting system for AEs implemented in the studied hospital been like? The objective of the investigation was formulated as understanding the reasons for AE reporting from the perspective of nursing professionals in the work environment.
The results of revealing these professionals motivation will certainly contribute to better understand the subject and may permit clarification and encourage reporting and support actions to settle the related negatives aspects and enhance the positives aspects, promoting patient safety in health care.

Method
The choice of this reference is due to the relevance of Schutz' ideas to approach nursing actions in the reporting process of AE since, according to him, the situations in the world of daily life are shared and interpreted by the group, where each individual constructs his/her own view with contributions they are offered in their continuous interaction with their peers and based on an inventory of previous experiences, which operate as a reference code (8) . According to Schutz, this is the social context man lives in and relates to and, in accordance with the relationships and experiences, continues formatting his "biographic self", which distinguishes him from others, motivating him in his natural attitudes (8) . Social action, in turn, is practiced among two or more people. It is projected by man in a conscious and intentional way, and contains a subjective meaning that gives him the direction (8) .
In line with Schutz, "reasons to" instigate the accomplishment of the action and, therefore, are directed to the future. The "reasons why" are evident in the events already completed. They are the facts, are immutable, but not forgotten, and can influence the actions of the present (8) . The total number of participants was not previously set. Instead, data collection was interrupted when data showed signs that the phenomenon had been unveiled, the researchers' concerns had been answered and the objectives achieved. The technicians and/or assistant nurses were interviewed after the nurses, since they use the AE reporting system less often. Interviews were identified with the letters "E" for nurses and TA for technicians and assistant nurses, followed by an ordinal number. The interviews, which lasted on average 10 minutes, were recorded and the tapes were destroyed after transcription of the content.
Data analysis: Units of meaning were obtained from the reading and description of the actions the subjects experienced and expressed in their testimonies, seeking what was common in the actions of professionals in reports of AE, the invariant. Then, the data were organized, searching for the typical action that was analyzed in the testimonies (8) . Finally, a comprehensive analysis of these groups was performed according to the motivational theory of A. Schutz (8) .

Results
As the adopted reference, the contents of the statements were analyzed and the staff's motivation was represented in six categories: all types of occurrences must be reported; the incident report is an auxiliary instrument to health care provision management; the culture of punishment in transition; nurses as the agents responsible for voluntary reporting; sharing problems with higher management and achieving quality in the work process. These categories were grouped in ""reasons why" and "reasons for", following A. Schutz' motivation theory (8) . Among the categories that are related to "reasons why" to notify AEs, the professionals' statements define and exemplify the AEs that should be reported, composing the category: all types of occurrences must be reported. (…)I understand that an AE refers to any event occurring to patients that escapes normality.

Discussion
In this research, what was typical in the data analysis were the inconsistencies related to the patients' This study indicated that different professionals participate in the process of health care work and, hence, use the reporting system. In that way, as regards the reporting of adverse situations, the respondents perceived that health care is constructed by the development of interdependent processes, so that all the professionals involved become responsible for the results. It is observed that reporting establishes, among those who share the social reality, a relation in which intersubjectivity and intercommunication are present, since people live together, influence and understand one another, thus acting and receiving the actions from others (8) .
It is relevant to mention that nurses have been responsible for the organization and coordination of care provision activities in hospitals, as well as for making it possible for other professionals on the nursing team and others on the health care team to work in hospitals (11) .
In this regard, the AE report presents itself as a data and information instrument that fosters communication among professionals and that is helpful to management.
Concerning management/staff dimensioning, the team's statements reveal the use of reporting to denounce the overload of activities with risk to patients. It is observed that, in situations where the team's capacity to provide care is disrespected, the pressure to do so forces professionals to rely on their memory more often to perform important actions, and this hinders effective communication among professionals, thus creating an environment of insecurity for care provision (12) .
Most of the professionals in this study reported  (8) , and giving rise to transition situations of the institutional culture.
Although nursing technicians and assistant nurses understand that they can report, they show doubt concerning the authorization to do so, and they do not feel knowledgeable about how to record events. Hence, they prefer to report incidents to nurses so that they can later record it. In this way, nurses are appointed as the professionals responsible for AE reporting.
Nurses routinely play the role of nursing care supervisors due to their condition of team leaders.
They are viewed as the ones who know about all the procedures associated with health care. Many times, in this activity, they emphasize work control and supervision and the recording of failures and sanctions. Nursing professionals and other team members acknowledge that nurses, in this condition, assume an authoritarian and centralizing attitude (16) .
Hence, the team's conceptualization concerning the nurse's role as the person responsible for reporting suggests a ranking of that action and makes it difficult for nursing technicians and assistant nurses, as well as for other professionals, to take responsibility for reporting the AE they experience. Furthermore, according to WHO, this conceptualization, in reality, needs to be reformulated so that frontline professionals can report undesirable facts, such as doctors, nurses, nursing technicians and auxiliaries, more than exclusively higherranked agents. Reporting systems must be designed to enable the processing of reports, including those from patients, their relatives and service users (10) . These individuals can contribute to the process by providing additional information about the events and subsequent impacts. Additionally, providing opportunities for all to report events promotes greater surveillance among health care service providers and organizations and permits integrating active participants in the search for improvement in patient safety (17) .
Underreporting may be related to the fact of it being restricted to records made by nurses and also to other causes, such as the voluntary, non-mandatory character, the lack of time and the habit to report. Institutions that do not make efforts to promote good work conditions for the nursing staff may place their patients in a situation of greater vulnerability in relation to error occurrence (18) . In this regard, a study describes that the level of development of an organization, its work processes and professionals can directly affect care provision outcomes and observes that the majority of accidents and failures result from failures in the workplace's system (19) .
Regarding the reporter's relationship with managers, the nursing professionals' statements showed the perception of the importance of managers' opinions recorded in the feedback to reporters. Such feedback establishes the intercommunication that grants meaning to the motivated action (8) . When they participate in that produces dissatisfaction and demotivation due to the lack of recognition of the collaboration provided.
Stressful situations are frequent in nursing professionals' lives, particularly in institutions with scarce resources, as often is the case of public hospitals.
Responsible for providing specialized care as well as the material and technological resources -process and structure -necessary for patient care, those professionals are pressured to make decisions, which many times pose risk to patients' and their own integrity (20) . according to Schutz, characterize it as typical (8) .
It is recommended that managers of health care organizations, in agreement with their employees, should define and document policies for managing risk situations. Risks must be identified and analyzed according to their origins and, based on such diagnosis, preventive actions must be implemented (21) . In order to contribute to the identification of risk situations and their management, the AE reporting bulletin, as an institutional document, must be preferably anonymous and confidential, and should not be used as an instrument to accuse professionals (22) .
In this study, the contribution to the prevention of future events, the learning obtained from the investigations and the non-punitive effect of reporting are perceived as a benefit of the system, expectation that provides security to professionals.
The statements in this study showed the team's motivation to report in order to correct and improve work processes continuously, so as to prevent future AE and prevent damage to patients. In the context of quality, the meaning of continuous improvement is the incessant search for error elimination as a way to adequately qualify the outcomes (23) . In order to solve quality problems, the first step is to examine each phase of the process so as to prevent problems before they occur, instead of correcting them after they have happened. However, despite providing visibility to failures, only reporting is not enough to achieve continuous improvement. To implement the continuous improvement of processes, it is necessary to use an established, tested and reliable methodology that is supported by effective instruments and permits the achievement of preset objectives. The systematic and problem-focused approach allows for the identification of problem causes and the development and implementation of solutions and action plans for process improvement (24) .

Final Considerations
The approach used in developing this study enabled us to understand the perception of nursing professionals that the AE reporting system helps patient care management, that it allows health care professionals