Influence of hospital Accreditation on professional satisfaction of the nursing team: mixed method study

ABSTRACT Objective: to analyze the influence of Accreditation on the professional satisfaction of nursing workers. Method: multicentric, cross-sectional research, outlined by the sequential explanatory mixed method. In the first preponderant, quantitative step, the validated Brazilian version of the Index of Work Satisfaction was applied to a sample (n = 226) representative of nursing professionals from three hospitals. One hospital was private and certified by Accreditation; another hospital was private and non-certified; and another was public and non-certified. By connection, the second step (qualitative) complemented the quantitative analysis. In this step, interviews (n = 39) were carried out and summarized through the method of Discourse of the Collective Subject. Descriptive and inferential statistical analyses were applied to the quantitative data connected to the qualitative support, as well as a joint presentation of part of the information in a joint display. Results: workers of the certified hospital had a better overall job satisfaction score. There were more statistical associations among workers in private hospitals. The comparison of the three groups investigated in the two steps of the mixed study confirmed Accreditation as a positive factor for professional satisfaction. The public hospital excelled in relation to the certified hospital in terms of salary, job requirements and interaction. Conclusion: Accreditation positively influenced the professional satisfaction of the nursing teams investigated.


Introduction
Wrapped in a scenario full of adversity that is tied to the competitiveness of the globalized market, the health sector and health services should enable organizational survival through active, rational and, mainly, strategic management practices (1) .
In this scope, based on the philosophy of quality management, evaluation is the aegis of the search for continuous improvements and indispensable practice for the rationalization and effectiveness of the work process (2) .
Due to the peculiarity of the modus operandi of the health area, evaluation can be a taboo. This differs from other service production branches such as aviation, hotel trade, and the financial/banking sector, which are nown to adopt evaluations in their daily work in a natural way. In spite of this, Accreditation has emerged throughout the world as a management system based, essentially, on thirdparty evaluation and demonstration of competence of the adherent organizations, with adaptations favorable to the unique reality of the health sector (3) .
The logic of Accreditation is mediated by the comparison of the institutional reality evaluated externally and periodically in the light of previously defined quality standards, determined in a clear and standardized way according to the accreditation methodology adhered by the country which, in the case of Brazil, is mostly represented by the National Accreditation Organization (NAO) (3)(4) . This logic reaffirms that Accreditation is conducted through the establishment of criteria, standards and indicators to leverage the strategic vision of institutions, which are driven by external evaluation (2) .
Although the main focus of Acreditation is the clinical-healthcare dimension, because it has emerged in the light of health production, this quality management system tends to have a positive impact on services in several organizational spheres, such as changes in top management, cost administration, and business marketing (3,5) . However, the real benefits of Accreditation, whether in the health care or administrative/strategic context, are still little known, both nationally and internationally and then studies are still needed to identify improvements attributable to this quality management system (5)(6)(7)(8) .
Considering the impossibility of dissociating the nursing services from the quality of care provided, including in hospitals (9) , it is postulated that the knowledge gap on the benefits of Accreditation is related to the professional satisfaction of the nursing team because, in theory, the dynamics of people management needs to be improved through adherence of organizations to Accreditation (4) .
The professional satisfaction of the nursing team is an important indicator of the quality of organizational results, especially in the context of human resource management. This is understood as a complex and multidetermined phenomenon that converges to a behavioral state of the worker toward his work (10) . Therefore, knowing the professional satisfaction of the nursing team can direct a relevant and dual perspective of evaluation, namely: the professionals' view about their work, and also the potential to impact the produced care (10)(11) .
The fact that professional satisfaction is an interest towards the improvement of nursing services and that investigating the real benefits of Accreditation to the overall quality of health is sorely needed (2,(5)(6)(7)(8) makes research on this theme necessary, especially the multicenter studies, i.e. those coducted in different places.
Once the inclination to investigate the problem has been justified, this study was guided by the following questions: "Does Accreditation influence the professional satisfaction of nursing workers? If so, in what way?". To answer these questions, the objective was to analyze the influence of Accreditation on the professional satisfaction of nursing workers.

Method
Multicentric, cross-sectional research, outlined by the sequential explanatory mixed method. In this study design, the research is conducted in steps of the following approaches: first, the quantitative (QUAN) analysis, which is priority and has a greater weight, and, second, the qualitative (Qual) analysis, of lesser weight (12) .
In order to be confirmed as a sequential explanatory mixed study, the approaches/steps of the study need to be interrelated by a connection procedure in which the analysis of the data collected from the "QUAN" step leads to the collection of data in the "Qual" step (12) .
The study sites were all Intensive Care Units with Excellence) of certification by the accreditation methodology in question, and that had the greatest durability for expiration, was searched in the NAO website (4) . After selection of the Accredited Hospital (HA), which was private, two other general hospitals with intensive care beds were selected at most 150 kilometers distant from the AH and of the same size (medium size) of the AH.
Two other non-accredited hospitals were selected through the National Registry of Health Establishments. Of these, one was private (HB) and the other was public (HC). This procedure of differentiating the type of care between the two hospitals to be compared to the certified organization (HA) was intentional and aimed to increase the possibility and variability of inferences about the objects of study. In turn, the procedure of maximum distance between institutions was adopted to reduce variation (deriving from geographic/cultural realities) of labor issues that could influence the professional satisfaction, such as working hours and remuneration. and nurse-nurse interaction (5,10) . In this study, the option was not to make such differentiation. In these six dimensions, the scale is distributed in 44 evaluative items raging from 1 (total agreement) to 7 (total disagreement); the lower the score, the greater the agreement of the subject with the phrase, which was translated into greater/better professional satisfaction (10) . First, the normality of the data of the IWS scale was checked by the Kolmogorov-Smirnov test. In case of normal distribution, the analysis continued with the t-student parametric test for independent samples to compare two groups, based on the "Accreditation factor" (HA x HB; HA x HC), and one-way ANOVA for comparisons of three groups. The statistical significance adopted in all inferential analyses was 5%, expressed as p-value and Confidence Interval between differences. The reliability (internal consistency) of the IWS was tested and considered satisfactory when Cronbach's alpha was higher than 0.7 (13) .
The data of the step "Qual" were transcribed verbatim in a digital medium. After that, the printed material was analyzed by the Discourse of the Collective Subject (DCS) to group the previously thematized data according to the previous connection to IWS domains and then presented in first-person speech, so that the testimonies, in each hospital, were unified according to the domains of professional satisfaction (14) . This means that the DCS was used as a technique for grouping the data that had already been directed to thematic organization in the collection according to the IWS dimensions, in order to converge to the sequential explanatory mixed methodology (12) .
In the presentation of the findings, the statements were edited educational standards but without changing the meaning in the DCS.
Understanding each discourse as coming from a colectivity (14) , the agglutinated statements were identified only by the reference hospital (HA, HB and HC). Furthermore, the averages of the IWS domains were re-presented in order to corroborate or confront the content of each DCS and present the results of the different approaches in the mixed research jointly, as recommended by contemporary scholars in mixed methods such as "joint display" (15) .
All ethical precepts governing human research were respected, including the use of the Informed Consent Term in the two steps of data collection.
Thus, the study was submitted and approved by the institutionalized Ethics Committee and is registered nationally with CAAE: 58571216.4.0000.0104.

Results
The      Rev. Latino-Am. Enfermagem 2019;27:e3109.   Table 4 shows the data of the last quantitative analysis, which consists of the statistical association between the three groups of workers of the hospitals.  (HC -4,08).

Interaction
Our relationship is good. I think we talk, understand each other. Everyone works in the same quantity and quality. We are very united (HA -3,43).
The relationship is fine. There are the "picuinhas" (division into small groups), but it's ok. Everyone works as a team. It also has some degree of intimacy. Everyone tries to help the other as much as possible. (HB -3,65).
The relationship is not only professional, we also have a relationship of friendship. We are very united and, perhaps, "little things" may happen, but we resolve them. I see harmony (HC -3,38).  is pointed out as an indicator of organizational quality at the heart of personnel management (16) .
A fact that is out of the objective of the research but that called attention in a critical reflection of the findings was the greater proportion of nurses who reported to be dedicated "only" to care provision in their units.
This may be a product of the service organization itself through a chart that includes the average management in the ICUs as the leadership of the "assistance" nurses.
However, not to recognize themselves as care managers -regardless of the position occupied -weakens the professional identity of nurses and the consolidation of nursing as a science.
It is important that the recognition or acceptance of nurses as care managers be debated since their professional training because, although nursing management and nursing care are complementary and inseparable, there is a dichotomy between them since undergraduate training and this can negatively affect the future professional identity and, perhaps, job satisfaction (17) . In contrast, despite the relevance of taking management to the work scope of nursing in any sphere of work, nurses occupying strategicadministrative positions were less satisfied than their peers who dedicate their attention to "assistance" positions (18) .
In relation to the average salary found in the three research sites, the positive contrast between the public institution and, secondly, the accredited organization, which paid the highest salaries, was evident. This raw/ isolated data is confirmed by assessments around this field of job satisfaction, either through quantitative or qualitative analysis. That said, it is important to recognize the positive statistical significance in the comparisons of two groups, and it can be inferred that remuneration was a domain influenced by Accreditation in the analysis among private institutions, but in the comparison with a non-accredited public hospital, the results were better for the latter.
Remuneration is not the only factor that influences professional satisfaction, but it is relevant for any worker, because favorable conditions to the quality of life demand financial resources (10)(11)18) . In this respect, it is praiseworthy that the accredited hospital, although private, presented a higher average payment of personnel than the non-accredited private institution.
This may be directed to a less mercantile view of work and greater appreciation of the human capital, producer of care, respecting the external needs to the work.
The evident difference between the remuneration in the three hospitals is an aspect that deserves attention, At the third level of certification (Accreditation with Excellence), as in the case of HA, the institution needs to demonstrate excellence in management through rational strategies over measured results in this and other evaluation perspectives, highlighting the organization's commitment to its human capital (4)(5) .
It can be seen that the logic of rationalization of health work mediated by Accreditation can be a factor that contributes to professional satisfaction of the nursing team. This is ratified by the data analyzed from the three groups of workers, in which the team working in the accredited hospital had the higher total score. This data alone can be considered relevant and even innovative for the knowledge of the management system investigated.
Even with some similar scores, Accreditation was a factor that defined statistical significance in several evaluative dimensions, either in paired or condensed comparison in the three groups.
In the overall analysis of the mixed study, the DCS Even more clearly, in the dimension organizational norms, the testimonies reinforce the better job satisfaction in the hospital that adheres to accreditation.
This was also ratified by the greater difference found in the comparison of average scores in the field evaluated by the IWS, a fact that placed the mixed study as an approach that promotes greater deepening and understanding of the investigated phenomenon.
As a management system based on the rational logic of the basic principles of management, but adapted to the unique reality of the health area, Accreditation tends to be clearly standardized, even because its well-defined principles and methods are based on full compliance with standards (i.e., the understanding of assessment for certification is based on the perspective of "all or nothing" in the pursuit of compliance with standards) (3)(4) .
In the Accreditation process, it is expected that management practices, especially in hospitals -where the pace of work is troubled and the technological density associated with care is high -that adhere to this quality management system be strictly rational, punctual and strategic, resulting in a formal apparatus of well-mapped rules, protocols, routines and work processes (5) .
When organizational norms are placed in check, it is reminiscent of the empirical but socially known conception that nursing workers may be "plastered" to caring actions or otherwise oppressed by a robust organizational apparatus. In the context of Accreditation, it must be acknowledged that the system is already regarded as a promoter of tension due to excessive collection of results and also for causing greater stress among Brazilian nurses, which may or may not be linked to the excessive standardization of work (19)(20) .
The findings of this study suggest that the professionals in the institution accredited with excellence attributed satisfaction to the "imposed" organizational norms. In the qualitative part of the research, such norms were related to markers of standardized conducts and better job security, for the adoption of protocols and well defined conducts. This is in line with a research conducted with 220 Korean nurses, in which Accreditation from the Joint Commission International was envisaged as an intermediary of development and better professional performance (21) .
It is noteworthy that this research happened in two The findings of a study carried out with 901 health professionals from Saudi Arabia corroborate with the results of this study, who referred to Accreditation as responsible for direct improvements in the work process, in face of their normative requirements (6) . On the other hand, another investigation carried out with 1312 nurses from Iran testifies that, despite bringing robustness to the work process, the impact of Accreditation on the quality of concrete results can not yet be taken as absolute truth (22) .
Regarding Accreditation as the only factor interfering with job satisfaction is premature and counterproductive, since the work dynamics in any organization hold variables that influence job satisfaction and other indicators, far beyond the management system or its absence. This is in line with the frankness of the fact that isolating the "Accreditation factor" is a challenge. Possibly, this is the major limitation of this research, besides being restricted to hospitals in the state of Paraná.
In spite of the above, the study brings interesting