Safety and satisfaction of patients with nurse's care in the perioperative

Objective: to investigate the safety and satisfaction of patients and their relationship with nurse's care in the perioperative period. Method: cross-sectional, multi-level, correlational study with 105 nurses in the surgical area and 150 patients operated in a Spanish tertiary hospital. For the nurses the sociodemographic variables, the perception of the work environment, the professional burnout and the satisfaction in the work were collected. For patients, the safety of adverse events and level of satisfaction, through the application of questionnaires. Univariate and multivariate analysis were used. Results: job satisfaction, professional commitment, and participation in hospital issues were negative predictors for adverse events related to the patient, while postoperative nurse care was a positive predictor. Conclusion: there is an increase in adverse events when nurses are dissatisfied at work, less professional commitment and low availability to participate in the subjects of their unit. On the other hand, adverse events decrease when nurses perform the care in the postoperative period. Satisfaction was good and there was no association with the characteristics of nurses’ attention. It is recommended to improve these predictors to increase the safety of surgical patients.


Introduction
The goal of a healthcare system is to ensure safe and quality health care. In this context, patient safety is a major concern today. In the context of the Patient Safety Program, the World Health Organization (WHO), develops programs that address the different risks to patients around the world (1) . In Spain, the Ministry of Health has placed patient safety as one of the key elements to improve the quality of care, according to the 2015-2020 Patient Safety Strategy. This guide describes details of the recommendations applicable to the different areas of care and to all professionals in the health team (2) . Nurses stand out as members of health care teams because they play a key role in direct patient care and an important role in the detection and prevention of adverse events (AE). An adverse event corresponds to any unintentional injury or complication resulting from healthcare. AE are indicators of patient safety and quality of care (3) . In the nursing field, AE are called nursing-sensitive outcomes (4) . The most common indicators of AE related to nursing care are errors in medication administration, falls, pressure ulcers, resuscitation failures, rescue failures, nosocomial infections, and follow-up of procedures (5) .
On the other hand, patient satisfaction about the care received is considered an indicator of quality (6) . The main causes of AE in healthcare are related to human factors, such as professional competence to assess risks, and also factors related to the system, such as conditions and characteristics of the environment in which the nurses develop their work (7) . The personal and environmental characteristics of their practice are critical predictors of patient care quality (8) . The association between the characteristics of the nurses' work environment and higher levels of training and personal endowment creates a better working environment and promote favorable outcomes in patient health, even with respect to mortality (9) . Other factors in the work environment have been associated to the quality and safety of patient care, including the physical environment, working hours, and the extent of exhaustion of nursing professionals (10) .
Most investigations have been carried out at the hospital level (11) . However, research in complex areas such as in the surgery context, is very scarce and yet a very important focus due to the volume of interventions performed worldwide each year (234 million). Surgical care leads to a considerable risk of AE that contributes to increasing the burden of morbidity. However, 50% of the complications that arise can be avoided through strategies such as "safe surgery saves lives" (12) . To avoid complications and AE in the surgical area, nursing interventions should cover the entire perioperative period, i.e. before, during, and after surgery (13) . In this sense, the impact of interventions provided by perioperative nurses on patient health outcomes, although relatively little known, seems to be of great importance. Some authors have investigated the relationship between the nursing team and complications in surgical patients (14) , as well as the phenomenon of Burnout in the surgical center (15) .
However, the relationship between perioperative nursing and patient outcomes has not been studied. For this reason, the present research raises questions about the impact of perioperative nurses and of the environment of their practice on the outcomes of surgical patients?
This study has therefore the objective to investigate the safety and satisfaction of patients and their relationship with nurse's care in the perioperative period.

Method
This work applied a cross-sectional and correlational design with two convenience samples. The first includes nurses from the surgical area, n = 105.
All the nurses who worked in the perioperative, transoperative and postoperative unit of the surgical area were contacted to participate. Nurses who were absent due to vacations or sick leave during the study period were not included. The second sample, n = 150, was composed of patients operated in different specialties: general surgery, orthopedic surgery and traumatology, thoracic surgery, gynecological surgery, neurosurgery, and plastic surgery. The patients excluded from the study were those under 18 years of age, with cognitive deficits, who had undergone endotracheal intubation for more than 48 hours, or those who had been discharged within 24 hours after the intervention. The sample size was calculated The study combines data collected from the perioperative nursing unit at the level of individual nurses and at the level of patient through various data sources. The first source was a questionnaire applied to nurses to collect information on the characteristics of the organization and of the perioperative unit (nurses' practice environment), and on sociodemographic (age and sex) and work (academic training, work experience, type of contract, job satisfaction, intention to leave the hospital, and burnout) aspects. The second source came from the patient satisfaction questionnaire, and the third www.eerp.usp.br/rlae 3 Sillero-Sillero A, Zabalegui A.
source was patient data on management, adverse event reports, mortality, and clinical outcomes.

The Spanish version of the Practice Environment
Scale of the Nursing Work Index (PES-NWI), which presented Cronbach's alpha values of 0.90 (95% CI: 0.87-0.93), was used to measure the environment or the practice environment of the nurses (16) . The index is composed of 31 items and is structured in five factors:  To measure the nurses' satisfaction, we followed the methodology used in the RN4CAST project. A single question with Likert-type scale (1 "Very dissatisfied" to 4 "Very satisfied") was used to evaluate satisfaction with the current work (coefficient of reliability 0.7).
The satisfaction questionnaire was also applied to nine specific aspects of the work: flexibility of time, professional development, autonomy at work, salary, training, vacations, commitment, sick leave, and permission to study (19)(20) . As to patients, data on sociodemographic aspects (age and sex), the specialty of the surgery to which they were submitted, the presence of comorbidities, and the length of hospital stay were collected. Patient safety outcomes were analyzed by assessing the presence of adverse events, including mortality and rescue failure. The indicators of EA of the 150 patients were collected from records of adverse events reported in the surgical area and in medical records. The criteria and data sources for each outcome were based on the SENECA100 model: pressure injuries, nosocomial infections, phlebitis, medication-related AE, postoperative complications and pain. This model was used in another study at the national level (21) , which coincided with reliable and valid indicators in international studies (22) . For this study, the AE were recoded in a dichotomous variable (absence/ presence of AE) to relate them to the characteristics of the nurses.

LaMonica-Oberst Patient Satisfaction Scale 12
(LOPSS-12) adapted in Spanish (23) , with Likert-type scale responses ranging from 1 (totally agree) to 5 (totally disagree) was used to analyze the satisfaction of patients with nursing care. All elements are related to the care provided by the nursing staff, for example: "They help me understand my illness". The original scale was structured in two satisfaction factors: the positive and the negative factor, which were difficult to measure.
For this reason, we chose to recodify it in one direction, calculating the arithmetic mean of the responses given to the 12 items: the higher the score obtained, the higher the degree of patient satisfaction, as in another study (24) .
The internal consistency of the LOPPS questionnaire was 0.81 (Cronbach's alpha). In addition, patients were asked if they would recommend the hospital to others.
The questionnaires were self-completed, after signing the Informed Consent Form.
Regarding the treatment and analysis of data, the descriptive analysis of the characteristics of nurses and patients was done using absolute frequencies and percentages for the qualitative variables, and means and standard deviation (SD) for the quantitative variables.
Considering that there were set of patients assisted by the same nurse (105 nurses for 150 patients), multiple-level analyses were performed incorporating the hierarchical structure of the data, that is, patients nested within nurses. The multilevel full regression model assumes a set of hierarchical data with the dependent variable (presence/absence of AE) measured at the lowest level (patients) and the explanatory variables that exist at both levels. In the present study, the efficient way to correct the variable nurse that assists the patient is to use the multilevel analysis, that is, the nurse variable as the second level. Observations made at the level of patient are nested at the level of nurse.
Taking into account this hierarchical structure of the data, the following analysis were made: estimation of the mean in different variables through the models that include the variable of random effects and variable of fixed effects. A univariate analysis was performed between each of the independent variables (fixed effects) www.eerp.usp.br/rlae 4 Rev. Latino-Am. Enfermagem 2019;27:e3142. and the scores of the dependent variables through simple multilevel linear regression models. In turn, a multivariate analysis was made using multilevel multiple linear regression models for the independent variables (fixed effects) that were taken to the multivariate models that were those that obtained a level of significance   Table 1.
The association between the existence of comorbidity and the appearance of AE in operated patients was highly significant. The relationship between the type of surgical specialty and the presence/absence of AE was also significant. The appearance of AE was more frequent in cases of neurosurgery (52.4%) than in the rest of the specialties (between 28.6% in thoracic surgery and 41.8% in general surgery). No association was found among the other analyzed variables.
In the second analysis, an association was made between the variables characteristics of the nursing work environment and presence/absence of AE within 30 days post-intervention. (  After this, a multivariate analysis was performed. The coefficients (r) are presented in the univariate way for all the independent variables analyzed and adjusted for those variables that were included in the final multivariate model (Table 3).   Table 4.
No variable was found to be significantly associated (p > 0.05) when the variables of nurses' characteristic were crossed with total patient satisfaction. Consequently, none of the nurses' characteristics was able to effectively predict patient satisfaction, as described in the table below (Table 5).
www.eerp.usp.br/rlae 7 Sillero-Sillero A, Zabalegui A.  to the maintenance of personnel, such as personnel changes and excessive use of temporary staff due to the generational change in our perioperative area influenced these associations. We agree that these problems are risk factors for patient safety (22,(28)(29) . Confirming the present results, the predictors of AE are job satisfaction, participation in hospital matters, professional commitments, and postoperative care, coinciding with other studies (27,(30)(31) .The importance of having a positive practice environment for the work of nurses was clear.
Such aspect increases the job satisfaction, commitment, and retention of nurses and the best outcomes for patients. Research in magnetic hospitals has extensively documented the impact of nursing care on both nurse and patient outcomes (32) . The record of the reported events was 38%. It is a value that is not high in relation to other investigations (33)  usual in other studies (34)(35) . There is another difference between our study and the others in which there was no mortality (9,36) . The most reported AE was the presence of pain, followed by postoperative complications (bleeding and wound infection). This is similar to national (21,37) and international (38) studies and suggest that efficient measures should be taken and safe practices applied (12) .
It is important to note that most AE, such as pain, can be prevented or eliminated if detected early.
Regarding patient satisfaction, the characteristics of the nurses did not present a significant association with it. The current findings may have been influenced by confounding factors that were not assessed, such as other individual or organizational characteristics that were not considered. However, the behaviors of nurses during perioperative care were positively evaluated by the patients (24) . This is a very positive aspect because the patient's experience results from the actual quality of care and from their perception (39) . One of the most important results was that the vast majority of patients (119), i.e. 91.3%, answered that they would recommend the hospital to others (for example, friends or relatives).
Patients had positive perceptions of the nursing care and a greater likelihood of satisfaction with general care. As different studies suggest that satisfaction with the care provided represents an important part of the quality of hospital care, the present findings are a good result for perioperative nurses and for the organization (40)(41) .
The main limitation of the study is that data collection was restricted to a single hospital, convenience samples It also showed the impact that different aspects such as job satisfaction, professional commitment, and work the environment have over the quality of care.