Nursing activities in central supply and sterilization: a contribution to personnel design

Abstracts

OBJETIVOS: Identificar e validar as atividades realizadas pela equipe de enfermagem em Centros de Material e Esterilização, como subsídio para definição da carga de trabalho da unidade. MÉTODOS: A identificação das atividades ocorreu, mediante consulta às indicações formuladas pelos órgãos oficiais, bem como levantamento bibliográfico sobre o assunto. Na validação das atividades identificadas, foi utilizado o método da Validade de Conteúdo, aplicando-se a Técnica Delphi. RESULTADOS: Participaram como juízas 11 enfermeiras que atuavam em Centros de Material e Esterilização. Os comentários e sugestões realizados na primeira fase da Técnica Delphi, determinaram alterações no conteúdo do quadro de atividades, que foram submetidas à nova avaliação do grupo, resultando na validação de seis áreas de trabalho, 25 subprocessos, 110 atividades e 25 atividades específicas da enfermeira. CONCLUSÃO: Com esta pesquisa evidenciam-se perspectivas para a realização de novas investigações que contribuam para a determinação de parâmetros que subsidiem o processo de dimensionar pessoal de enfermagem nestas unidades.

Recursos humanos de enfermagem no hospital; Papel do profissional de enfermagem; Administração de materiais no hospital

ORIGINAL ARTICLE

Nursing activities in central supply and sterilization: a contribution to personnel design^*

Actividades de enfermería en centro de material y esterilización: contribución para el tamaño del personal

Janaína Anchieta Costa^I; Fernanda Maria Togeiro Fugulin^II

^IMaster in Nursing, School of Nursing, Universidade de São Paulo - USP - São Paulo (SP), Brazil

^IIDoctor in Nursing, Professor at the School of Nursing, Universidade de São Paulo - USP - Sao Paulo (SP), Brazil

^{Corresponding Author}

ABSTRACT

OBJECTIVES: To identify and validate the activities performed by nursing staff in the Central Supply and Sterilization department, in order to define the workload of nurses on this unit.

METHODS: Nursing activities were identified through a review of literature and statements made by official agencies on the subject. To validate these identified activities, we used the Delphi technique to achieve content validation.

RESULTS: 11 nurse experts working in Central Supply and Sterilization participated in the study. Comments and suggestions made in the first phase of the Delphi technique led to changes in the content of these activities. These changes were then re-assessed by the experts, resulting in the validation of six areas of work, 25 sub-processes, 110 activities and 25 specific nursing activities.

CONCLUSION: This research identified prospects for new investigations that contribute to parameters supporting the process of scaling the nursing staff in these units.

Keywords: Nursing staff, hospital; Nurse's role; Materials management, hospital

RESUMEN

OBJETIVOS: Identificar y validar las actividades realizadas por el equipo de enfermería en Centros de Material y Esterilización, como subsidio para la definición de la carga de trabajo de la unidad.

MÉTODOS: La identificación de las actividades se llevó a cabo mediante la consulta a las indicaciones formuladas por los órganos oficiales, así como por el levantamiento bibliográfico sobre el asunto. En la validación de las actividades identificadas, se utilizó el método de Validez de Contenido, aplicándose la Técnica Delphi.

RESULTADOS: Participaron como jueces 11 enfermeras que trabajaban en Centros de Material y Esterilización. Los comentarios y sugerencias realizadas en la primera fase de la Técnica Delphi, determinaron alteraciones en el contenido del cuadro de actividades, que fueron sometidas a la nueva evaluación del grupo, resultando en la validación de seis áreas de trabajo, 25 sub procesos, 110 actividades y 25 actividades específicas de la enfermera.

CONCLUSIÓN: Con esta investigación se evidencian perspectivas para la realización de nuevas investigaciones que contribuyan a la determinación de parámetros que subsidien el proceso de establecer el tamaño del personal de enfermería en estas unidades.

Descriptores: personal de enferméria en hospital; rol de la enfermera; administración de materiales de hospital

INTRODUCTION

In recent decades, the Brazilian healthcare system has been struggling with improving quality of services offered to the population. To achieve this goal, it is paramount to incorporate new management strategies that can reduce costs, improve services and meet customers' needs and expectations⁽¹⁾.

However, the lack of understanding of effective measures that can enable control of costs and reduction of expenses has had an impact on human resources policies of health care institutions, strongly affecting nursing professionals, who account for the highest number of employees within these institutions.

Faced with limited budgets, managers of healthcare institutions frequently resort to quantitative/qualitative decrease of nursing personnel, which implies on work overload, impairs organization and delivery of patient care, and compromises implementation of strategies to improve quality of care.

Consequently, nurses in charge of managing nursing services have found it hard to allocate their personnel. Faced with the challenge of offering immediate and safe care to patients, nurses try to distribute human resources available prioritizing patient care, rather than areas not directly involved in direct patient care.

Therefore, in spite of the pivotal role that Central Sterile Supply Units (CSSUs) perform in the quality of care, particularly when performed within hospitals, they frequently struggle with insufficient or under-qualified personnel to develop activities regarding processing odontological-medical-hospital items.

This situation is worsened by the lack of standardized approach to estimate personnel needs, taking into account the specificity of the tasks carried out in this area, and provide nurses with the necessary evidence to estimate needs and assess personnel performance in CSSUs, providing solid data to subsidize proposals related to allocating additional personnel when negotiating with higher management.

The main approach to estimate nursing personnel relies on the concept of workload per nurse, which is calculated according to the average number of patients, taking into account the patient's degree of dependence on the nursing team or the type of care provided, the average time necessary per patient, considering the degree of dependence or type of care⁽²⁾.

From this point of view, the workload is based on patients' needs for direct and indirect care, and the time spent by the nursing team to provide such care⁽³⁾.

Based on the same principle, a similar calculation could be made at CSSUs, identifying the tasks performed and determining the time spent on each task required to process materials.

Considering the lack of a widely accepted model to subsidize the estimation of personnel for these units, this study aimed at identifying and validating activities developed in each area of hospital CSSUs, in order to subsidize the definition of the time spent to perform them and provide parameters to plan and assess a suitable personnel structure to provide these services adequately.

METHODS

This is a study of methodology development⁽⁴⁾, aiming at identifying and validating activities carried out by the nursing team at CSSUs, to generate initial data to subsidize assessment of workload at these units.

In order to identify activities developed by the nursing team at CSSUs, we initially consulted recommendations issued by Brazilian departments of health, as well as the few guidelines available. Secondly, we reviewed the literature on the subject, considering the pertinent activities performed in each area of CSSUs, as well as those which are carried out specifically by nursing professionals.

In order to validate activities identified as being representative of those performed by nurses at CSSUs, we used the content validation approach⁽⁵⁾ applying the Delphi technique⁽⁶⁾.

The panel of experts consisted of nurses, board-certified and/or with at least 5 years experience at CSSUs in hospitals in São Paulo that were appointed as references for the high quality of their services.

These hospitals were indicated by four university professors with extensive expertise and work experience in this area, who contribute for the definition of minimum criteria for these activities and carry out academic activities in this area of expertise. Out of the fourteen institutions appointed, we excluded the ones that did not qualify as general hospitals (n=3). The panel of experts who participated in our study consisted of 11 nurses, each representing one of the 11 remaining institutions.

This panel evaluated the relevance, clarity and objectivity of the definitions of the work areas and the related sub-processes; clarity and objectivity in describing activities performed in each area; representativeness of the activities described regarding nursing-related work in each area; performance of these activities, need for inclusion or exclusion of activities in each area.

Areas, work sub-processes and activities that reached agreement of at least 70% in any phase of the Delphi Technique were considered valid.

All participants were informed of the aim of the study, the confidentiality regarding individual participations, the voluntary character of participation and signed the Informed Consent. The study was approved by the Ethics Review Board of the School of Nursing - University of São Paulo (registration number 728/2008).

RESULTS

Review of literature initially identified 200 articles in local and/or international publications, but only 12^(7-18) of which allowed for the identification of activities performed by nursing professionals at hospital CSSUs .In addition, we complemented our research with regulations and guidelines related to the topic^(19-30).

Activities identified in the literature were analyzed and organized in a specific instrument, which was later be subjected to analysis by the panel of experts.

In the literature we identified 44 activities related to 5 work areas and 18 activities that are attributable to the nurse.

Analysis of literature showed that activities performed at CSSUs are structured according to the work processes developed at the different areas of the unit.

Based on that, in our instrument each area was defined and presented as a specific work process, identified by a letter (A-F). Within each area, each work sub-process was identified, defined and represented by a number. Related activities were represented by letters and numbers.

Although sterilization is a single step in the preparation process, the area was divided according to the type of sterilization performed (autoclaving under pressure and low temperature sterilization), as the use of certain sterilization agents and/or equipment demands specific procedures and separate area for execution^(6,17,19-20).

Therefore, the instrument presented to the panel consisted of 6 work areas, 24 sub-processes, 96 activities and 18 activities which are attributable to the nurse.

Throughout our study the panel consisted of 11 nurses, all female, ranging in age from 27 to 54 years (64% over 40 years). Participants had significant work experience in this area (55% of participants, 6 - 15 years work experience) and/or were certified in management of Operating Room, Central Sterile Supply and Post-Operative Recovery (73%).This specialization encompasses management of the area of Central Supply.

In the first phase of the Delphi Technique all items described in the data collection instrument- areas, sub-processes and activities - were validated, reaching agreement level of 70% or above. However, comments and suggestions made by the panel required alterations in the content of the table of activities, which was re-evaluated by the panel.

After the second phase of the Delphi Technique, activities carried out by the nursing team at CSSUs, as well as the areas and sub-processes were considered validated, resulting in six work areas (represented by letters), 25 sub-processes (represented by numbers) and 110 activities (represented by letters and numbers), as show in Tables 1, 2, 3, 4 and 5.

Activities which are attributable to the nurse in CSSUs and were validated by the panel were:

1. Coordination of the work process in the unit;

2. Supervision of activities carried out in the unit;

3. Definition of work schedule in each area of performance of the nursing team;

4. Monitoring execution of activities, especially when done by recently hired personnel;

5. Supervision of operation of equipment used in each work area;

6. Monitoring testing of products, supplies and equipment;

7. Supervision and control of receipt of loaner supplies to the unit;

8. Supervision and control of use and invoicing of loaner supplies to the vendor;

9. Supervision and control of return of loaner supplies to the unit;

10. Confirmation of the daily schedule of surgeries, checking the delivery of loaner supplies;

11. Confirmation of the daily schedule of surgeries, checking the availability of sterile supplies;

12. Checking documentation of sterilization;

13. Follow up and control of stock of sterile supplies;

14. Follow up and assessment of maintenance of instruments and equipment;

15. Follow up and assessment of validation and qualification of equipment;

16. Follow up, planning and implementation of training programs;

17. Participation in purchasing supplies and equipment;

18. Participation in assessment of personnel performance;

19. Participation in administrative/management meetings regarding CSSU;

20. Participation in programs, committees, courses and events regarding CSSU;

21. Participation in defining programs to prevent occupational hazards and improve safety of workers;

22. Development of research;

23. Control of unit productivity;

24. Interaction with client units; and

25. Follow up on assessment of indicators of quality in the unit.

DISCUSSION

Review of the literature allowed us to observe that publications in the area of CSSU focus on technical knowledge and efficacy in the processing of odontological-medical-hospital items. Few studies were found regarding the activities performed, as well as the work processes developed by the nursing team in these units.

Comments and suggestions made by the panel of experts who participated in the first phase of the Delphi Technique of our study determined the implementation of alterations in the content of the table of activities initially proposed.

These alterations were subsequently compared to data found in the published literature regarding CSSU and comments/suggestions considered relevant were incorporated and subjected to a new analysis by the panel.

Definitions of three out of the six work areas described were modified: Area A - Soiled or Contaminated, Area B - Control of Loaner Supplies and Area C - Preparation of Materials.

Five out of the 24 work sub-processes proposed were also altered and subjected to assessment by the panel. Three of them were in area A - Soiled or Contaminated: sub-process 1 - receipt, sub-process 4 - disinfecting supplies for respiratory support and sub-process 7 - delivery of supplies/instruments to outsourced sterilization services. One of them was in area B - Control of Loaner Supplies - sub-process 2 - checking supplies returning from Operation Rooms. The last alteration was in area D - Sterilization in Pressurized Autoclave: sub-process 2 -removal of sterile load from autoclave and verification of efficacy of sterilization process.

The panel suggested inclusion or exclusion of a few interventions in five areas of the table of activities, except for Area C - Preparation of Supplies and inclusion of actions in the list of activities attributable to the nurse.

Alterations were subjected to new evaluation, and were only included in case they reached consensus agreement of 70% or above in this second phase. Otherwise, the original text was maintained.

Minimum agreement level was not reached in six of the alterations proposed to the table of interventions performed by nursed at the CSSUs.

FINAL CONSIDERATIONS

This study allowed us to identify and validate the activities developed by the nursing team at CSSUs.

The use of the Delphi Technique allowed nurses with extensive experience in the area to point out specific aspects which characterize work performed at the CSSUs, thus contributing to the definition of concepts regarding the areas and work sub-processes identified.

This panel of nurses evaluated the areas, work sub-processes and activities as being relevant, stating that they adequately reflect the practice of the nursing team at CSSUs.

The better understanding of activities comprised in processing ondontological-medical-hospital items may subsidize future studies of time spent to perform them and the establishment of parameters to help plan and assess personnel suitable to achieve the goals for CSSUs.

REFERÊNCIAS

Received article 31/05/2010 and accepted 07/10/2010

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*

Extracted from Dissertation Thesis "Atividades de enfermagem no Centro de Material e Esterilização: subsídios para o dimensionamento de pessoal", Escola de Enfermagem, Universidade de São Paulo, 2009.

Publication Dates

• Publication in this collection
  14 Oct 2011
• Date of issue
  2011

History

• Received
  31 May 2010
• Accepted
  07 Oct 2010