Nursing care and its relationhisp to patient outcomes

Lima, Antônio Fernandes Costa

doi:10.1590/S0103-21002009000700005

PALESTRA

Antônio Fernandes Costa Lima

PhD in Nursing. Director of the Clinic Nursing Division of Hospital Universitário da Universidade de São Paulo (USP School Hospital) - São Paulo (SP) Brazil

Corresponding Author

INTRODUCTION

Florence Nightingale was a pioneer assessing the results of nursing care during the Crimea war. As of then, nurses have been trying to identify, measure, and use the patient results to assess the nursing care provided^(1-2).

The assessment of patient results derived from nursing care is a great challenge to the nurses who make this profession their life philosophy, once, when they assume the role in the healthcare context, care and responsibility for such care results is the essence of their action⁽¹⁾.

With this aim, searching for the continuous nursing care improvement, it is essential for nursing professionals to comply with the qualitative and quantitative aspects of the profession, investments - both institutional and personal - in order to enhance their abilities, as well as work conditions that enable the appropriate performance of their activities, and have the patient/client expectations and needs fulfilled.

In the contemporary literature, the research development is a proof of the direct connection between nursing professionals work conditions and the results presented by patients, demonstrating that nurses care about the results of their actions⁽³⁾.

Therefore, the concern with a quality in the healthcare sector defined as being a group of attributes that includes a level of professional excellence, the efficient resource usage, minimum risks to the patient / client, a high level user satisfaction, and the observation of existing social values⁽⁴⁾, points out to the urgent need of a transformation to the managerial practice.

In this context, the Nursing Department (ND) of Hospital Universitário da Universidade de São Paulo (HU-USP - School Hospital), considering the relevance of implementing strategies that allow the patient results obtained from actions developed by the nursing professionals, adopted assistance and people management indicators, which make it possible to study the results in comparison with the Institution internal and external standards.

It is worth highlighting that, in healthcare service programs, measuring quality is indispensable for the planning, organization, coordination, and assessment of the developed activities⁽⁵⁾ and, in order to do so, it is necessary to elaborate and monitor indicators⁽⁶⁾. An indicator is a quantitative measure of an activity that may be used as a guide to monitor and assess the care quality, as well as the activities developed in a service⁽⁷⁾.

PRESENTING THE INSTITUTIONAL SCENARIO

The HU (School Hospital) is a complementary organ of USP, assigned to the teaching and research, providing integral multi-disciplinary care of average complexity, based on the epistemological profile of the population using the Sistema Único de Saúde (SUS - Public Healthcare System) and USP students' services in Butantã District. It is registered in the National Healthcare and Education Departments, and as Hospital Amigo da Criança (Child-friendly Hospital). It has 247 beds and an Ambulatory that provide services to patients in the clinic-surgical, pediatric, and gynecology-obstetrics areas. The hospital financial resources come from USP's appropriation bill and services provided by SUS (Public Healthcare System).

The HU-USP Superior Administration Organs are the Deliberative Council (DC) and the Superintendent's office ("S"). The DC is comprised of the Medicine Faculty, Pharmacy Sciences Faculty, Public Health Faculty, Dentistry Faculty, Nursing Faculty (NF), and Psychology Institute directors, besides the HU-USP superintendent, the students' representation, and one community representative. One of the main functions of the DC is to define the basic guidelines for the healthcare provided, research, didactic cooperation and community healthcare provision. The "S" is the executive management organ that coordinates, supervises, and controls all the institution activities. Directly connected to it are the Medical Department and the ND, both aiming to coordinate, supervise, and control the activities developed at the medical and nursing areas, respectively subordinated to them⁽⁸⁾.

The ND professionals' board is comprised of 667 employees, of which: 1 is the Department Director nurse, 4 are the Division Director nurses, 1 is the Service Director nurse, 14 are Section Director nurses, 168 are Assistant nurses, and 479 are Nursing Technicians/Auxiliaries. Such professionals are distributed around 4 Divisions: Surgical Nursing, Clinical Nursing, Mother/Child Nursing, and External Patient Nursing that cover 13 Units and 3 Sectors. This department is assisted by the Educational Service Support (EdS) on the development of healthcare, teaching, and research activities in the nursing area. This Service mission is to keep the nursing team with a high level of personal qualification, ethics, and technique, as well as involved with the institutional proposals and results, aligned with the different hospital sectors and the clients' needs. It also collaborates promoting the integration between the Professors and Care team, the HU-USP and EEUSP (Nursing Faculty).

The hospital is the main theoretical and practical teaching field for the EEUSP Nursing Graduation Course due to the care quality and nursing area management excellence⁽⁹⁾.

Since the HU-USP was inaugurated, in 1981, the ND management adopted the Nursing Process, denominated later on Nursing Care System (NCS), as the main proposal to plan healthcare and, as of 2001, implemented the Nursing Diagnosis Classification System, which has contributed to the nurses knowledge organization and development, favoring the clinic reasoning and the decision making processes, aiming to reach the desired patient results⁽¹⁰⁾.

Due to the NCS documentation informatization, HU-USP nurses elaborated specific instruments, according to each Unit/Sector most frequent diagnosis, standardized the nursing prescription language, and altered the nursing diagnosis evolution register considering the results of the care provided⁽¹¹⁾.

The data obtained through the nursing history are summarized and descriptively documented in the Admission/Transfer/Hospital Release Register. The Nursing diagnosis, evolution and prescription are integrated in a unique instrument that contains the most frequent nursing diagnosis, the defining characteristics, the factor related, and the risk factors, either specific or according to the profile of patients helped by the Units/Sectors, besides the main corresponding nursing activities. The nursing evolution is registered through acronyms regarding the results assessment of the activities proposed to solve the diagnosis: P (Present); I (Improved); W (Worse); U (Unaltered); S (Solved).

Upon this scenario, HU-USP nurses, aiming to enhance the patients nursing assistance effectiveness results assessment adopted indicators related to the following incidences: patient fall, injury by pressure, accidental extubation; nursing team non-compliance with the medication administration and central venous catheter application; urinary tract infections related to the vesical sounding and pneumonia associated to mechanical ventilation.

The results assessment process feasibility through such care indicators comprised the following steps: evidence-based care protocols elaboration; nurses training, so as to make them protocol contents multipliers; elaboration of instruments for the NCS documentation information collection from the Occurrences Notification File and the Hospital Infection Control Commission reports; collection systematization and results assessment based on the institutional and literature goals.

The information obtained are precious management tools, for the care process conditions assessment favors the correlation with people management indicators: nursing absence rate; average hours of nurse/patient intensive care; average hours of nurse/patient semi-intensive care; average hours of nurse/patient high, medium, and minimum dependence care; average hours of nursing technician/auxiliary/patient intensive care; average hours of nursing technician/auxiliary/patient semi-intensive care; average hours of nursing technician/auxiliary/patient high, medium, and minimum dependence care; nursing professionals rotation rate and nursing professionals training index.

The data collected are forwarded, monthly, by the Director nurses of the Units/Sector to EdS, where the indicator values are converted into graphics and tables so as to facilitate its visualization, comprehension, and critical analysis. Afterwards, all the indicators become reports that are forwarded to HU-USP "S" and, finally, integrate the documentation presented to the Secretaria de Estado de Saúde de São Paulo (São Paulo State Health Office), which assesses, and points out the actions developed by the hospital, aiming to direct the funds transferred by SUS (Public Health System).

FINAL CONSIDERATIONS

The patient results process assessment summarized above allows the ND management to control, systematically, the higher risk areas, review the recommended interventions adequacy, and propose changes to the care reality that demonstrate results efficacy, and effectiveness, ensuring, therefore, the internal and external visibility of the actions developed by nursing professionals.

It is also worth highlighting that the developed actions meet the needs of a storage system that allows a simple, reliable, agile and low-cost database to exist, besides the history series elaboration that allows a comparison with other nursing services or with the same service, when time analysis are performed⁽⁵⁾.

The ND current nurses perspective is to continue improving the nursing activities performed, in the HU-USP context, intensifying the Nursing Interventions Classification⁽¹²⁾ and adopting the Nursing Results Classification⁽²⁾.

When the ND established that one of its main goals was to informatize the NCS, it aimed that the triad Diagnosis/Results/Intervention could contribute - even more - with the profession autonomy and scientificity, so that the NCS is also recognized as an instrument to facilitate the patient results quality assessment.

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