HOSPITAL CARE : ASSESSMENT OF USERS ’ SATISFACTION DURING HOSPITAL STAY

Health care teams have followed the National Health System’s (SUS) principles to ensure quality improvement in healthcare, and patient satisfaction is one of the instruments used to evaluate quality. This study aimed to evaluate patient satisfaction regarding the assistance to their needs during hospitalization, in a general hospital of a city in the interior of São Paulo. Data were collected through participant observation and use of focal group techniques in this qualitative research. A theme guide was used and a total of 20 subjects participated in the study. Data were analyzed through content analysis and interpreted through triangulation. Study results demonstrate that patients were satisfied with the care rendered. However, the researcher concluded that the institution’s work organization is not directed to the attainment of quality.


INTRODUCTION
The interest on the quality of services is present on the principles of SUS (National Health Program) and is part of the routine of hospital organizations (1)   .Quality can be defined as a priority, feature, or condition of things and people that make them different from others and determine their nature (2)   .To control and ensure quality of actions in the health sector, it is essential to introduce indicators to assess the outcomes reached and plan the necessary changes (3)(4) .
To assess means to determine the value of something making the notion of quality explicit (2) .
In addition to those, there are the indicators that assess care using three components (5)   , structure, involving physical, human, material, equipment and financial resources needed for medical care; processes, that refer to the activities involving health professionals and patients; and outcomes, corresponding to the final product of the care given; In nursing, critical points of care are commonly used to assess quality of care, such as nursing records, ethical processes, appearance of pressure ulcers, falls, administration of medications, organizing personnel, among others (7) .Currently, users' satisfaction has been considered as an important component of quality of care, as part of the model of participative care proposed by SUS and because users are more aware of their rights; they also play a significant role in the interaction between care givers and users, because it expresses the expectations and the evaluations of users regarding the care received (3)(4) .Using users' satisfaction as an assessment instrument means to understand and act according to their needs regarding the services and products of the team, considering their subjectivity and their perception on the process of work (8) .
Based on these statements, this study was develop with the objective of assessing users' satisfaction regarding meeting their health needs during hospital stay, as an element to assess quality.Inclusion criteria in focus groups was users that stayed in the hospital for at least four days, because this was considered the period necessary for their adaptation to the hospital environment; adults living in the city, that could communicate verbally, that were chronologically and spatially aware, and that were self-sufficient regarding physical mobility.

METHODOLOGY
The choice to use focus groups as a methodological strategy was because we believe it allows a broad process of experiences, information and because individuals are more susceptible of being encouraged when they are with others rather than alone (9) .
Users were informed about the research and those who agreed to take part, received guidelines on the confidentiality and anonymity of the information and on the written consent.The document was read with them, and then, they were asked to sign it.They were also explained about the need for recording and noting down the meeting.Thus, 12 people took part on the survey.
Two focus groups were formed, group A, formed by Iara, Márcio, Carolina, Ronaldo and Fabrício (fictional names) and group B, formed by Natal, Fábio, Selmo, Ana, Jair, Álvaro and Naldo (fictional names), from the theoretical reference (10) .We have chosen to work with the groups outside the hospital, after -what difficulties did you face to be admitted?
-who were the professionals that cared for them?
How did you like the care?
-how did you assess if care was good?
-what situations made you happy about hospital stay?
To perform with the groups, the researcher had the help of a nursing student playing the role of observer who was previously guided for this role and that was in charge of recording the comments of the group, monitoring time, and controlling the tape recorder.
Content analysis was used in data analysis (11)  .
Based on this perspective of analysis, tapes have been transcribed and the data obtained in observations were systematized as texts; next, the material of focus groups was organized.We aimed at working with the set of observations and statements of the groups horizontally, making the cuts, categorization and coding in the pre-analysis stage.In the second stage, we cut off the significant unities, getting to the register nuclei and, on the third stage, data interpretation was performed, using triangulation of the statements of groups, of the data of the field diaries, and of participative observation (12) .

OUTCOMES AND CASE DISCUSSION
Characterization of the subjects Data demonstrated that 6 of the subjects were retired, 2 did household chores, 2 were workers, 1 was a student, and 1 was unemployed.Males were predominant, with 10 subjects.Mean age was 54 and, regarding education, 11 had finished elementary school.These data was important because it enabled to learn that participants presented a low socioeconomic and cultural level.

Analysis Category
Analysis was performed with the help of a theoretical reference structure following Donabedian's model, based on structure, process, and outcomes (5)   .Thus, the tangible aspects emerged from the category structure; the subcategories: access, care, work process and treatment emerged from the category process; and the subcategories: resoluteness and strategies for speeding health actions emerged from the category outcome.These data are presented on Table 1, according to their meanings, achieved from the analysis, and interpretation of thematic sentences.Regarding structure, the tangible aspects were related to problems with the facilities, as we could see.
It needs painting, the windows have to be fixed, those in our bedroom were all broken (Natal).
Cleaning of the place was also mentioned and there were contradictory opinions.Regarding maintenance of the using conditions of the toilets, it was considered as unsatisfactory unanimously among the participants.
The showers near the corner and at the back were the only that were hot, you get electric shock from all of them, you have to use a towel (Natal).
Regarding human resources, users noticed the shortage of staff.
I was very well treated, no doubt about it, the nurses were well trained, careful, but there was a small number of nurses for the amount of patients, I think they share there 4 bedrooms for each 2 of them, so they have no time left for them, they get exhausted, sometimes it is time for medications, after a short while it is in that hurry again (Ronaldo).
Assessment of the structure also includes the technical skills of the nursing team and knowing how to do.Technical skills were related to technical performance and the behavior of care givers.Technical performance involved how to manage and inject medication, puncture a vein, and how to perform a bed bath.

I noticed they were trained because of how they do the job, how they apply an injection, place the serum, I mean,, what is basic for a "nurse", within their standards, they do everything perfectly, I've noticed that (Ronaldo).
The behavior of care givers involved their attributes, as Iara's statement illustrates.

Ah, I saw them taking care of the old lady with tenderness, bath her on the bed, soaking the cloth with soap, passing it on her skin gently, one worker passes it and the other dries, very gently, and when they had to change her, they were very careful, I thought this was very beautiful (Iara).
These statements demonstrate that the assessment of the performance of the professionals was technical and very limited, because they did not have scientific knowledge enough to assess if a care was well done, and in the human dimension through the relationship of them and the professionals who took care of their health.
Diet was considered good for the majority, and they mentioned food presentation, preparation, and the amount, as positive aspects.
Although data demonstrate that the infirmary structure was poor, expressed by minimum conditions that could be improved, and that would make a difference in care, there was resignation in the attitude of participants.We believe that this was due to their low socioeconomic and cultural level.However, thinking about quality and humanization in health care, also implies thinking about the environment conditions, including investments to recover physical facilities of the institutions, and renovating equipment and technology to improve the infrastructure (13) .
The category Process enabled to conform to the subcategories: access, care, work process, and treatment.
Data showed that most participants were satisfied with access, exemplified by Iara's statement in group A.

I arrived at 6h 30 in the morning, my admission was done immediately, when it was 6 h 50 I was already in the bedroom, I had no problems with admission, they did not ask me anything (Iara).
Regarding care, data express that, in the users' opinion, care must go beyond the procedure and it is to take into account the human essence and to value their most essential needs.The attitudes of care givers, according to the statements, must have the following characteristics: human warmth, care, love, dedication.As we can see, respect to the other were important in the satisfaction of care, because it rescues humanization and do not appear as rejection to the technical aspects but rather as a creative, intuitive, and affective way that form the professional side of nursing, reinforcing the definition that nursing is a career that integrates science and art in the care of human beings (14)   .This attitude requires a reflexive process on the values and principles that guide professional practice, assuming besides treatment, proper and welcoming care, a new ethical posture Care was also related to gender in nursing, as we could see.
I was very well treated, I loved the girls and the boys, but I will confess something, in my opinion, women take better care, they are more tender (Natal).
The practice of care in nursing has always been related to the female figure and this issue, in the institution, is still more present due to the presence of religious people in the hospital, which brings back their vocation for nursing, guided by the ideal of serving.
The process, represented by the subcategory work process, was designed from the analysis of data obtained by the statements of users in the groups and by participative observation, and it may be said that the later was an important assessment tool that enabled to learn how work was organized in the institution, being a reference to base the information brought by users, to establish comparisons, and to make a critical reflection on the concrete reality of the empirical field.
Thus, it was possible to learn that work organization follows the functional model of scientific approach of management, in a hegemonic and rational work conception.Work is not performed as a team; each professional is responsible for their activities.
Work is broken and it loses its articulation with the  Shortage of personnel, and work overload were noticed by users and pointed out in the groups, as we could see.
There is no doubt I was very well treated, the nurses were skilled and helpful, but I but there was a small number of nurses for the amount of patients, I think they share there 4 bedrooms for each 2 of them, so they have no time left for them, they get exhausted, sometimes it is time for medications, after a short while it is in that hurry again, sometimes they leave some things undone (Ronaldo).
Another important aspect worth mentioning is the lack of flexibility in the nursing routine.In all hospital environment, nursing actions are driven by routine that are generally strict making it more difficult for users to adjust to this context.
Then you go with all that difficulty take a shower, then you get an electric shock, there is lot of cold water, it is too much, you'll get a bad cold because it's cold, then the "nurse" comes and says good morning, when she says that " good morning" (Fabrício).
It was also noticed that the subjects could identify, among health professionals, first the physicians and the nursing team.In their opinion, medical care was considered satisfactory unanimously, highlighting the punctuality of care as an important factor.
Medical care was very good the physician is good; she would go in the morning and in the night to see me (Ana).
I liked my doctor's punctuality very much, every day at seven, seven thirty, he would go there to check on me, he did not miss one day, he was one of the first to come all days (Natal).
Regarding nursing care, participants demonstrated some disinformation and confusion regarding Professional category.When they referred to the nurse, actually they were referring to professionals who had finished high school.
There were the nurses, the father, and the nun too (Natal).
There is the standard nurse that takes care of the nursing area, the nuns that come and check if we need anything (Naldo).
These statements enabled to suppose that this situation may occur because nurses do not take their space as therapy agents, and because they do not place users as the center for their approach.
Still in the process category, assessment of the treatment was considered positive.
The care I received was excellent, my doctor checked on me every day, she would go there twice a day (Iara).

978
For me it was very good, I was very well treated, the doctor would go there twice or three times a day to visit me, I have nothing to complain about (Álvaro).

Medications were good, I improved (Márcio)
The outcome of health services is the effect of the programs and interventions on the users' health and, according to the statements of the subjects in the group, it was possible to see that most of them were satisfied with the outcomes of care.
I can sum up this way, I was admitted, underwent treatment, it was great, I left, I have nothing to complain about, I reached my goal (Fabrício).
I was satisfied because I was taken here, and I left walking.I am still in pain, but that is how it is, it is not healed, it will be good just in October when winter is over (Jair).
Users were also satisfied with the speed of resoluteness in health actions I was pleased with admission because all my examinations were advanced (Márcio).
When you are admitted, then all examinations are conducted, but when you schedule them it takes two, three months and then another two, three months to look for them, I don't know why that occurs if it is ready, why taking so long to look for an X-Ray, two, three months (Álvaro).
Organization of SUS requires control and assessment of health care departments through monitoring of medical appointments and the performance of complementary and laboratory examinations, assuring necessary quality and resoluteness for adequate work of health services (15) .
These statements, however, demonstrate that the public departments of the city are not organized to provide fast and resolute health services to the population, and admission was used in some cases to speed up the examinations.

FINAL CONSIDERATIONS
We have learned, by the participants' statements, that they have pointed out significant elements that expressed their satisfaction with health care received during admission and that showed the quality of care, thus demonstrating the correlation between satisfaction and quality.
However, the outcomes obtained lead to the conclusion that users' practice very little their rights to be cared for in public services, placing themselves in a submissive position as if they were receiving a favor and not performing their right to health.Putting care in a broader perspective, led the researcher, from her experience as an observer of the empirical field, to consider that the organization of the work process in the hospital, does not aim at reaching quality of care.
To manage a health service aiming at quality of health actions requires changing the focus of attention from the disease to the health production focusing on the subject, the work cannot be broken up, individualized, and hegemonic.The hospital does not follow the considerations of the 9 th National Health Conference, which advocates health care models not to be limited to individual and healing care, but rather to develop programs that aim at group works, and actions on health education, continuous personnel education, and ensuring favorable working conditions to all health professionals.
Methodology chosen was the qualitative research, and data collection started after the project was approved by the Ethical Committee of the Nursing School of Ribeirão Preto (EERP-USP).The study was conducted in the Unidade de Clínica Médica (Clinical Unit) of a private philanthropic hospital in the countryside of the State of São Paulo.Data collection techniques were used together with participative observation and focus group, complemented by documental assessment of the charts.Participative observation was important for the study, because it enabled to characterize the context of the unit, understand how the work is organized technically and socially, and the aspects of the relationship of the team and users.Additionally, it enabled continuous interaction with the subjects to hear about their experiences, their relationship with professionals and it was essential to notice the "cues" that allowed to select the subjects to conform to the focus groups.It was conducted from May to July 2005, daily, in the morning.

I
will put here something I want to say, because there are many people who think hospitals are cold places, that people are working there, taking care of people just because its their obligation, and what I saw there was completely different, I saw there, humane people taking care of human beings, with tenderness, love, you know, I was touched to see people there getting paid to perform a job, but they are not there just to do the job out of obligation, I saw tenderness, dedication of the nurses taking care of patients (Iara).
work process, represented by a set of routine practices that are repetitive and mechanical.It occurs so as to ensure medical activity and determines the relation of power and authority of physicians towards the other professionals.In addition to this technical division of the nursing team, there is the division of the work of nurses in management and care functions, and as there is one nurse for each work shift in the Unit, this occurs basically regarding the management function, where they coordinate the work performed by the nursing team and divides themselves between listening to the medical orders and passing them on to the nurse assistants and technicians.Most nursing records are done by nurse assistants and technicians; and systematization of nursing has yet to be introduced on the unit.Guidelines and routines are standardized on a nursing guide.Working under these characteristics and with overload cannot offer conditions to perform their work in a more humane way.Workers, themselves, frequently complain about the working conditions, as we can see in the statement of one of the nursing technicians sharing his feelings.
the indicators used, we can highlight social indicators (illiteracy rate, level of education, income, and unemployment rate); standard indicators of hospital management, focusing on human resources (absenteeism, turnover); indicators focusing on hospital management (rate of bed use) and indicators focusing on the clients (mortality rate, infection rate, and client satisfaction)

Table 1 -
Analysis and meaning of speech of subjects based on Donabedian's principlesIt is worth mentioning that these outcomes presented are important to this population studied.
Hospital care: assessment of users' satisfaction... Paiva SMA, Gomes ELR.Rev Latino-am Enfermagem 2007 setembro-outubro; 15(5):973-9 www.eerp.usp.br/rlae976 The women's toilet is very bad; we have to take a shower 5 o' clock in the morning, after six it is impossible to shower.The cleaners clean it, but there are times there is no condition for use (Ana).
liked the cleaning, the cleaner comes all the time, and good care is taken (Iara).