Nursing research priorities in critical care in Brazil: Delphi Study

Objective: to analyze the nursing research priorities in critical care in Brazil identified by specialists and researchers in the area, as well as to establish the consensus of the topics suggested by the experts. Method: a descriptive study, using the e-Delphi technique in three rounds. The research participants were 116 Brazilian nurses who are experts in critical care in the first round, ending up with 68 participants in the third round of the study. Descriptive statistics were used to analyze the demographic variables and the results of the research topics in the second round. In the final analysis, the Kappa agreement coefficient was calculated, comparing the answers between rounds two and three. Results: 63 research topics were generated, grouped into 14 domains of intensive care practice in the first round, and consensus was settled in the subsequent rounds. Topics such as humanization of care (0.56), bloodstream infection control (0.54), and nursing care for polytrauma patients (0.51) were items rated above 0.50 in the agreement analysis between the topics in the two rounds using the Kappa coefficient. Conclusion: this study provides an important guideline for nursing research in critical care in Brazil, guiding for future research efforts in the area.


Introduction
The need to involve as many people as possible in the identification and prioritization of research topics is highlighted and has been recognized by researchers.
This strategy can not only guarantee that the interests of relevant knowledge groups are considered, but also meets the increase in research properties, being real that the probability of these results influence the development of the clinical practice (1) .
To achieve the greatest impact at the end of these studies, it is essential to identify priorities within intensive care research. Even with the continued development of international research, many unanswered questions remain about the prevention, diagnosis, and treatment of serious illnesses, as well as the care of critically ill patients. It is observed that research agendas have been largely determined by researchers and medical scientists, but there is a growing expectation that multidisciplinary teams will be involved in identifying clinical research priorities (2) .
Nurses constitute the largest health workforce and play key roles in improving results in the area. One of these roles is to carry out research that can support the improvement of these results, strengthening their position as protagonists that influence the health system and the generation of evidence. However, nursing research presents challenges to be overcome, which cover the category in general (3) . It is known that the specialty of critical care as an area of assistance, given its complexity and the advances, require increasingly sustained knowledge bases, highlighting the need for this assistance to be based on the results presented by research studies on the theme (4) .
Over the past 30  observed is that all of these studies used some form of expert consensus method to generate priorities (5) .
Although there are review studies that present nursing research priorities in the health systems and services, no research study focusing on nursing research priorities in critical care in Brazil has been identified in the search for health journals and databases. Thus, this study was proposed with the aim of analyzing the nursing research priorities in critical care in Brazil identified by specialists and researchers in the area, as well as to establish the consensus on the topics suggested by the experts.

Method
A descriptive and exploratory research with a quantitative nature. For the development of this study, the on-line Delphi technique was used, which is characterized by the possibility of generating consensus on a topic and occurs through a systematic communication structure, controlled by the researcher, allowing that, at the end of the rounds, consensus be reached for the problem in question (6)(7) .
The research participants were Brazilian nurses who are specialists and researchers in critical care, being PhDs and Masters in nursing and specialists in the care practice. The sample was intentional and nonprobabilistic, and the selection was made through a search on the Lattes Platform of the National Council for Scientific and Technological Development (Conselho
Regarding the selection of the participants, the relevant level of professional qualification on the thematic area to be studied was considered of extreme importance to obtain a consensus of ideas. To this end, filters were applied to the database in this search, regarding academic training, professional performance, specialties, and updating of curricula. After selecting the experts, the summary of all curricula found was read to confirm the performance in the theme; the existence was also verified of developed research projects or under development related to critical care, to the publication of articles in this area in the last five years, and to the performance in the area of the specialists also from at least 5 years.
For selection criterion, the professionals that had at least two of the items mentioned above were included.
To ensure data representativeness, the participants were selected from all the Brazilian states. Nurses with doctoral and master degrees in areas unrelated to the topic and specialists who were not working in the area were excluded.
With the application of the participant selection procedure, a list of 422 professionals was obtained. It was decided to send the invitation to all these professionals Acosta AS, Barbosa SFF, Sasso GTMD. priorities aimed at the patients, their family, and the professional needs, content analysis was adopted (8) .
The answers of the initial consultation process regarding the research priorities were categorized and To establish the consensus degree of the participants to the research topics suggested by the experts, the literature indicates that establishing such consensus degree should be done by the researchers, with no rules for such (9) . In order to determine the degree of consensus The level of significance was set at <0.05 (11)(12) . The Google Forms ® version was selected to administer the e-Delphi questionnaires, and data analysis was performed using the Microsoft Excel software, version 16.10, and the SPSS ® statistical program for Windows, version 20.0.
The three-round Delphi method used in this study was collected from May to September 2018, as shown in Figure 1.

Results
One hundred and sixteen nurses with expertise in critical care answered the questionnaire of the first round.
In the second round 81/116 (69%) participants responded and, in the third round, 68/81 (84%). With regard to the sociodemographic data, 75.8% of the participants were Acosta AS, Barbosa SFF, Sasso GTMD. In the first round, 445 research topics were From the research topics identified, the following definitions were created for each domain of intensive care practice as shown in Figure 2.
Rev. Latino-Am. Enfermagem 2020;28:e3370.  Topics such as "Humanization of care in the ICU" and "The role and involvement of the family in palliative care at discharge" were also well cited by the participants in the first round of the study.
In the second round of the study, of the 63 topics that were grouped into 14 domains of the intensive care practice suggested by the participants in the first round of the research, 41 (65%) reached a very high consensus, as they presented an agreement greater than 80%, a median of 4, and interquartile range of 0, as shown in Table 2. For this, a very high consensus was considered for topics that obtained an agreement equal to or greater than 80%, a median of 4, and Interquartile Interval of 0.
For the high consensus, we considered an agreement greater than 80%, a median equal to or greater than 3, and Interquartile Interval of 1.  being that nine topics obtained a moderate agreement classification between the rounds of consensus according to Table 3.  (18)(19) .
Among the several studies published with regard to patient safety, emphasis is placed on the approach to assessing the culture of patient safety. These assessments make up the basis for identifying areas for improvement and interventions to be carried out. Therefore, it is essential that these instruments demonstrate acceptable levels of reliability and validity when studied (20) . The development of these research studies presents results that, in the medium term, help guide the direction of the safety policies, easing the construction of a positive safety culture, committed to patient safety (21)(22) .
Likewise, HCAIs offer challenges to patient safety, in particular the variation in the incidence of methicillin-  (23) .
Related to the topics that covered patient safety, there is another domain well evaluated by the participants that presented the use of preventive care protocols. The protocols aim to reduce variation and improve the efficiency of the practices, minimizing the influence of the subjectivity of judgment and to the unit were also identified as priority research areas.
It is worth highlighting that these priorities are similar to the research priorities previously identified in other studies carried out by several critical care organizations, with prominence in the world scenario, referring to the theme (2,6,(13)(14) .
Another important aspect to be emphasized is that all the studies developed about the research priorities in nursing in critical care used the Delphi technique to establish consensus among specialists to identify and generate research priorities (2,6,(13)(14)(15) . It is not surprising that topics related to patient safety have been ranked among the critical nursing research priorities in this study. Patient safety is a global issue that involves concerns related to critical incidents, such as adverse events and health care-related infections (16) .
Therefore, it is crucial to support research activities aimed at developing effective programs to improve patient safety practices (17) . Adverse Events (AEs), that is, harms Acosta AS, Barbosa SFF, Sasso GTMD.
experience, seeking to apply objectivity in care (24) . The adoption of these protocols generates standardized care and in accordance with technical-scientific parameters instituted and accepted by the scientific community (25) .
In the ICU, it is of outmost importance that the nursing team, which is responsible for most of the procedures, knows and understands measures to prevent infections and specifically Ventilation-Associated Pneumonia (VAP).
The risk for VAP is associated with several variables such as: malnutrition, dental diseases, traumatic injuries, immuno-suppression, and previous exposure to antibiotic therapy. The use of bundles for care/prevention can be mentioned, which have measures that, when put into practice together, allow for a great chance of decreasing VAP acquisition (26)(27) . In a recent study, the association of a learning strategy with a bundle of care for critically ill patients undergoing mechanical ventilation showed a decrease in the incidence rate of sustained VAP over the time of the experience (28) .
Regarding provide the care (29) . A number of studies on the theme reveal that the most implemented comfort measures aim at relieving strategies for the comfort of the patients, and greater presence of relatives, as well as actions and behaviors of the team (30) .
Among the comfort-promoting strategies analyzed, those that determine general consensus in the primary studies analyzed were the management of analgesia/ sedation, the performance of passive exercises, and the implementation of structured information programs, in order to provide a more humane nursing practice, which sees individuals as beings with their own experiences, even when these cannot be expressed in words (29)(30) . concern about providing more targeted, effective, and immediate care is evident (31) .  The definition of nursing research priorities in critical care is the first step to start a reflection on these topics, establishing research priorities in each related domain throughout the study.

Conclusion
Thus, it is considered that establishing the consensus presented in this research can contribute to minimize the academy-practice gap, allowing for research needs to be achieved according to the professional focus. Likewise, among nurse researchers, these questions can be used to define future research efforts.
In addition, it is considered that these results can contribute at the international level, given that there is a global need to establish research programs that focus on priority areas related to national health priorities.