ASSESSMENT OF THE NURSING CARE PRODUCT DURING THE COVID-19 PANDEMIC IN BRAZILIAN UNIVERSITY HOSPITALSABSTRACT
Objective: to assess the nursing care product during the COVID-19 pandemic in Brazilian university hospitals.
Method: this descriptive, cross-sectional, multicenter study included 544 nurses working in COVID-19 patient care units across ten university hospitals distributed throughout the five geographic regions of Brazil. The Assessment of the Nursing Care Product scale was used. Data were collected online between February 2021 and March 2022.
Results: although the initial hypothesis assumed that the pandemic would negatively affect the nursing care product, nurses predominantly assessed it as good. Better performance was observed in the dimensions meeting the care needs (n=498; 91.5%), care monitoring and transfer (n=445; 81.8%), nursing care planning (n=444; 81.6%), and patient and/or family care (n=424; 77.9%). Conversely, resources required for care provision (n=252; 46.3%), interaction and multidisciplinary activity (n=297; 54.6%), and estimation of nursing staff requirements (n=330; 60.7%) showed lower adequacy rates, highlighting structural and organizational weaknesses within the investigated context. Differences were also observed among hospitals and across Brazilian regions.
Conclusion: the nursing care product was assessed as good, with better performance in the dimensions related to nursing care planning, care follow-up, and meeting patients’ care needs. Weaknesses were identified in the components related to resources required for care provision, estimation of nursing staff requirements, and interprofessional interaction, highlighting relevant aspects for care planning and management in public health emergency settings.
DESCRIPTORS:
Nurses; Process Assessment; Health Care; Nursing Care; COVID-19; Pandemics; Unified Health System
RESUMO
Objetivo: avaliar o produto do cuidar em enfermagem na pandemia da COVID-19 em hospitais universitários brasileiros.
Método: estudo descritivo, transversal e multicêntrico, realizado com 544 enfermeiros atuantes em unidades de atendimento a pacientes com COVID-19 de dez hospitais universitários distribuídos nas cinco regiões do Brasil. Utilizou-se a Escala de Avaliação do Produto do Cuidar em Enfermagem. A coleta ocorreu online entre fevereiro de 2021 e março de 2022.
Resultados: embora a hipótese inicial considerasse impacto negativo da pandemia sobre o produto do cuidar, os enfermeiros o avaliaram predominantemente como bom. Houve melhor desempenho nas dimensões atendimento das necessidades assistenciais n=498 (91,5%), acompanhamento e transferência do cuidado n=445 (81,8%), planejamento da assistência n=444 (81,6%) e atenção ao paciente e/ou familiar n=424 (77,9%). Em contrapartida, recursos necessários para assistência n=252 (46,3%), interação e atuação multiprofissional n=297 (54,6%) e dimensionamento de pessoal n=330 (60,7%) apresentaram menores percentuais de adequação, evidenciando fragilidades estruturais e organizacionais no contexto investigado. Também foram observadas diferenças entre hospitais e regiões do país.
Conclusão: o produto do cuidar em enfermagem foi avaliado como bom, com melhor desempenho nas dimensões relacionadas ao planejamento da assistência, ao acompanhamento do cuidado e ao atendimento das necessidades assistenciais. Fragilidades foram identificadas nos componentes relacionados aos recursos necessários para assistência, ao dimensionamento de pessoal e à interação multiprofissional, evidenciando aspectos relevantes para o planejamento e a gestão do cuidado em contextos de crise sanitária.
DESCRITORES:
Enfermeiras e enfermeiros; Avaliação de processos de cuidados de saúde; Cuidados de enfermagem; COVID-19; Pandemias; Sistema Único de Saúde
RESUMEN
Objetivo: evaluar el producto del cuidado de enfermería durante la pandemia de la COVID-19 en hospitales universitarios brasileños.
Método: estudio descriptivo, transversal y multicéntrico, realizado con 544 enfermeros que trabajaban en unidades de atención a pacientes con COVID-19 de diez hospitales universitarios distribuidos en las cinco regiones de Brasil. Se utilizó la escala de Evaluación del Producto del Cuidado de Enfermería. La recolección de datos se realizó en línea entre febrero de 2021 y marzo de 2022.
Resultados: aunque la hipótesis inicial consideró que la pandemia tendría un impacto negativo sobre el producto del cuidado de enfermería, los enfermeros lo evaluaron predominantemente como bueno. Se observó un mejor desempeño en las dimensiones atención de las necesidades asistenciales (n=498; 91,5%), seguimiento y transferencia del cuidado (n=445; 81,8%), planificación de la atención de enfermería (n=444; 81,6%) y atención al paciente y/o familiar (n=424; 77,9%). En contraste, los recursos necesarios para la atención (n=252; 46,3%), la interacción y actuación multidisciplinaria (n=297; 54,6%) y la dotación de personal de enfermería (n=330; 60,7%) presentaron menores porcentajes de adecuación, evidenciando debilidades estructurales y organizativas en el contexto investigado. También se observaron diferencias entre hospitales y regiones del país.
Conclusión: el producto del cuidado de enfermería fue evaluado como bueno, con mejor desempeño en las dimensiones relacionadas con la planificación de la atención de enfermería, el seguimiento del cuidado y la atención de las necesidades asistenciales. Se identificaron debilidades en los componentes relacionados con los recursos necesarios para la atención, la dotación de personal de enfermería y la interacción multidisciplinaria, lo que pone de manifiesto aspectos relevantes para la planificación y la gestión del cuidado en contextos de crisis sanitarias.
DESCRIPTORES:
Enfermeras y Enfermeros; Evaluación de Procesos; Atención de Salud; Atención de Enfermería; COVID-19; Pandemias; Sistema Único de Salud
INTRODUCTION
The COVID-19 pandemic, caused by the coronavirus (SARS-CoV-2), spread rapidly across the globe. It represented one of the greatest, if not the greatest, challenges of the 21st century because of its unprecedented impacts, particularly on health and the economy, affecting societies worldwide1-2.
For healthcare professionals, the pandemic embodied Edgar Morin’s principle of uncertainty. His perspective describes knowledge as navigating an ocean of uncertainties, a concept that became unavoidable during the crisis. An unknown virus challenged previously established protocols, revealing them to be provisional and constantly evolving3.
For frontline nurses, this meant working under dual pressure: saving lives while continuously reassessing their professional practice. Such instability required technical competence, adaptability, and resilience in the face of uncertainty, which are central elements of Morin’s understanding of the complexity of the world.
The international public health emergency resulting from COVID-19 lasted for just over three years, from January 2020 to May 20234. During this period, nursing care emerged as a major challenge within a dynamic context in which new adversities arose while preexisting ones became even more pronounced.
The response to COVID-19 highlighted the essential role of healthcare professionals in protecting lives and strengthening health systems. Nursing stood out in the response to the pandemic through the provision of comprehensive care, implementation of preventive measures, and delivery of health education practices5-6.
Amid social distancing measures and the structural limitations of healthcare services, nurses were challenged to respond to complex human needs in a scenario characterized by high levels of stress, fear, and uncertainty, shortages of personal protective equipment, increased workload, workforce shortages, and job dissatisfaction1,6-12.
The public health crisis required rapid adaptations in care delivery, particularly in Brazil, with its universal healthcare system. Frontline nurses demonstrated remarkable resilience and innovation by adopting patient-centered care practices, incorporating biosafety measures, using technology to communicate with family members, and implementing stress management strategies10,13-14.
The nursing care product, which may be defined as the outcome or impact of the nursing care provided to patients, is not tangible like material goods. Rather, it is reflected in health promotion, health maintenance, health recovery, disease prevention, and relief of suffering. Its essential elements include improvements in patient well-being and quality of life, satisfaction with care, the effectiveness of evidence-based interventions, and an ethical and humanized contribution to public health15-16.
Recent studies have demonstrated that the nursing care product quality is directly related to working conditions, staffing, workload, and the availability of institutional resources. During the COVID-19 pandemic, increased care complexity, team overload, and the reorganization of work processes intensified the challenges associated with maintaining safe, high-quality care, highlighting the influence of organizational factors on care outcomes1 7-19.
Furthermore, favorable nursing practice environments, adequate institutional support, and organizational strategies aimed at strengthening the nursing workforce have been associated with better patient outcomes, greater professional satisfaction, and improved conditions for delivering nursing care20-21. In this context, assessing the nursing care product constitutes an important tool for monitoring the quality of care and supporting interventions aimed at improving nursing work processes.
Although the impact of the pandemic on nursing working conditions has been widely described in the literature, evidence regarding its effects on the nursing care product remains limited, particularly in Brazilian university hospitals. Assessing this product makes it possible to understand how structural, organizational, and professional factors influence care outcomes in situations of high care complexity.
Accordingly, there is a knowledge gap regarding the nursing care product assessment during the COVID-19 pandemic across different regional and institutional contexts in Brazil. Addressing this gap may provide evidence to support actions aimed at strengthening care delivery, workforce management, and the preparedness of healthcare services for future public health emergencies.
Against this background, the following research question emerged: How was the nursing care product in Brazilian university hospitals during the COVID-19 pandemic, according to nurses’ assessments using the Assessment of the Nursing Care Product (APROCENF - Avaliação do Produto do Cuidar em Enfermagem) scale?
The study was based on the hypothesis that the COVID-19 pandemic compromised structural and organizational aspects of nursing work, thereby negatively affecting the nursing care product.
Accordingly, this study aimed to assess the nursing care product during the COVID-19 pandemic in Brazilian university hospitals.
Assessing the nursing care product may provide evidence to improve clinical practice, workforce management, and professional education, particularly in contexts of public health crises and healthcare service reorganization.
METHOD
This was a descriptive, cross-sectional, multicenter study. Cross-sectional studies are recommended when the objective is to estimate the frequency with which a given health event occurs in a specific population, as well as the factors associated with it22.
This study analyzed data collected at a single point in time based on nurses’ perceptions of the nursing care product during their care of patients with COVID-19.
This study followed the STrengthening the Reporting of OBservational studies in Epidemiology guidelines23.
The study included ten university hospitals located in different states, with two hospitals from each of the five geographic regions of Brazil. The participating hospitals were selected through the establishment of a research network created to conduct this national multicenter project.
The participating hospitals were distributed across the five Brazilian geographic regions and were part of the research network established to conduct the study, encompassing different organizational and care contexts during the COVID-19 pandemic.
The inclusion criteria were being a registered nurse and having at least 3 months of experience providing direct care to patients with COVID-19 during the pandemic. Nurses who were on leave during the data collection period were not eligible, and questionnaires with incomplete or improperly completed responses were excluded.
A convenience sample was obtained from responses to an invitation sent by email to the target population. The ten participating hospitals employed a total of 2,715 nurses. The sample size was calculated using WINPEPI version 11.65 for proportion estimation. Considering a 95% confidence level, a 5% margin of error, and an estimated proportion of 50%, the minimum sample size was calculated based on a finite population. The estimated minimum sample consisted of 337 nurses. However, the final sample included 544 nurses.
Participation was voluntary and occurred after acceptance of the electronic invitation sent to eligible nurses by the local researchers at each participating institution.
The data collection instrument was APROCENF, which is based on the concepts of care production, management, and healthcare quality. The scale classifies nursing care by assessing structural aspects (human resources and support services) and work organization methods (nursing care planning, patient and/or family care, and multidisciplinary interaction), with the aim of identifying critical factors in nursing care management16.
APROCENF is an important tool for improving professional nursing practice by enhancing both the quality of care and the nursing care product delivered. The scale was developed and validated for use in Brazil and comprises eight components: nursing care planning; resources required for care provision; estimation of nursing staff requirements; educational actions and staff development; care monitoring and transfer; interaction and multidisciplinary activity; patient and/or family care; and meeting the care needs. Each item is scored on a four-point scale, with higher scores indicating a better nursing care product: poor (8-12 points), fair (13-20 points), good (21-28 points), and excellent (29-32 points)16.
It is important to emphasize that the instrument does not assess nurses’ performance; rather, it assesses structural factors and work organization methods that influence the production and delivery of nursing care during work shifts16.
The study variables included the total APROCENF score, classified as poor, fair, good, and excellent, as well as its eight components: nursing care planning; resources required for care provision; estimation of nursing staff requirements; educational actions and staff development; care monitoring and transfer; interaction and multidisciplinary activity; patient and/or family care; and meeting the care needs.
In accordance with the social distancing measures recommended by health authorities during the pandemic, participants were invited through digital platforms (email, WhatsApp®, and QR codes), where they were provided with information regarding the study objectives, methodology, and ethical aspects.
The local researchers at each hospital were responsible for disseminating the study and sending invitations to potential participants.
After agreeing to participate, participants accessed a Google Forms® link containing the Informed Consent Form and APROCENF.
The questionnaire was self-administered, completed electronically, and collected without personal identification, ensuring participant anonymity and data confidentiality. The estimated completion time was approximately 10-15 minutes.
Participants were instructed to complete the scale only once, basing their responses on the period during which they provided direct care to patients with COVID-19 during the pandemic.
Data collection was carried out from March 2021 to February 2022.
Data were entered into a Microsoft Excel® spreadsheet, and statistical analyses were performed using Statistical Package for the Social Sciences version 20.0 and STATA version 17. A significance level of 5% was adopted for all statistical tests.
Initially, descriptive analyses were performed using absolute and relative frequencies, as well as measures of central tendency and dispersion, according to the nature of the variables analyzed.
The overall internal consistency of APROCENF items was assessed using Cronbach’s alpha and McDonald’s omega coefficients. Cronbach’s alpha assesses the degree of correlation among the items of a scale, whereas McDonald’s omega is considered a more robust coefficient when items present different factor loadings. Values ≥ 0.70 were considered acceptable for both coefficients.
The Kruskal-Wallis test was used to compare more than two groups. When statistically significant differences were identified, Dunn-Bonferroni multiple comparisons were performed to identify the groups that differed while maintaining the overall significance level.
Comparisons of the adequacy percentages of the eight APROCENF components among hospitals were performed using Cochran’s Q test. For this analysis, scores of 3 (Good) and 4 (Excellent) were considered adequate responses because they represented a more favorable nursing care product assessment. This test was used to determine differences in the proportions of adequate responses among the hospitals assessed.
This study is part of a multicenter research project and was approved by the Research Ethics Committees of all participating centers.
No artificial intelligence tools were used during the preparation of this study.
RESULTS
A total of 544 nurses from Brazilian university hospitals participated in the study. Most participants were female (82.0%), worked in emergency and intensive care units (47.1%), and held a specialist or residency qualification (55.5%). Most participants had provided direct care to patients with COVID-19 for more than one year (61.8%) and reported having received institutional training on the disease (78.7%).
Table 1 presents the corrected item-total correlation, Cronbach’s alpha, and McDonald’s omega coefficients, as well as the values obtained if each item was excluded.
Corrected item-total correlation, Cronbach’s alpha, and McDonald’s omega (overall and if the item is excluded). Brazil, 2021-2022 (n=544).
As shown in Table 1, APROCENF demonstrated acceptable internal consistency, with both Cronbach’s alpha (0.783) and McDonald’s omega (0.792) exceeding the recommended threshold of 0.70.
Table 2 presents the summary measures of APROCENF scores by hospital:
As shown in Table 2, significant differences in APROCENF scores were observed among hospitals (p<0.001). Hospital A achieved the highest mean score, indicating a more favorable nursing care product assessment, whereas Hospitals C, E, H, and J showed the lowest mean scores. Although all hospitals achieved scores corresponding to the good APROCENF classification, variability was observed among the participating institutions regarding nursing care product assessment, indicating differences in nurses’ perceptions of the assessed components.
Table 3 presents the percentage of adequate responses 3 and 4 for the eight APROCENF components according to Brazilian geographic region.
As shown in Table 3, positive assessments predominated in the dimensions meeting the care needs, nursing care planning, and care monitoring and transfer, which exhibited the highest percentages of adequate responses across all geographic regions. Conversely, the components required to provide care, interaction, and multidisciplinary practice showed the lowest adequacy percentages and the greatest regional variability. Overall, these findings demonstrate differences among Brazilian geographic regions regarding APROCENF components during the COVID-19 pandemic.
Table 4 presents the percentage of adequacy for responses 3 and 4 regarding the eight aspects of APROCENF assessed:
As shown in Table 4, heterogeneity was observed in the assessment of APROCENF components across the participating hospitals. The dimensions meeting the care needs, nursing care planning, and care monitoring and transfer showed the highest percentages of adequate responses in most institutions.
Conversely, the components resources required for care provision, interaction and multidisciplinary activity, and estimation of nursing staff requirements exhibited lower adequacy percentages and greater variability among hospitals. Notably, some institutions reported adequacy percentages below 30% for resources required for care provision, indicating substantial structural weaknesses.
Differences were also observed in nursing care product assessment among nurses working within the same institution, highlighting variability in perceptions of the care provided. Since Hospital G included only three respondents, no statistically significant differences were identified among the assessed components.
The adequacy percentages for the eight APROCENF components are illustrated in Figure 1, according to geographic region:
Percentage of adequate responses for the eight components of the Nursing Care Product Assessment Scale according to Brazilian geographic region. Brazil, 2021-2022 (n=544).
In Figure 1, polygons with larger areas represent higher adequacy percentages for the APROCENF components, whereas more regular polygon shapes indicate greater homogeneity among the assessed components. In contrast, irregular polygons reflect greater variability in the assessment of the scale components.
Greater consistency was observed for the components meeting the care needs, nursing care planning, and care monitoring and transfer, while the items related to the resources required for care provision, multidisciplinary interaction, and estimation of nursing staff requirements showed greater variability among the regions.
DISCUSSION
According to the findings of this study, the COVID-19 pandemic compromised structural and organizational aspects of nursing work, particularly those related to care resources, multiprofessional interaction, and staffing levels. However, these weaknesses were not enough to reduce the care product overall assessment, which remained predominantly rated as good. Hospitals A, B, C, D, E, G, H, and I showed lower percentages regarding multidisciplinary interaction and performance, indicating challenges in collaboration among healthcare professionals and highlighting the need to strengthen communication and coordination across teams to ensure a more integrated approach to patient care.
Although the initial hypothesis predicted that the nursing care product would be classified as fair or poor during the pandemic, nurses predominantly assessed it as good. This finding suggests that, despite excessive workload, resource shortages, and institutional weaknesses, nurses prioritized direct patient care, nursing care planning, and meeting the needs of patients and their families, thereby preserving the core elements of nursing care.
The pandemic highlighted, more than ever, the importance of multidisciplinary collaboration in healthcare delivery. A study conducted in a university hospital in northeastern Brazil that investigated barriers and facilitators to teamwork during the COVID-19 pandemic identified factors consistent with the findings of this study. Reported barriers included the absence of regular meetings and feedback, task overload, excessive workload, hierarchical relationships, individual accountability for errors, limited understanding of teamwork principles, and low levels of job satisfaction, trust, energy, and personal commitment24.
Another study conducted in Spain emphasized that the need to prioritize patient care to ensure survival resulted in the temporary suspension of several evidence-based projects and strategies, including ventilator-associated pneumonia prevention guidelines and pain, agitation/sedation, and delirium protocols. This occurred because of excessive workload, shortages of qualified professionals, inadequate physical infrastructure, and insufficient material resources25.
The allocation of resources required for patient care emerged as a critical issue in several hospitals, as evidenced by the low adequacy percentages observed for this APROCENF component. Hospitals B, F, and J stood out in this regard, emphasizing the need for more efficient and strategic management of available resources to ensure the sustainable delivery of high-quality care. These findings identify priority areas requiring targeted interventions to improve the quality of care provided by the hospitals assessed.
This issue was observed both nationally and internationally. A Brazilian study conducted in a public hospital in the state of São Paulo, which investigated working conditions and their effects on nursing professionals’ health during the pandemic, reported worsening of several workplace conditions26. Excessive workload, shortages of equipment, essential supplies, and personal protective equipment contributed to a perception of dehumanized work, leading professionals to feel like “machines” or “numbers”26.
A study conducted in the United States found that the lack of protective measures impaired interpersonal relationships with patients because nurses had to limit the frequency of entering patient rooms, thereby increasing stress during care delivery27.
In addition to these issues, several hospitals experienced concerns related to nursing staffing, particularly Hospitals C, E, H, and J. This finding highlights the need to review staffing policies and human resource allocation to ensure an adequate and equitable distribution of nursing personnel, thereby promoting high-quality care and patient safety.
It is important to note that different approaches are available for determining appropriate nursing staffing levels. In Brazil, COFEN Resolution 543/2017, recently revoked by COFEN Resolution 743/2024 and replaced by Normative Opinion 01/2024, updated and established parameters for nursing staffing in healthcare services28. However, although this represents an important regulatory update, it may weaken the nursing workforce because it introduces greater flexibility into previously established technical criteria, potentially increasing workload and compromising both quality of care and patient safety.
A Brazilian study published in 2020, which expanded the discussion on nursing staffing during the pandemic, reported that even before COVID-19 there was an estimated shortage of 23,961 nursing professionals in Brazil (8,430 nurses and 15,531 nursing technicians/assistants), negatively affecting the country’s capacity to respond to the public health emergency29. The United Kingdom experienced a similar shortage. In 2019, there were 43,590 vacant nursing positions in the National Health System, reflecting high levels of stress, absenteeism, presenteeism, staff turnover, and intentions to leave the profession, all of which were exacerbated during the pandemic11.
These findings suggest that some of the weaknesses identified during the pandemic, particularly those related to resources required for care provision, staffing levels, and multidisciplinary interaction, already represented important challenges within healthcare services and were further intensified by the pandemic. Recent evidence indicates that inadequate working conditions, insufficient human resources, and organizational limitations remain associated with poorer care outcomes and reduced quality of nursing care, even after the most critical phase of the pandemic16,20-21.
Furthermore, educational and staff development initiatives were also identified as areas of concern in several hospitals, particularly Hospitals C, E, and H, reinforcing the importance of investing in continuing education and professional training during public health emergencies. A Spanish study demonstrated that the urgent need to train nurses without previous critical care experience increased occupational risks and reduced patient safety21. An Italian study found that public health restrictions interfered with nurse-patient relationships and educational practices, although nurses developed creative strategies to maintain interactions throughout the pandemic30.
Accordingly, the role of nurses in promoting comprehensive care, implementing educational activities, and adopting preventive and health promotion measures is particularly important in emergency settings31.
Distinct adequacy percentages were observed across the Brazilian geographic regions for the dimensions resources required for care provision and interaction and multidisciplinary activity, reflecting longstanding inequalities in access to and quality of healthcare services in Brazil. These disparities highlight persistent challenges faced by the SUS and reinforce the need to strengthen the healthcare workforce, ensure adequate funding, and expand the capacity of healthcare services to respond to public health emergencies, in line with the Sustainable Development Goals (SDGs), particularly SDG 3: Good Health and Well-being32-33.
In addition to regional differences, heterogeneity was observed in nursing care product assessment across hospitals and even among nurses working within the same institution, suggesting that institutional and organizational factors influence perceptions of care quality. This finding reinforces the need for further studies to better understand these relationships.
The findings of this study also raise important considerations regarding the preparedness of healthcare services for future public health emergencies. Recent evidence indicates that strengthening nursing practice environments is an essential strategy for improving the resilience of healthcare systems during crises by promoting better working conditions and higher-quality care21.
These areas of concern underscore the importance of adopting a complex approach to analyzing and improving healthcare quality. According to Edgar Morin, “the shortcomings and deficiencies of knowledge and thought during the crisis confirm that we need a way of thinking capable of responding to the challenges of complexity and uncertainty”34. Thus, problems related to multidisciplinary interaction, nursing staffing, and inadequate resource allocation should be understood as interdependent expressions of a complex system.
Despite the structural and organizational challenges, the best nursing care product assessments were associated with nursing care planning, care follow-up, and meeting the needs of patients and their families. These findings suggest that, during emergency situations, nurses prioritize essential components of care, such as direct patient care, planning, and continuity of care, whereas aspects related to multidisciplinary collaboration, educational activities, and structural organization are more vulnerable to the demands imposed by emergency situations.
This study has limitations related to its cross-sectional design and the use of self-reported data, which may have influenced participants’ perceptions of the nursing care product. Furthermore, the variability in the number of participants across hospitals and the extended data collection period, which encompassed different phases of the COVID-19 pandemic, may also have influenced the findings. Nevertheless, the study included hospitals from different Brazilian regions and contributes to a broader understanding of the nursing care product during the pandemic, providing evidence to support future research and strengthen nursing care practice and healthcare management.
CONCLUSIONS
The results demonstrated that the COVID-19 pandemic compromised structural and organizational aspects of nursing work, especially related to the availability of resources for care, staffing levels, and multidisciplinary interaction and performance. Despite these weaknesses, the outcome of the care provided was predominantly rated as good by nurses in Brazilian university hospitals.
The dimensions meeting the care needs, care monitoring and transfer, nursing care, planning and patient and/or family care stood out positively. Conversely, the lowest adequacy percentages were observed in the components of resources required for care provision, interaction and multidisciplinary activity, and estimation of nursing staff requirements, highlighting structural and organizational weaknesses present in the investigated context.
The differences observed among geographic regions and hospitals suggest that institutional, organizational, and contextual characteristics may influence nurses’ perceptions of the nursing care product, reinforcing the importance of considering the specific characteristics of different healthcare settings in nursing care management and planning actions aimed at improving the quality of care.
Considering the regional disparities and inequities that characterize a country of continental dimensions, these findings highlight the need to strengthen the SUS and advance progress toward achieving the targets established in SDG 3, particularly those related to equitable financing and the recognition and appreciation of the nursing workforce.
From the perspective of complexity theory, understanding the nursing care product requires recognizing the interdependence among structure, process, and outcomes, as well as the inseparability of the human, organizational, and political dimensions that shape nursing care. In this sense, the findings reinforce that the quality of nursing care results from the interaction of multiple factors and requires integrated approaches to strengthen care delivery in both routine practice and public health emergency situations.
ACKNOWLEDGMENT
We thank the institutions participating in the study and the nurses from university hospitals in different regions of Brazil for their collaboration and willingness to share their experiences during the COVID-19 pandemic.
REFERENCES
-
1. Barbosa DJ, Gomes MP, Souza Abiana BA, Gomes AMT. Fatores de estresse nos profissionais de enfermagem no combate à pandemia da COVID-19: síntese de Evidências. Comun Ciênc Saúde [Internet]. 2020; [cited 2023 Aug 24]. Available from: https://doi.org/10.51723/ccs.v31iSuppl1
» https://doi.org/10.51723/ccs.v31iSuppl1 -
2. Freitas ARR, Napimoga M, Donalisio MR. Análise da gravidade da pandemia de COVID-19. Epidemiol Serv Saude [Internet]. 2020 [cited 2023 Aug 24];29:e2020119. Available from: https://doi.org/10.5123/S1679-49742020000200008
» https://doi.org/10.5123/S1679-49742020000200008 - 3. Morin E. Os sete saberes necessários à educação do futuro. 2nd ed. São Paulo, SP(BR): Cortez; 2018.
-
4. OMS declara fim da Emergência de Saúde Pública de Importância Internacional referente à COVID-19 - OPAS/OMS | Organização Pan-Americana da Saúde [Internet]. Brasília: OPAS; 2023 [cited 2023 Aug 24]. Available from: https://www.paho.org/pt/noticias/5-5-2023-oms-declara-fim-da-emergencia-saude-publica-importancia-internacional-referente
» https://www.paho.org/pt/noticias/5-5-2023-oms-declara-fim-da-emergencia-saude-publica-importancia-internacional-referente -
5. Gandra EC, Silva KL, Passos HR, Schreck RSC. Enfermagem brasileira e a pandemia de COVID-19: desigualdades em evidência. Esc Anna Nery [Internet]. 2021 [cited 2023 Aug 26];25(spe):e20210058. Available from: https://doi.org/10.1590/2177-9465-EAN-2021-0058
» https://doi.org/10.1590/2177-9465-EAN-2021-0058 -
6. Sousa AR, Santos GLA, Silva RS, Carvalho ESS. Reflexões sobre o Processo de Enfermagem no trabalho de enfermeiras frente à pandemia da COVID-19. Enferm Em Foco [Internet]. 2020 [cited 2023 Sept 10];11(1. esp). Available from: https://dx.doi.org/10.21675/2357-707X.2020.v11.n1.ESP.3501
» https://dx.doi.org/10.21675/2357-707X.2020.v11.n1.ESP.3501 -
7. Humerez DCD, Ohl RIB, Silva MCND. Saúde mental dos profissionais de enfermagem do Brasil no contexto da pandemia COVID-19: ação do conselho federal de enfermagem. Cogitare Enferm [Internet]. 2020 [cited 2024 Jan 23];25. Available from:Available from:https://doi.org/10.5380/ce.v25i0.74115
» https://doi.org/10.5380/ce.v25i0.74115 -
8. Gomes MP, Barbosa DJ, Gomes AMT, Souza FBA, Paula GS, Espírito Santo CC. Perfil dos profissionais de enfermagem que estão atuando durante a pandemia do novo Coronavírus. J Nurs Health [Internet]. 2020 [cited 2023 Aug 30];10(4):20104026. Available from:Available from:https://doi.org/10.15210/jonah.v10i4.18921
» https://doi.org/10.15210/jonah.v10i4.18921 -
9. Campos DB, Gomes IVG, Alves AR, Moreira TMM, Figueiredo SV. Reflexões sobre a pandemia COVID-19 e ações de educação permanente em enfermagem num hospital. Glob Acad Nurs [Internet]. 2021 [cited 2023 Sept 10]. Available from: https://doi.org/10.5935/2675-5602.20200050
» https://doi.org/10.5935/2675-5602.20200050 -
10. Gnatta JR, Vieira RCA, Santos LSC, Penha SL, Sanchez GN, Oliveira JC, et al. Safety of nursing professionals and patient facing COVID-19 pandemic in critical care unit. Rev Lat-Am Enfermagem [Internet]. 2023 [cited 2024 jan 05];31:e3861. Available from: https://doi.org/10.1590/1518-8345.6317.3862
» https://doi.org/10.1590/1518-8345.6317.3862 -
11. West M, Bailey S, Williams E. The King’s Fund [Internet]. London: The King's Fund; 2020 [cited 2023 Sept 09]. The courage of compassion. Available from: https://www.kingsfund.org.uk/publications/courage-compassion-supporting-nurses-midwives
» https://www.kingsfund.org.uk/publications/courage-compassion-supporting-nurses-midwives -
12. Foye U, Dalton‐Locke C, Harju‐Seppänen J, Lane R, Beames L, Juan NVS, et al. How has COVID‐19 affected mental health nurses and the delivery of mental health nursing care in the UK? Results of a mixed‐methods study. J Psychiatr Ment Health Nurs [Internet]. 2021 [cited 2023 Sept 09];28(2):126-37. Available from:Available from:https://doi.org/10.1101/2020.11.05.20226472
» https://doi.org/10.1101/2020.11.05.20226472 -
13. Labrague LJ, Santos JAA, Fronda DC. Factors associated with missed nursing care and nurse-assessed quality of care during the COVID-19 pandemic. J Nurs Manag [Internet]. 2022 [cited 2023 Aug 25];30(1):62-70. Available from:Available from:https://doi.org/10.1111/jonm.13483
» https://doi.org/10.1111/jonm.13483 -
14. Yoo HJ, Lee H. Critical role of information and communication technology in nursing during the COVID-19 pandemic: A qualitative study. J Nurs Manag [Internet]. 2022 [cited 2023 Aug 25];30(8):3677-85. Available from:Available from:https://doi.org/10.1111/jonm.13880
» https://doi.org/10.1111/jonm.13880 -
15. Batista FR, Rodrigues Melgaço NP. O COVID-19 e o SUS. Sin Mult [Internet]. 2020; [cited 2023 Aug 28];9(1):2-6. Available from: https://periodicos.pucminas.br/sinapsemultipla/article/view/24395
» https://periodicos.pucminas.br/sinapsemultipla/article/view/24395 -
16. Cucolo DF, Perroca MG. Assessment of the nursing care product (APROCENF): a reliability and construct validity study. Rev Lat-Am Enfermagem [Internet]. 2017 [cited 2023 Nov 23];25. Available from: https://doi.org/10.1590/1518-8345.1495.2860
» https://doi.org/10.1590/1518-8345.1495.2860 -
17. Babamohamadi H, Davari H, Safari AA, Alaei S, Valizadeh L, Mahmoudi H. The association between workload and quality of work life of nurses caring for patients with COVID-19. BMC Nurs [Internet]. 2023 [cited 2026 May 28];22(1):234. Available from: https://doi.org/10.1186/s12912-023-01395-6
» https://doi.org/10.1186/s12912-023-01395-6 -
18. Ross P, Howard B, Ilic D, Watterson J, Hodgson CL. Nursing workload and patient-focused outcomes in intensive care: a systematic review. Nurs Health Sci [Internet]. 2023 [cited 2026 May 28];25(4):497-515. Available from: https://doi.org/10.1111/nhs.13052
» https://doi.org/10.1111/nhs.13052 -
19. Santos WC, Lopes MCBT, Vancini-Campanharo CR, Okuno MFP, Batista REA. Nursing workload and severity of COVID-19 patients in the intensive care unit. Rev Esc Enferm USP [Internet]. 2024 [cited 2026 May 30];58. Available from: https://doi.org/10.1590/1980-220X-REEUSP-2024-0107en
» https://doi.org/10.1590/1980-220X-REEUSP-2024-0107en -
20. Aiken LH, Sloane DM, McHugh MD, Pogue CA, Lasater KB. A repeated cross-sectional study of nurses immediately before and during the COVID-19 pandemic: implications for action. Nurs Outlook [Internet]. 2023 [cited 2026 May 30];71(1):101903. Available from: https://doi.org/10.1016/j.outlook.2022.11.007
» https://doi.org/10.1016/j.outlook.2022.11.007 -
21. Ribeiro OMPL, Cardoso MF, Trindade LL, Fernandes A, Rocha LP. From the first to the fourth critical period of COVID-19: what has changed in nursing practice environments in hospital settings? BMC Nurs [Internet]. 2023 [cited 2026 May 29];22(1):53. Available from: https:// doi.org/10.1186/s12912-023-01207-x
» https:// doi.org/10.1186/s12912-023-01207-x -
22. Bastos JLD, Duquia RP. Um dos delineamentos mais empregados em epidemiologia: estudo transversal. Sci Medica [Internet]. 2007 [cited 2023 Sept 18];17(4):229-32. Available from: https://revistaseletronicas.pucrs.br/scientiamedica/article/view/2806
» https://revistaseletronicas.pucrs.br/scientiamedica/article/view/2806 -
23. Cevallos M, Egger M. STROBE (STrengthening the Reporting of Observational studies in Epidemiology). In: Moher D, Altman DG, Schulz KF, Simera I, Wager E, organizadores. Guidelines for Reporting Health Research: A User’s Manual [Internet]. Hoboken (NJ): Wiley; 2014 [cited 2023 Sept 18]. Available from: https://www.equator-network.org/wp-content/uploads/2016/12/CevallosEgger-Chapter-17-Guidelines-for-Reporting-Health-Research-A-Users-Manual.pdf
» https://www.equator-network.org/wp-content/uploads/2016/12/CevallosEgger-Chapter-17-Guidelines-for-Reporting-Health-Research-A-Users-Manual.pdf -
24. Theodosio BAL, Ribeiro LF, Andrade MIS, Mpomo JSVMM. Barreiras e facilitadores do trabalho multiprofissional em saúde na Pandemia da COVID-19/ Barriers and facilitating factors of multiprofessional health work in the COVID-19 Pandemic. Braz J Dev [Internet]. 2021 [cited 2023 Sept 28];7(4):33998-4016. Available from:Available from:https://doi.org/10.34117/bjdv7n4-044
» https://doi.org/10.34117/bjdv7n4-044 -
25. Torres-González JI, Arias-Rivera S, Velasco-Sanz T, Mateos DA, Planas PB, Zaragoza-García I, et al. ¿Qué ha sucedido con los cuidados durante la pandemia COVID-19? Enferm Intensiva [Internet]. 2020 [cited 2023 Sept 28];31(3):101-4. Available from:Available from:https://doi.org/10.1016/j.enfie.2020.07.001
» https://doi.org/10.1016/j.enfie.2020.07.001 -
26. Galon T, Navarro VL, Gonçalves AMS. Percepções de profissionais de enfermagem sobre suas condições de trabalho e saúde no contexto da pandemia de COVID-19. Rev Bras Saúde Ocupacional [Internet]. 2022 [cited 2023 Oct 03];47:ecov2. Available from: https://doi.org/10.1590/2317-6369/15821PT2022v47ecov2
» https://doi.org/10.1590/2317-6369/15821PT2022v47ecov2 -
27. Reynolds NR, Baker D, D’Aoust R, Docal M, Goldstein N, Grubb L, et al. COVID‐19: Implications for Nursing and Health Care in the United States. J Nurs Scholarsh [Internet]. 2023 [cited 2024 Jan 10];55(1):187-201. Available from:Available from:https://doi.org/10.1111/jnu.12853
» https://doi.org/10.1111/jnu.12853 -
28. Resolução COFEN No 543/2017 - Revogada pela resolução COFEN No 743/2024 [Internet]. Brasília: COFEN; 2017 [cited 2024 May 3]. Available from: https://www.cofen.gov.br/resolucao-cofen-5432017/
» https://www.cofen.gov.br/resolucao-cofen-5432017/ -
29. Nishiyama JAP, Moraes RMR, Magalhães AMM, Nicola AL, Trevilato DD, Oliveira JLC. Dimensões laborais, éticas e políticas do dimensionamento de pessoal de enfermagem diante da COVID-19. Esc Anna Nery [Internet]. 2020 [cited 2023 Sept 18];24:e20200382. Available from: https://doi.org/10.1590/2177-9465-EAN-2020-0382
» https://doi.org/10.1590/2177-9465-EAN-2020-0382 -
30. Clari M, Luciani M, Conti A, Sciannameo V, Berchialla P, Di Giulio P, et al. The Impact of the COVID-19 Pandemic on Nursing Care: A Cross-Sectional Survey-Based Study. J Pers Med [Internet]. 2021 [cited 2023 Sept 28];11(10):945. Available from: https://doi.org/10.3390/jpm11100945
» https://doi.org/10.3390/jpm11100945 -
31. Pinheiro PNC, Mondragón-Sánchez EJ, Costa MIF, Rodrigues IP. Reflections on nursing and COVID-19 in light of health education. Rev Bras Enferm [Internet]. 2021 [cited 2023 Oct 10];75:e20201305. Available from: https://doi.org/10.1590/0034-7167-2020-1305
» https://doi.org/10.1590/0034-7167-2020-1305 - 32. Pinto NGM, Coronel DA, Müller AP, Guerra PAC, Carvalho GS. Observatório socioeconômico da Covid-19: Perspectivas econômicas e sociais diante da pandemia. 1st ed. Paco e Littera; 2022.
-
33. Pinheiro FMG, Martinho RML, Moreira RC, Martinho LSAB. Iniquidades regionais e sociais na mortalidade por COVID-19 no Brasil. Rev Bras Gest Desenvolv Reg [Internet]. 2020 [cited 2025 Oct 09];16(4). Available from: https://www.rbgdr.net/revista/index.php/rbgdr/article/view/5978
» https://www.rbgdr.net/revista/index.php/rbgdr/article/view/5978 - 34. Morin E. É hora de mudarmos de via: as lições do coronavírus. Rio de Janeiro, RJ(BR): Bertrand Brasil; 2020.
NOTES
-
ORIGIN OF THE ARTICLE
Extracted from the thesis “Avaliação do produto do cuidar em enfermagem no contexto da pandemia da COVID-19”, which will be presented to the Graduate Program in Nursing of Escola Paulista de Enfermagem, Universidade Federal de São Paulo, in 2026.
-
FUNDING INFORMATION
This research was conducted with support from the Brazilian National Council for Scientific and Technological Development (CNPq - Conselho Nacional de Desenvolvimento Científico e Tecnológico) under Call MCTIC/CNPq/FNDCT/MS/SCTIE/Decit 07/2020- Research to address COVID-19, its consequences and other severe acute respiratory syndromes (Process 402392/2020-5).
-
APPROVAL OF ETHICS COMMITTEE IN RESEARCH
This study was approved by the Research Ethics Committee of Universidade Federal de Santa Catarina, under Opinion 5,452,034 and Certificate of Presentation for Ethical Consideration 38912820.3.1001.0121.
-
TRANSLATED BY
Letícia Belasco.
-
DATA AVAILABILITY
The data supporting the results of this study are described in the manuscript. Additional data may be made available upon request to the corresponding author.
Edited by
The data supporting the results of this study are described in the manuscript. Additional data may be made available upon request to the corresponding author.
