Of the 30 nurses working in the ICUs (maternal, pediatric, and neonatal) and neonatal semi-ICU, 28 (93%) and 18 (64%) participated in the interview’s first and second phases, respectively, whereas 10 (36%) who did not participate in the second phase were excluded for reasons, such as dismissal, transference, medical and maternity leave, and meeting pre-established criteria. Thus, the final sample of the study included 18 nurses eligible for participating in both phases, whose sociodemographic and professional characterization data are shown in Table 1.
Table 1. Sociodemographic and professional characterization data of the study sample (n = 18)
Variables
|
A (SD)
|
N
|
%
|
Age
|
41 8
|
18
|
100%
|
Sex
|
F
|
18
|
100%
|
M
|
0
|
0%
|
Place of performance
|
Neonatal ICU
|
3
|
17%
|
Pediatric ICU
|
3
|
17%
|
Maternal ICU
|
4
|
22%
|
Neonatal semi-ICU
|
8
|
44%
|
Formal education (years)
|
From 3 to 10 years
|
15
|
83%
|
Over 10 year
|
3
|
17%
|
Specialization
|
It has
|
18
|
100%
|
Does not have
|
0
|
0%
|
Professional performance time (years)
|
From 3 to 10 years
|
16
|
89%
|
Over 10 year
|
2
|
11%
|
A= Average; SD= Standard Deviation; F= Feminine; N= Male; A= Amount
Considering the answers of the objective questions, the nurses were asked to talk about healthcare quality. The theme “delivery of values" emerged from the analysis of the first phase and subsequently two categories emerged from the nuclei of meaning, which showed their concern related to the healthcare quality and its importance during treatment. The first category refers to excellence and error minimization and the second to efficiency and effectiveness without mentioning health indicators, as shown below:
[...] Quality I understand, like giving the patient a better condition [...] (Nurse 01A)
[...] I understand that it optimizes our time and procedures; minimizes errors in the ICU; and provides good care [...] (Nurse 06A).
[...] Quality is a service that you efficiently provide for someone [...] (Nurse 05A).
[...] It is what you do best for your patient, seeking the result he needs [...] (Nurse 08A).
The second phase (post-intervention) showed the empirical emergence of the theme quality indicators in health and focused on the delivery of results. In addition, the importance of the use of quality tools in health, such as: dispersion diagram (category 1), process flowchart (category 2), and pareto chart (category 3), were discussed in the intervention.
[...] It will help in the best possible way, with more confidence, by knowing all the processes: Service flow, promptitude, reception of the family, confidence in what one is doing, knowing the binomial, as a whole, within what we can offer (materials, medicines, physical, and quantitative staff structure). And that is it [...] (Nurse 9B).
[...] The processes are well designed and completed. It comprises patient care without harming the patients, exactly the opposite, that the patients leave well and receive the best possible care [...] (Nurse 17B).
Most of the answers in both phases indicated concerns on the importance of quality in healthcare actions. However, the need for indicators to measure healthcare eminently appeared in the second phase, sometimes implicitly and at other times explicitly, showing the importance of measuring the healthcare provided, and the results obtained using some management tools. This resulted in the third theme, which included the following categories: First category: Dispersion diagram, identified in the statements below:
[...]Quality for me is assistance with... According to what the patient needs or what the person expects: quality healthcare, scientific knowledge, acquired through quality indicators, identifying problems that could interfere with quality (Nurse 1B).
[...]Quality? That is what we do best, right? Additionally, if we are prepared to offer what he really needs [...] (Nurse 2B).
[...] The indicators that we present are from these protocols. Do they refer to what is done in healthcare? These indicators really show if quality services are being provided or not. So, what is relevant for me is to really work on these indicators, right? It is through protocols and check lists, that we can really reach a denominator that our work is really going well (Nurse 7B).
Some lines originated, in a somewhat veiled way, the second category: Process flowchart, as described below:
[...] It is all that involves care, both for the patient, the team itself, and the service, which is in accordance with the routine, the standard protocols, with beginning, middle, and end (Nurse 4B).
[...] This management is done by employees who are not from the healthcare area, but by using some tools, they can see, where we can improve, where we go wrong. So, their feedback helps us to provide better quality of care [...] (Nurse 5B)
As shown below, sine qua non conditions listed from the answers of most participants are highlighted, in the first and second phases, about relevant quality of care factors, such as: adequate inputs, technical training, process adjustments, and interdisciplinary work. However, in the second phase, the interviewees assimilated that these punctuality problems caused the greatest impact on the result, from which originated the third category: the Pareto chart, according to the quotes below:
[...] There is no use in just providing good care down there because if the manager does not do the right thing, if he does not maintain the equipment’s quality, or if he does not do his part, then our part decreases too. (Nurse 1B).
[...] It is trying to organize things so as to improve them during the shift, for the patient. Let me see here, in the actions, together with the technical team, materials, equipment, all of this [...] (Nurse 14B).
[...] You must maintain a standard; how can I explain... It is no use having all the materials on one day, and the next day not having even the basics to provide healthcare. We are never sure, we have it today, but tomorrow? It causes a great deal of confusion in everyday life [...] (Nurse 2B).
[...] Team training to use check lists for invasive procedures, systematization of our services, action planning (Nurse 4B).
In both phases, when questioned about the concept of quality management in care, the interviewees’ answers pointed to things that resulted in the fourth theme - Care Management, and its categories - perception, hierarchy, and empowerment, as described below:
[...] Having mastery of the care provided makes one aware of any situations that may cause problems, which enables preventing and solving problems before they affect or harm patients[...] (Nurse1B).
[...] Because I think some professionals, not all, do not accept it, right?! Sometimes, what I see as quality, the others do not see it in the same way. That is why I think a protocol has to be implemented by the directors, manager. Do you also think so? It is not an “option” for the professional whether to comply or not to comply, so that everyone speaks the same language [...] (Nurse 3B).
[...] I understand like this... if we have protocols approved by the institution and a team duly trained for the application of these protocol procedures, nursing becomes safer, more respected too, with more power for decision making [...] (Nurse 07B).