Keywords: Quality management; organization and administration; health services; nursing.

INTRODUCTION

Today, quality is a frequently investigated and polemic term that can be understood from different foci1. As a management model, however, quality has a broad sense and is used to systemically structure the range of services at a given institution².

The quality movement started in Japan, when statistical criteria were applied to the production line. Over time, this theme gained considerable dimensions inside organizations, involving all sectors, including relations with suppliers and clients³. Today, the search for quality is found not only in the industrial sector, but also in service delivery, including health institutions.

In search of higher quality in the delivery of their services, health institutions are discussing, implanting and implementing quality through strategies like total quality management (TQM) for example, which is a progressive and continuous process in search of excellence⁴.

Nursing professionals, in turn, which are an important part of these institutions, are also engaged in the quality movement².

Nurses have identified studies that highlight strategies nurses use to accomplish actions committed to the quality of nursing care¹. One of these studies discusses leadership through the application of the 14 principles of quality⁵.

Although quality management (QM) has become a source of discussions in health institutions and in management subjects taught in nursing programs, experience reports are needed, deriving from the implementation of this model in health and nursing services, with a view to gaining better knowledge about the results achieved and checking the credibility of this management form⁶.

The use of this management model should still be considered with caution, as there are still few studies that show results to assess the effects of quality programs with regard to infrastructural improvements, qualification of human potential and agility in client care².

Driven by these thoughts, we undertook an integrative literature review to identify studies that demonstrate the contributions of QM to Brazilian nursing.

METHODOLOGY

The integrative literature review is the search for information on a given theme with a view to summarizing the knowledge produced on a research problem and to enhance the readers’ understanding of what has been published about the theme. By providing the research results, this method can help professionals, researchers and students to make decisions⁷. This type of study can offer potential contributions and represents a valuable part of the creation and organization process of the body of knowledge on a given theme⁸.

To achieve the study objective, the review was undertaken in accordance with criteria defined and used by researchers^8-10, which made us define the following methodological steps: selection of the review question: what contributions does QM offer to Brazilian nursing according to studies published in Brazilian journals between 2000 and 2010?; sample selection, executed between February and June 2011; definition of the characteristics of the studies in the sample based by the study authors; analysis of the results using an instrument elaborated by the authors of this paper; discussion of the results; presentation and publication of the results.

The inclusion criteria to define the study sample were: papers published in Brazilian journals, between 2000 and 2010; studies whose full version was available and which presented contributions of QM to Brazilian nursing.

The publications included in the review sample were found in the databases affiliated with the virtual health library (VHL). To access the databases, the terms quality management and nursing were used.

RESULTS AND DISCUSSION

During the search in the VHL, initially, we identified 110 national studies, 73 of which were published between 2000 and 2010. Forty of these did not address aspects that demonstrated contributions of QM to nursing. The remainder (33 studies) included four theses and two monographs, which resulted in 27 published studies. Out of 27 publications, we recovered 20 full studies that complied with the inclusion criteria.

Characteristics of the studies analyzed

All studies found were indexed in the database Latin American Literature for the Health Sciences (LILACS), and two were also indexed in the database Medical Literature Analysis and Retrieval System Online(MEDLINE).

The mean publication rate is 1,6 per year, with 2009 showing the largest number of publications, followed by 2000 and 2006, as shown in Table 1.

During the first five years of the previous decade, publications about QM in nursing were scarce, perhaps reinforcing the thoughts experts expressed in 2005⁶ about the need to produce experience reports about the implementation of this model in health and nursing services. The data for these years also reinforce other researchers’ comments² about the need to consider the use of the management model with caution, due to the small number of studies on the theme.

On the opposite, a concentration of publications is observed between 2005 and 2010, strengthening the idea that this strategy is increasingly present in health organizations. Each age develops an organizational form appropriate to its characteristics and requirements³. Thanks to the great impact of technological development and information technology, we are currently in the age of information, marked by uncertainties, but also characterized by the change in organizations’ focus. In view of the above, the way health services function has also gone through transformations, including the need to continuously seek quality.

The implementation of QM in health services dates back to the end of the 1980’s, when Donald Berwick, a pediatrician and professor at Harvard University, coordinated a project to prove the applicability or not of TQM concepts in the health area¹¹. In the Brazilian health area, however, this movement only started to happen as from the 1990’s and, although some theoreticians consider it as a set of universal techniques, applicable to organizations of any kind, it still faces difficulties and failure in the country’s hospital institutions. After all, this type of institution is part of a complex environment, conditioned by a singular functioning, in view of the market logic of profitable accumulation. The hospital is subordinated to ethical and legal principles that confront it with a range of interests that cannot be ignored when trying to implement this kind of management strategy¹².

It is possible that, because of these factors, Brazilian nursing professionals have only more recently discovered the importance of using and investigating the principles of QM for care delivery and for the institution where they work as a whole.

As regards the journal where the papers were published, Acta Paulista de Enfermagem and the Latin American Journal of Nursing predominated with four (20%) publications each.

The journals that published more recently were the Revista Enfermagem UERJ (Universidade do Estado do Rio de Janeiro), with one (5%) publication in 2010, and the Revista Gaúcha de Enfermagem with 2 (10%) publications in 2009, as displayed in Table 1.

In total, there were 60 authors for the studies analyzed. Fifty-four (90%) of them are nurses, three (5%) physicians, one (1.67%) psychologist, one (1.67%) electrical engineer and one (1.67%) mechanical engineer.

As regards the authors’ degrees, 28 (46.7%) hold a doctoral degree, followed by ten (16.6%) professionals holding an undergraduate with specialization degrees in hospital management, human resource management, nephrology, nursing audit and informatics, according to Table 2.

Among the 54 nurses, only 9 (16.67%) are active in care delivery, demonstrating that most professionals who research on the theme work in the academic context and are affiliated with research centers and groups.

As regards the frequency of the study design, we found ten (50%) exploratory and descriptive studies, four (20%) experience reports, two (10%) theoretical reflections and the same number of literature reviews. We also identified one (5%) descriptive study and one (5%) critical analysis.

Contributions of the studies

In the analysis of the publications regarding the contributions of QM to Brazilian nursing, we identified three thematic categories: assessment of quality standards of nursing services, with (40%) studies; nursing actions in the set-up and/or implementation of quality programs, with six (30%) texts; and use of QM in health service organization, also with six (30%) articles.

Assessment of quality standards

In institutions with high quality levels, hospital accreditation processes are considered important developments of the quality movement in recent times. Among the institutions that promote these processes, we can highlight the Organização Nacional de Acreditação ONA), which aims to promote the implementation of a continuing health service quality assessment and certification process¹³.

In one of the studies in the first category, the intention was to identify the result assessment criteria applied to nursing services, used in the accreditation programs. The data were collected at seven institutions accredited by the ONA and the findings revealed that the outcome criteria of the nursing administration area are emphasized, indicating that, perhaps, the accreditation programs still need a more precise measurement of care and teaching and research criteria¹⁴. On the other hand, experts identified the opinion of nurses at an accredited hospital about the indicators to assess nursing care and found that they highly value the indicators related to specific nursing care processes, while not all nurses considered the indicators related to the management processes as pertinent to assess the quality of care¹⁵.

Experts have studied the reflections of nursing faculty and managers about the use of quality indicators in nursing human resource management. The interviewees emphasized aspects related to participation in decision making and compatible remuneration and satisfaction at work as relevant to assess quality indicators in human resource management¹⁶.

Some authors offer particular contributions in the analysis of the quality policy the hospital management implemented at a central pharmacy, as well as the characteristics of medication administration by the institution’s auxiliary nurse. They concluded that the implemented quality policy and the quality required in medication administration made it difficult to perform that task¹⁷.

Other studies in the first category aimed to assess the quality standards of nursing services based on the nurses’ opinion about the application of Deming’s principles at the service where they work. Among the 57 nurses who participated in the study¹⁸, 79% observed improvements in staff satisfaction after the implementation of QM, 89.5% observed improvements in patient satisfaction and only one professional indicated not believing that QM could provide good results. The nurse’s opinion about Deming’s 14 principles were also discussed by other researchers. The principle the nurses scored highest was the seventh, related to the establishment of leadership focused on the search for quality¹⁹.

Experts investigated the opinion of nurses who manage primary health care units about the implementation of QM. One of the interviewed professionals believes that, once it has been firmly implemented, QM could promote a true revolution in public health service delivery².

Nurses’ actions in quality programs

In the second category, we highlight studies that emphasize the importance of nurses’ role in the entire planning, implementation and maintenance process of quality programs in health and nursing services, serving as a link between management, the care team and the client^20-22.

In that sense, some authors highlight the importance of nurses’ leadership role in the assessment process of a quality program at a pediatric intensive care center, undertaken by the British Standards Institution to grant the International Organization for Standardization 9002 (ISO 9002) certificate²³.

Other researchers developed a reflexive critical analysis based on the theoretical quality framework and their own experiences in the implementation of quality systems. They highlighted nurses’ insufficient political participation in an institution’s strategic planning, mainly with regard to the initiative to get organized and claim an active role in decisions on processes related to the organization of nursing²⁴.

Experts identified studies that highlight strategies nurses use through actions committed to QM. One of the strategies relates to the promotion of satisfaction at work in the nursing team involved in care quality improvement. The auxiliary nurses’ participation in service planning and organization activities showed to be fundamental for the professionals’ satisfaction¹.

Use of QM in nursing services

Finally, the third category of studies contributes to the discussion about the use of QM tools and/or techniques in the planning and organization of nursing work^25-27. Tools like Brainstorming, the Ishikawa Diagrams and Pareto Charts helped nurses to identify the main problems at the service where they worked²⁸.

In the search for quality in nursing work at a surgical center, authors submitted an administrative and care quality standard instrument to the judgment of 12 nurse experts in the area²⁹.

To improve a nursing team’s rates of satisfaction at work, activities were developed at an intensive care unit. Although the authors considered that the rates remained low after the intervention, they increased from 12.08 to 15.05 among the nurses and from 11.33 to 12.13 among the auxiliary nurses³⁰.

Authors present experiences at Brazilian hospitals and nursing services in the adoption of QM to organize their services. In the analysis of these experiences, they verified gains related to human resources, guaranteeing people’s satisfaction in their work environment. In addition, they observed modifications in statistical indicators related to patient satisfaction. The authors considered that the experiences at the health institutions under analysis in the adoption of QM achieved satisfactory results, granting credibility to this management model⁶.

The analysis of the publications presented in this study demonstrates the nurses’ current concern with getting involved in the implementation of QM in Brazilian nursing services. Nevertheless, we highlight the lack of studies that explore quality indicators in nursing processes. In this respect, we want to emphasize a recent publication, which was not included in this sample and exemplifies this kind of study. In an analysis of adverse events notified by nurses at a surgical clinic, 264 events were found related to the removal of probes, drains and catheters, falls, pressure ulcer, medication errors and burns, among others. The study evidenced the underreporting of adverse events, as well as severe consequences for the patient. Also, possible causes and preventive actions were indicated³¹.

In addition, it should be highlighted that, from the perspective of a continuous search for excellence in the improvement of care, techniques, financial resources and power are not sufficient without health system that function with guaranteed access, problem solving, social justice and quality. Efforts should be made to enhance the human capital, as a source of all energy to put in practice changes³². In that sense, experts have recently attempted to discover the bottlenecks that trigger the absence of humanized care in nursing practices and were confronted with an inappropriate environment, lack of human resources, limited incentives towards professional qualification, among others³³.

Thus, we agree that the incorporation of new behaviors demands coping and willingness to sensitize the institutional agents to cast a new look on their activities, in view of management practices with a participatory and democratic focus, moving towards new perspectives in nursing and health planning, in view of the reality experienced in the sector. Thus, we can offer better care and management quality in a healthy work environment^34,35.

CONCLUSION

The publications analyzed indicate the nursing professionals’ current concern, more specifically in the latter half of the period 2000-2010, with establishing QM in Brazilian nursing services, as well as with studying the results achieved after the implementation of the management strategy. Nevertheless, we still observe a small number of practical studies, which explore quality indicators in nursing services and are capable of determining the efficiency of the practices adopted in the implementation of QM in health.

The minority of the nurses who authored the studies analyzed is active in care practice, indicating a low level of interaction between clinical and academic professionals. This fact can be one of the factors that hamper the development of studies that are capable of exploring quality indicators of nursing practice before, during and after the implementation of QM models, whose lack was highlighted in this review.

Finally, the main limitation in this study is due to the small number of papers that defined the sample, not permitting statistical inferences and generalization of the findings.

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