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Quality of nursing care in a pediatric emergency department: the companions' view


Chayenne Karoline Rosa SantosI; Juliana Rezende Montenegro Medeiros de MoraesII; Nereida Lucia Palkos dos SantosIII; Tania Vignuda de SouzaIV; Rita de Cássia Melão de MoraisV; Suellen Dias AzevedoVI

I Graduate nurse from the Anna Nery Nursing School, Federal University of Rio de Janeiro. Brazil. Email:
II PhD in nursing. Adjunct Professor, Federal University of Rio de Janeiro. Brazil. E-mail:
III PhD in nursing. Adjunct Professor, Federal University of Rio de Janeiro. Brazil. E-mail:
IV PhD in Nursing. Adjunct Professor, Federal University of Rio de Janeiro. Brazil. E-mail:
V Assistant Professor and PhD Nursing student, Federal University of Rio de Janeiro. Brazil. Email:
VI Graduate nurse from the Anna Nery Nursing School, Federal University of Rio de Janeiro. Brazil. Email:





Objective: to describe the quality of nursing care for children in a pediatric emergency room from the companion's perspective. Method: this descriptive qualitative study was conducted from September to October 2014, through semi-structured interviews of 20 companions in a pediatric emergency room at a hospital in Rio de Janeiro. Data were submitted to thematic analysis. The study was approved by the research ethics committee of Rio de Janeiro Municipal Health and Civil Defense Department (No. 2017A/2013). Results: quality was associated with the hospital structure (the physical and human resources necessary for health care) and the activities of the nursing team work process. Conclusion: In the companions' view, quality of care should center on humanization, dialogue and care focused on patient safety, especially in drug care.

Keywords: Emergency service, hospital; child health; quality of health care, pediatric nursing.




Pediatric emergency units receive children with serious health conditions, at imminent risk of death, acute suffering, acute problems and in need of immediate care and treatment. In these places, high complexity and diversity of services are offered to meet the demand and ensure all maneuvers of support to life, providing conditions to continuity of assistance on-site or at another level of care within the health network1.

In 2014 in Brazil, the main cause of search for pediatric emergencies among children aged between 1 and 4 years were problems in the respiratory system followed by infectious and parasitic diseases and problems in the digestive system. In the age group of 5-9 years, respiratory diseases predominate too, followed by infectious diseases and poisoning and external causes2.

Emergency services of the Unified Health System (SUS) for critically ill children are also used by children with simple illnesses and cases that are not emergencies. Families use them as a gateway in the system. However, this causes an increase in the demand for services and affect the care for patients in severe situation, who are forced to face queues in overcrowded emergency rooms3.

This situation seems to justify the inadequacy of demand for hospital care, resulting in the overcrowding of pediatric urgency/emergency services and, consequently, low quality of care provided to those who really need emergency care, thus compromising the comprehensive care4.

Thus, the imbalance between offer and demand for care becomes evident. The reorganization of non-emergency cases by primary care is of fundamental importance. This should be able to take care of 85% of the health needs of the population, through a network of resolute and decentralized services with universal access3,5.

In an attempt to resolve the problem of emergency services, including pediatric emergencies, a Network of Attention to Urgency and Emergency (NUE) has been implemented throughout the national territory since the second half of 2012. This network consists of: the Mobile Emergency Service (SAMU), Emergency Care Units (ECUs) and the Family Health Strategy (FHS). The NUE aims to ensure the reception and assistance to users who need emergency care, referring them to the basic health care network, to specialized network or hospitalization. In this regard, the services comprise units that operate 24 hours per day and represent the entry to the municipal emergency system6.

However, the implementation of the NUE in the municipality of Rio de Janeiro needed an evaluation of the quality of hospital care emergency, especially nursing care, to children6.

The evaluation is fundamental for improving the system management and, when performed in an effective and orderly manner, it specifies clearly the greatest needs of the public assisted, turning the development of strategies and improvements of health service more rational. The evaluation of user satisfaction, one of the evaluative modes, aims at a greater input of information on the quality of services offered to the public. This gives support to the ability of decision-making of managers in the construction and implementation of SUS policies7.

Therefore, we sought to describe the quality of nursing care provided to children assisted in pediatric emergency from the perspective of the companions.



Seeking to improve the evaluation from the perspective of users, this research was based on the study of Donabedian, a major scholar on health care quality, restricted to the dyad structure and process8.

The structure is composed of physical, human, material and financial resources for health care. The process refers to activities involving health professionals and patients, including diagnosis, treatment, ethical aspects of professional relationship, health staff and patients8.

The literature points multifactorial causes that affect the quality of care in emergency departments and that are considered difficult to resolve. These include overcrowding, fragmented care, process labor disputes and power asymmetries, exclusion of users in the entryway, structure, among others. These factors are in strong barriers to the quality of health care because they require high financial investment, great effort of managers and workers, and especially the commitment of users to understand the processes involved in the health care network7,9.

Integrative reviews conducted in Brazil point out that this issue has been studied from the nursing professional perspective, focusing on hospital services that assist adults and with quantitative approach. However, the evaluation of nursing care quality in pediatric emergency departments has not been explored7,10. In turn, an international study conducted in England shows that the focus is on families and health professionals and that greater attention has been given to the quality of primary care and home care to children in order to avoid unnecessary visits to emergency services11.



This is a descriptive research with a qualitative approach developed in a hospital in the municipality of Rio de Janeiro, part of the NUE, which offers pediatric emergency care. Data were generated in the period from September to October 2014 through semi-structured interviews. Twenty-four randomly chosen companions of children aged from 1 month to 12 years assited in the pediatric emergency room were invited to participate in the study. Among these, only 20 accepted the invitation, and this was the total number of interviews carried out and validated. The number of participants was defined during the fieldwork, when the organization of the statements allowed the identification of data saturation, that is, the recurrence of ideas, practices and worldviews12.

The interviews were conducted using a script with two open questions, registered with recorders (MP3) after prior authorization of the participants and after they have signed the Informed Consent (IC). All the ethical principles of research involving human beings set forth in the Resolution nº 466/12 were respected, and the study was approved by Research Ethics Committee of the Municipal Department of Health and Civil Defense of the Municipality of Rio de Janeiro, under the number 2017A/13.

Anonymity to participants and confidentiality of interviews were assured. For this, we used the letter C followed by a number that indicates the sequential order of the interview to identify participants of the research, and therefore, there is the sequence C1, C2, C3 up to C20. Full length interviews were accesssed only by the authors of the study.

Inclusion criteria were: treated at the emergency department, at least 18 years old and who willingly agreed to participate. Exclusion criteria were: companions of children with eminent discharge, transferred to other health institutions and that evolved to death.

Empirical data generated in the interviews was treated by the method of thematic analysis by following the three steps proposed13. The first step was the initial reading of the transcript of interviews recorded in digital media. This material was the textual corpus of the research. In the second step, material was explored for identification of thematic units. In the third and final step, treatment and interpretation of results were carried out.



We attempted to describe, through the testimonies of companions, the quality of nursing care provided to children in situation of emergency in a public hospital. These speeches are analyzed according to the three thematic units: inappropriate furniture; medication by the nursing staff; and interpersonal relationships.

Inappropriate furniture

The evaluation of companions regarding the quality of nursing care to children in situations of emergency included aspects related to the hospital's physical structure, especially the furniture.

The chair is very hard, it is very uncomfortable, here at the hospital. (C6)

The only one bad thing of this hospital are these chairs. (C14)

The hospital staff should give attention to this [furniture]. Because otherwise, we companions will end up becoming patients, because these old and inadequate furniture is bad for our health. (C20)

In the hospital setting, the furniture influenced negatively the welfare of companions. The chair was the biggest target of criticism for not offering comfort, for being very hard and uncomfortable. Hospital furniture is an intervening factor in the quality of health care and is a support for the recovery of the health-disease process of the user and for the companions8,14.

The public policy of NUE states that the Centers of Access and Hospital Quality, along with the management team of the hospitals, must be responsible for implementing measures to improve the quality of services and to reduce overcrowding. This includes the suitability of the physical structure of hospitals6.

However, for participants of the present research, this physical and structural adequacy did not include the furniture to make them enjoy a comfortable stay with the child.

In this sense, the companion must also be the focus of nursing care. Providing a place for rest in the midst of so many distressing feelings that surround the emergency care and hospitalization is part of the nursing and hospital management. Granted, the Statute of Children and Adolescents, assures the right of children to have a companion during provision of health care.15 Thus, a minimum acceptable physical structure is needed. This includes proper furniture that accommodation those accompanying the child with comfort, so that they may keep close to the child, assisting in its recovery. Discomfort and lack of structure can damage the health of companions, compromising their physical condition and turning them into patients, as mentioned in the speech of one of the study participants.

Hospital care for children in situations of emergency focuses on disease/client. This contributes to the invisibility of the companion in the eyes of health staff and health managers responsible for maintaining the physical structure and the purchase of furniture 16,17. However, it is necessary to break this current model and start the construction of hospitals that promote health. This would ensure quality of care through strategies of training professionals and users in order to make them active and co-participants of the management of the health services available17.

Medication by the nursing staff

Regarding the nursing care to children in situations of emergency, companions revealed different perceptions and evaluations. Here is a testimonial:

The care of pediatric emergency was very good. The nursing technician made the bed, then the nurse went preparing the medication. Then the nurse cleaned the skin of my son with alcohol, sanitized it. Stuck, found the vein and put the serum. (C11)

According to this report, the care provided in the emergency room was very good, and it is possible to identify the members of the nursing staff involved in accordance with the duties performed. The nursing technician was responsible for the organization of care and comfort to the child, including the making the bed, while the nurse held the invasive procedure and prepared and administered the medication and the serum intravenously.

In the process of work in pediatric emergency rooms, the care of children in serious and life-threatening conditions is the responsibility of nurses, while nursing technicians exercise mid-level activities involving orientation and development of the nursing work17,18. The establishment of effective dialogue, development of teamwork, evaluation and diagnosis of the clientele, partnership with other professionals, planning and evaluation of care and management actions are competencies of nurses working in these sectors. The maintenance of the service flow according to the system of Reception with Risk Rating, prioritizing the most serious cases and referring cases that are not emergencies within the NUE is also a responsibility of this professional8,17.

However, the roles of members of the nursing staff seem poorly defined and clear in the eyes of society. For this reason, the implementation of strategies to increase the visibility of the public identity of nursing and its professionals is necessary18.

But I had to remind the time of giving the medication to the nursing technicians, the time to apply medication to the nurse and to the technicians. (C3)

When the serum was over, my son stayed there with the empty bottle hunging, and the other full glass there, at the side. The technicians and the nurse were laughing and talking and I was there. just looking, and nothing. No one would come to see. (C13)

And I saw, the nurses delay to apply the medication. And they want to give a drug right after the other but my daughter is just a child. (C18)

Nursing care to children in emergencies was focused on medication. In this care, the nursing staff counted on the participation of companions who would remind the time of giving the drug and would call the nursing professionals at the end of the infusion of intravenous therapy. Companions demonstrated dissatisfaction with the human resources of the hospital (nursing staff) and with the assistance.

Drug administration must be performed carefully in children because they have a different metabolism of absorption and excretion of drugs when compared to adults19.

In emergency care, a high number of people requires intravenous administration of medications, and this is an important indicator to assess the quality of care. Drug therapy is associated with high rate of complications resulting from inflammation or infections and other adverse events. Therefore, it is recommended to check nine "right " points before administering any drug to ensure the safety of the patient. These points are: right patient, right drug, right dose, right route, right time, right medication compatibility, guidance to the right patient and companion, right response and right notes. There are also other safety measures including the control of the permeability of the catheter and monitoring the phlebitis in the venous system9,17,20.

Therefore, in the process of work, the nursing staff should ensure patient safety and prevent adverse effects from medications. Delayed drug administration negativelly affects the desired therapeutic results and can bring undesirable consequences to patients such as disability, prolongation of hospital stay and delayed recovery, child exposure to a greater number of procedures and therapeutic measures, delay or impediment of resumption of social functions and even death18,19.

The attitude of the members of the nursing staff of laughing, talking loud and administering a medication right after the other generated the impression of lack care in the eyes of companions. The professional attitude of technicians and nurses compromise the work process and violates the ethics of care and patient safety, in this case children under clinical vulnerability18,19.

Interpersonal relationships

The communication of the members of the nursing staff with the child and with the companion was evaluated with ambiguity, since at times this was effective and favored the hosting, while in other moments it compromised the result of the assistance given, according to the interviews.

The nurses would talk to my son, they were all concerned about him. (C1)

Nurses demonstrate affection, well, you know? They are thoughtful, that is, in general. (C6)

Nurses, when they talk to the child under emergency care, demonstrate attention and affection and thus unveil a humanized care that goes beyond the development of techniques and life maintenance procedures 6,18. Thus, this humanized care was positively evaluated, demonstrating quality of nursing care. To maintain integrality while providing care, humanization should be initiated at Reception with Risk Rating and must be maintained during the the stay of the child and its companion in the health unit. At discharge, the client must be re-directed to the health care network in order to continue monitoring the levels of lower complexity16.

Although stated in the public policy of the NUE, the reception and the humanization of care were not perceived by all companions, as shown in the following lines:

In the pediatric emergency, we were treated with great disregard ... Then no one of the nursing staff informed me what was happening. I arrived there with my daughter and they gave me a bed that had no blanket and it took hours for them to give me a sheet for my daughter. (C17)

The pediatric emergency is not a place to talk loudly. There are sick children felling very unwell, do you understand? I got very angry, really ... And my son is not a puppet, that nurses will come and make things, and come and go. They don't even say what they are doing. (C13)

I do not know if it's because people of the nursing staff are tired, it is because they have another job and are working too much here. Then I do not know, but people of the nursing staff don't explain much. (C8)

The work process in emergency units is centered in the rush to save lives and sometimes the family is excluded8. The cold and distant attitude of nursing professionals towards children and companions expresses a personal defense to avoid emotional involvement. This is a non-justified attitude, but perceived in the professional-patient-family dialogue.

The poor interaction between health professionals and users shows an asymmetrical relationship of care where there is no time to listen, to the meeting between professional and client nor the hosting of the family demands during emergency care15,21,22.

Effective communication through sensitive listening and explanation of the therapeutic process being applied can help to strengthen the relationship between companion and nursing professional. To improve the result, which is the final product of care, members of the nursing staff should provide care in a humane way, in their actions of reception and care, in order to strengthen the bond and establish effective communication with their customers20,21,23.



The quality of nursing care in a pediatric emergency, according to the perpective of companions, was associated with hospital structure, with its physical and human resources needed for medication and interpersonal relationships proper of that work process.

It was found that nursing care should not be centered only on the care model of saving lives. Attention should value the humanization, the relationship between user and health professional, dialogue/communication, comfort also to the person accompanying the patient and the assistance with a focus on patient safety, especially in the care related to medication. It is also necessary that integrality of health care be maintained after hospital discharge, with the insertion and referral of children within the care network.

The limitation of the study was the small number of participants in a single hospital part of the NUE.



1.Nascimento ERP, Hilsendeger BR, Neth C, Belaver GM, Bertoncello KCG. Risk classification in emergency: evaluation of the nursing staff. Rev Nurse UERJ [Internet] 2011 [cited on March 11, 2016]. 19 (1): 84/88. Available in:

2.Datasus. SUS Department of Informatics [web site]. SUS hospital morbidity. [cited on March 10, 2016] Available at:

3.Lima LMB, Almeida NMGS. Mothers searching for pediatric emergency: implication on overcrowding at the emergency units. Health Debate [Scielo-Scientific Electronic Library Online] 2013 [cited on March 10, 2016]. 37 (96): 51-61. Available in:

4.Azevedo ALCS, Pereira AP, Lemos C, Coelho MF, Chaves LDP. Organization of hospital emergency services: an integrative review of research. Rev Elect Enf [Internet] 2010 [cited on March 11, 2016]. 12 (4): 736-45. Available in:

5. Ministry of Health (Br). National Council of Health Secretaries. Primary Care and Health Promotion/National Council of Health Secretaries. Brasília (DF): CONASS. [Internet]. 2007 [cited on March 12, 2016]. Available in:

6. Ministry of Health (Br). Secretariat of Health Attention. Instructional Manual of the Care Network to Urgencies and Emergencies in the Unified Health System (SUS) [Internet] 2013 [cited on March 14, 2016]. Available in:

7.Caldana G, Gabriel CS, Bernardes A, Évora YDM. Performance indicators in hospital nursing service: an integrative review. Rev RENE [Internet] 2011 [cited on March 10, 2016]. 12 (1): 189-97. Available in:

8.Donabedian A. The definition of quality and approaches to its assessment. Ann Arbor (MI): Health Administration Press; 1999.

9. Cavalcante PS, Rossaneis MA, Haddad MCL, Gabriel CS. Quality indicators used in the management of hospital nursing care Rev Nurse UERJ [Internet] 2015 [cited on March 16, 2016]. 23 (6): 787-93. Available in:

10. Bellucci Junior JA, Matsuda LM. Rev. The nurse in the management of the quality of emergency hospital services: an integrative literature review. Rev Gaucha Enferm [Scielo-Scientific Electronic Library Online] 2011 [cited on March 11, 2016]. 32 (4): 797-806. Available in:

11.Kyle GR, Banks M , Kirk S,Powell P, Callery P. Avoiding inappropriate pediatric admission: facilitating general practitioner referral to community children's nursing teams. BMC Fam Pract [National Center for Biotechnology Information] 2013 [cited on March 12, 2016]. 14 (4). Available in:

12.Fontanella BJB, Luchesi BM, Saidel MGB, Ricas J, Turato ER, Melo DM. Sampling in qualitative research: proposal of procedures to observe theoretical saturation. Cad Public Health [Scielo-Scientific Electronic Library Online] 2011 [cited on March 13, 2016]. 27 (2): 389-94. Available in:

13.Minayo MCS. The challenge of knowledge: qualitative research on health. 10th Ed. São Paulo: Hucitec; 2007.

14.Karlsson C, Tisell A, Engström A, Andershed B. Family members' satisfaction with critical care: a pilot study. Nurs Crit Care [National Center for Biotechnology Information] 2011 [cited on March 12, 2016]. 16 (1): 11-8. Available at:

15. Ministry of Social Action (Br). Brazilian Center for Children and Adolescents. Statue of Children and Adolescents. Law nº 8069 of July 13, 1990: features on the Statute of Children and Adolescents and other measures [Internet] 1990 [cited on March 13, 2016]. Available in:

16. Wegner W, Pedro ENR. The multiple social roles of lay caregiver women of hospitalized children. Rev Gaucha Enferm [Scielo-Scientific Electronic Library Online] 2011 [cited on March 11, 2016]. 31 (2): 335-42. Available in:

17.Freitas VJEGL, Peripolli RA, Silva MJ, Aquino PS, Ximenes LB. Evaluation of duties of nurses to promote health during pediatric assistance in the emergency department. Acta paul. Nurse [Scielo-Scientific Electronic Library Online]. 2015 [cited on March 10, 2016]. 28 (5): 467-74. Available in:

18.Casa Civil (Br). Law nº 7498 of June 25, 1986. Provides for the regulation of nursing exercise and other measures [Internet] 1986 [cited March 9, 2016]. Available in:

19. Machin AI, Machin T, Pearson P. Maintaining equilibrium in professional role identity: a grounded theory study of health visitors perceptions of their changing professional practice context. J Adv Nurs [National Center for Biotechnology Information] 2012 [cited on March 11, 2016]. 68 (7): 1526-37. Available at:

20. Dopico SL, Camerini FG. Analisys the intravenous medication administration in sentinel network hospital. Text context - Nurse [Scielo-Scientific Electronic Library Online] 2012 [cited on March 14, 2016]; 21 (3): 633-41. Available in:

21. Souza RFF, Silva LD. Exploratory study of initiatives on patient safety in hospitals of Rio de Janeiro. Rev Nurse UERJ [Internet] 2014 [cited on March 12, 2016]. 22 (1): 22-8. Available in:

22. Kunyk D, Austin W. Nursing under the influence: a relational ethics perspective. Nurs Ethics [National Center for Biotechnology Information] 2012 [Quoted on March 17, 2016] 19 (3): 380-9. Available at:

23. Santos AMR, Amorim NMA, Braga CH, Lima FDM, Macedo EMA, Lima CF. The experiences of relatives of children hospitalized in an emergency care service. Rev esc Nurse USP [Scielo-Scientific Electronic Library Online] 2011 [cited on March 15, 2016]. 45 (2): 463-8. Available in: