Healthcare quality indicators used in hospital nursing care management


Paloma de Souza CavalcanteI; Mariana Angela RossaneisII; Maria do Carmo Lourenço HaddadIII; Carmen Silvia GabrielIV

I Enfermeira. Mestre em Enfermagem pela Universidade Estadual de Londrina. Universidade Estadual de Londrina. Paraná, Brasil. E-mail: cavalcanteps7@gmail.com
II Enfermeira. Doutora em Enfermagem pela Universidade Estadual de Maringá. Docente do Departamento de Enfermagem da Universidade Estadual de Londrina. Paraná, Brasil. E-mail: marianarossaneis@gmail.com
III Enfermeira. Doutora em Saúde Pública pela Universidade Estadual de São Paulo. Docente do Departamento de Enfermagem da Universidade Estadual de Londrina. Paraná, Brasil. E-mail: carmohaddad@gmail.com
IV Enfermeira. Doutora em Enfermagem pela Faculdade de Saúde Pública de São Paulo. Docente de Enfermagem Geral e Especializada da Escola de Enfermagem de Ribeirão Preto da Universidade de São Paulo. E-mail: cgabriel@eerp.usp.br

DOI: http://dx.doi.org/10.12957/reuerj.2015.7052




This descriptive, quantitative, cross-sectional study examined opinions of nursing care quality indicators among nurses at four secondary and tertiary hospitals in Northern Paraná State, in 2012. Sixty-four nurses who deliver health care directly participated in the study. Data were collected using a questionnaire that identified nurses' opinion of quality indicators in nursing care management. The nurses gave more importance to structure and process indicators, among them incidence of pressure ulcers, which may relate to these indicators' proximity to care activities. According to the participants, evaluation by indicators contributes to the development of permanent and continued education actions. However, this information is little discussed with the nursing teams. Care management based on assessment by indicators contributes to improving service quality.

Keywords : Nursing assessment; healthcare quality indicators; hospital administration; nursing.




The reflection on the quality refers directly to the evaluation of health services. Evaluation is understood to be the act of assigning values to a product or service, describing it through scientifically valid criteria, aimed at the improvement and enhancement of the object in question1.

The relevance of the evaluation of health services relates to the possibility of knowing the reality of the institution, identifying weaknesses and strengths. It is a decision-making and hospital management tool that allows the providence of assistance in suitable user conditions2.

More and more healthcare institutions adopted methods of evaluating their services based on indicators3. Quality indicators are tools used to understand situations, and to analyze trends or changes over time4. They allow systematic evaluation of the work process in an institution to subsidize improvements to the service5. The development and validation of indicators to compare hospitals and other institutions has been a concern of managers of hospital services6.

The assistance management related processes are present in nursing practice; therefore, nurses should use planning tools and organization of services, aimed at improving the quality of care delivered to users. Among these tools are quality indicators for the nursing staff, allowing them to understand complex phenomena, making them quantifiable, so they can be analyzed in conjunction with other indicators for the understanding of the work process and meet the targeted goals 5.

Knowing what nurses working in nursing care think about the quality indicators is of great importance, as these professionals are in daily contact with health service users, allowing them a greater bond and understanding of their needs and expectations. Therefore, this study aimed to identify the opinion of nurses about the quality indicators used in the management of nursing care in public hospitals.



The search for quality in Brazilian health services began around 1980, due to rising healthcare costs, technological advances and changes in the profile of users of health services, who took active stance, demanding higher quality care1.7. In the area of ​​health, the concept of quality is related to a set of attributes that includes professional excellence, efficient resource use, minimal risk to the patient or family and a high degree of user satisfaction8.

Avedis Donabedian was one of the first authors to write about evaluation of health quality. This author proposes the concept of quality guided by seven pillars. These are: effectiveness, understood as the ability to promote the improvement of care; effectiveness, defined as the maximum possible extent of improvement; efficiency, it is the ability to obtain the best result from the lower cost; optimization, relationship between costs and benefits of activities; acceptability, related to the adaptation of the care the patient's needs; legitimacy, refers to conformity between the culture of the company and the services provided by the institution; equity, as the distribution of services according to people's needs8.

He also established that the evaluation of the quality of a health service should be based on three pillars, being service structure, work processes and outcomes of care. The structure comprises the necessary resources for assistance development, including infrastructure, human resources, material and financial issues. The process corresponds to the activities involving health professionals and patients. The result is related to the final product of care, which includes health and user satisfaction5.9.

In the area of ​​nursing, managers have also adopted indicators to evaluate the quality of care provided in health institutions. Noteworthy in this area is the work of the Center for Support to Hospital Management (NAGEH), belonging to the Commitment to Hospital Quality Program (CQH), which is disclosing materials and methods related to the use of quality indicators. This program also monitors the indicators of the participating institutions and assists in the self evaluation of the same10.

In 2006, NAGEH published the first edition of the Nursing Indicators Manual, containing a list of indicators to be analyzed for the nursing services of the hospitals participating in the CQH10. This manual was revised in 2012 when the indicators were subdivided into two categories: welfare indicators and people management indicators6.

It is noteworthy that this move of building quality indicators, such as ensuring the quality of nursing care, increasing the relevance of the topic as a management tool for the evaluation of nursing services.



This is a descriptive study with a quantitative approach. The study setting consisted of four average and high complexity hospitals, located in northern Paraná State, identified in the text with the letters A, B, C and D.

The "A" Hospital is a public institution that provides medium complexity of care and has 130 beds. The "B" Hospital comprises a teaching hospital of high complexity public, with 316 beds. The "C" Hospital is a public institution of medium complexity that provides 141 beds. Hospitals A, B and C provide care exclusively to users of the Unified Health System (SUS). The "D" Hospital comprises a philanthropic institution of high complexity, which has 335 beds for SUS service users, health plans and individuals.

The invitation to participate in the survey considered the non-probability sampling. Adopted when access to information or resources are limited, the researcher uses data that are at your fingertips11.

Therefore, we asked 140 nurses. It has been established as inclusion criteria hold the position of hospital nurses and not practice nurse role manager in the institution.

To keep the sample is representative, called up 30 nurses from the hospital A, 40 nurses from the hospital B, 30 nurses from the hospital C, and 40 D hospital nurses.

From the nurses invited, 64 agreed to participate and signed an informed consent form. Among these nurses 21 were from the hospital A, 15 from hospital B, eight from the hospital C and 20 from hospital D.

The data collection instrument was developed in the program Google drive® and consists of nine questions regarding the characterization of the nurses and a matter to identify the opinion of respondents on the relevance of quality indicators for the management of nursing care, using a Likert scale. On such a scale, the participant assigns degrees of importance to each of the proposed items12. Our study has adopted the relevance rating, with no relevant variation (1 point), very relevant (2 points), relevant (3 points) and very relevant (4 points) for each indicator displayed. The indicators selected for this study are on the list of indicators described in Core Nursing Booklet for Hospital Management6.

The data collection tool was first validated through a pilot test conducted with three nurses working in direct assistance to users of a health service of high complexity not in the present study.

Data collection was carried out from July to December of 2012. There was direct contact with each subject, to invite you to participate. Those who agreed were asked for their email address to proceed to issue the free and informed consent form as well as the data collection questionnaire.

The deadline set for responding to the instrument was 15 days, performing referral in case of no return, after the stipulated period. The person not responding to the sent electronic questionnaire was considered as a loss.

Data analysis proceeded after codification of the variables and double entry in the database for statistical analysis program SPSS version 20.0.

This research is part of the project entitled Quality indicators of Grande Porte Hospital Nursing Services developed according to the provisions of Resolution No. 466/2012 on research involving humans13, after submission and approval by the Ethics Committee of the State University of Londrina with CAE 04053112.0.0000.5231.



It is a predominantly young sample, in which 27 (42.2%) participants aged between 20 and 29 years, with the hospital D contributed to such a characterization, as 35 (55.5%) nurses in this age group were allocated in this institution. Most, 42 (65.6%), were female.

Such dominance is similar to results found in other research on quality assessment14. A fact which refers to the historical building of the nursing process, in which the female was present mostly from the beginning, perpetuating up to the present day, although the percentage of men have increased in recent years15.

Still, the prevalence of young nurses can be attributed to changes in the labor market that lead individuals to seek early to college. In addition, health has been considered a promising field, given the need for trained professionals to work in this sector16.

However, it has also identified a group of more experienced nurses, since 24 (37.5%) subjects completed the nursing program for over 10 years. Divergent results to the feature mentioned in other studies14,17,18, in which we observe the predominance of newly formed between subjects.

As for training, 32 (50%) graduated nurses in private school and the same percentage of public university. The average elapsed time since graduation of participants was 13 years.

Of the total of 54 participants (84.4%) have graduation. Most professionals, 51 (94.4%), owned specialist title broad sense. Only 02 (3.7%) nurses held master's and only 1 (1.9%) a doctoral degree in nursing.

The existence of a greater number of professionals with specialist title broad sense similar to the literature17, in which the percentage of nurses with titration surpassed the others. The quest for professional development is linked to the need to articulate knowledge and apply them in their work process. The completion of postgraduate course demonstrates the concern of professionals to provide quality care19.

It is noteworthy that the listed quality indicators for this research belong to the list of NAGEH indicators. Applied a Likert scale to identify the degree of relevance of each item, as shown in Figure 1.

Figure 1: Score of quality indicators according to their relevance to manage the care of nursing in the opinion of hospital nurses Public Paraná, Brazil, 2012

Nurses attributed higher scores to gauge incidence of pressure ulcers, 232 points. This result is similar to the study of nurses, in which 100% of the sample considered this bookmark as very relevant to assess quality of care17.

The indicator incidence of pressure ulcers is defined as the ratio between the number of new cases of patients with pressure ulcers at a given period and the number of individuals at risk of acquiring such disease in the same time interval10. This indicator is allocated in the process of indicator set9.

The nursing staff constantly develops strategies for prevention and management of pressure ulcers, which implies direct assessment of the care provided. Therefore, this indicator has been associated with quality care20.

Still, the quality indicators assessed by nurses seconds membership level, were classified as the trilogy of Donabedian8.9 as process indicators, structure and results show in Table 1.

TABLE 1: Nurses opinion on quality indicators used in management of nursing assistance and classified in indicators and structure, process and result. Paraná, Brasil, 2012. (N=64)

(*) Very Relevant (**) Relevant (***) Little Relevant (****) Irrelevant

It was shown that nurses gave more relevance to the structure and process indicators, including the incidence of pressure ulcers reported by 47 (73.4%) participants as a very useful indicator to assess the quality of nursing care. In addition, 37 (57.8%) subjects of the research also considered the incidence of non-compliance in medication administration as a very relevant tool for the evaluation process.

Similarly, other process indicators and structure showed high scores and were mentioned by most participants as very relevant or relevant, such as: nursing absenteeism rate; incidence of phlebitis; incidence of non-compliance in medication administration.

The indicator nursing absenteeism rate is related to work overload, decreased quality of care and increased costs in the institution21. Which explains the relevance attributed to it, being inferred that nurses directly relate to nursing care experience more closely the consequences of non-attendance of workers employed.

Regarding the indicator errors in medication administration, a similar study presented this as the second most important indicator for participants 14. It is inferred that the importance given by the hospital nurses, may be related to responsibility for it assumed in administering medications safely, carefully targeted to minimize risks and harm to the patient.

The indicator incidence of phlebitis was also reported in other studies14.17 as relevant to the assessment of quality of care. The high number of people requiring intravenous administration of medications associated with the high rate of complications from inflammation or infection, justifies the recognition of the importance of this particular indicator22.

However, some outcome indicators did not show the same relevance to the study participants. As an example, the death rate indicator, considered by 17 (26.6%) subjects as very relevant and only 11 (17.2%) as very relevant. Equally, this draws attention to the mean hospital stay, reported by 12 (18.8%) participants as very relevant.

Regarding the mortality rate, the above result differs from another study on the opinion of nurses regarding quality indicators17 in which 90.0% of respondents recognized this bookmark as relevant or very relevant to evaluate nursing care.

The difficulty in recognizing the relevance of mortality rate indicator may be related to the fact that factors not directly related to nursing care, such as the person's age and underlying cause of hospitalization, influence the occurrence of deaths in institutions. Therefore, professionals have greater resistance to use this indicator as the parameter of quality of care.

The low recognition of the important indicator of average hospital stay is similar to the results found in other research17 where 17.4% of the nurses considered this bookmark as little relevant or irrelevant to qualify nursing care.

Currently, one of the main challenges for healthcare institutions who seek quality in care, relates to evaluating the results of these services. Guided by indicators, this method requires the restructuring of a culture based on the educational process, then to demystify the resistance of professionals to the records and events that require notification so that there is no distortion in the later results23.

It is observed among the study participants, the valuation of specific care indicators at the expense of outcome indicators. Situation explained by the fact that these events relate to not only the care provided by the staff, but suffer influence of external factors.

As for the contributions of quality indicators for the management of nursing care, 51 (79.9%) nurses considered that the identification of nursing staff training needs is the greatest benefit of the use of indicators. The aid in setting goals for the improvement of nursing care was also cited by the majority, 47 (73.4%), as shown in Table 2.

TABLE 2: Contributions of quality indicators in the management of nursing care. Paraná, Brazil, 2012 (N=64)

It is noteworthy that the contributions of indicators as support for the development of continuing and lifelong learning strategies, as well as assistance in setting goals for the improvement of nursing care were also identified in similar studies18.23.

Quality indicators are important management tools, contributing to the improvement of nursing care to demonstrate the advances related to the care provided in institutions18. Furthermore, they subsidize the decision making of officers ahead of the identification unsatisfactory results. However, the use of indicators not only has supervisory character, but acts as an educational tool for achieving improvements in services23.

Participants also reported the occurrence of disclosure and discussion of evaluation results for quality indicators in different hospitals surveyed.

Most of the sample, 35 (54.7%) nurses reported occur dissemination of results indicators for the nursing staff. Highlight is the hospital D, in which 48 (75%) participants reported the existence of time for presentation and discussion of results. However, 33 (52.3%) nurses linked to the hospital mentioned no dates for the presentation of evaluation results by indicators.

With regard to the discussion of the evaluations, 44 (68.8%) participants reported no time to discuss these indicators. It is noteworthy the hospital D, in which 51 (80%) nurses reported not occur such debate.

The discussion on indicators has played a central role in the management of nursing services23. Thus it is expected that the discussion with the nursing staff has been adopted as a strategy to identify weaknesses and set goals in order to improve the assistance provided. This should be a joint effort between managers and workers involved in the care.

Similar results were found in a survey aiming to identify the perception of nurses on the nursing quality processes, where 90% of the subjects reported receive feedback from their supervisors about the results of quality indicators18.

The moment of dialogue with the team shows up as a key tool for understanding the results achieved in nursing care, as well as allow it to identify weaknesses and thus targets to be set for the improvement of their quality23.



The results point to a predominantly female sample, young, with additional training in postgraduate courses, with a predominance of expertise broad sense.

Yet, the nurses give more relevance to the structure and process indicators, including pressure ulcer of non-compliance of medication administration, incidence of phlebitis and distribution of technical and bed for nursing assistants. We emphasize that these indicators provide proximity to the practice of nursing assistants, which contributes to the ease in recognizing its importance.

It highlights the contributions of the indicators identified by participants. Consistent with the literature, the majority of nurses points the aid for the development of continuing education strategies, and to establish targets for improvement of nursing care quality.

It was identified that the results of the indicators are disclosed to professionals involved in nursing care in hospitals. However, a minority of institutions promotes the discussion of the data with the members of the nursing team. This reality reinforces the need to implement spaces to reflect on these tools used to assess the quality of care.

The use of quality indicators is beneficial to health institutions such as the ability to monitor the adequacy of nursing services in different hospital areas and with predetermined intervals. So the realization of the management of nursing care based on periodic assessments by indicators boosts professionals in the search for improved services and enables the understanding of quality care.

Thus, this study identified that nurses recognize the indicators as an important management tool for nursing care. In addition to providing grants for the implementation of continuing education activities for the nursing staff. It is hoped that this, the results achieved contribute to the improvement of the process of evaluation of services in hospitals.

It is noteworthy that despite the small sample composition is representative since it covers a portion of nurses from the main hospitals in the region, with regard to the provision of services to the National Health System.



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Direitos autorais 2016 Paloma de Souza Cavalcante, Mariana Angela Rossaneis, Maria do Carmo Lourenço Haddad, Carmen Silvia Gabriel

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