ISSN: 1981-8963 https://doi.org/10.5205/1981-8963-v12i6a234593p1532-1538- 2018 Silva AT, Camelo SHH, Terra FS et al. Patient safety and the nurse’s performance… ORIGINAL ARTICLE PATIENT SAFETY AND THE NURSE’S PERFORMANCE IN HOSPITAL SEGURANÇA DO PACIENTE E A ATUAÇÃO DO ENFERMEIRO EM HOSPITAL SEGURIDAD DEL PACIENTE Y LA ACTUACIÓN DEL ENFERMERO EN HOSPITAL ABSTRACT Objective: to analyze the performance of nurses in patient safety in a hospital. Method: qualitative, descriptive study with 42 nurses from a hospital. The data was collected from a semi – structured interview and submitted to the dialectical hermeneutics technique, identifying these categories “Quality – basis for a safe praxis”; “Patient safety” and “Pathways to the humanization of nursing care and performance in the hospital environment”. Results: It was verified that the use of strategies, such as communication, permanent education and the participation of the companion, was essential for the strengthening of patient safety in the institution. Yet, the overcrowding and the work overload were presented as detrimental to their performance. Conclusion: the nurses’ performance is based on the legislations and the exercise of management and the assistance contributing to the improvement of care, quality and for the advancement of scientific knowledge. Descritores: Nurses; Nursing Care; Patient Safety; Quality Management; Humanization of Assistance; Hospitals. https://orcid.org/0000-0001-9216-6283; 5PhD, Federal University of Alfenas / UNIFAL. Alfenas (MG), Brazil. E-mail: roberta.sanches@unifal-mg.edu.br ORCID iD: https://orcid.org/00000001-7557-5560; 6PhD, Federal University of Alfenas / UNIFAL. Alfenas (MG), Brazil. E-mail: zelia.resck@unifal-mg.edu.br ORCID iD: https://orcid.org/0000-0002-3752-8381 English/Portuguese J Nurs UFPE online., Recife, 12(6):1532-8, June., 2018 1532 Aline Teixeira Silva1, Silvia Helena Henriques Camelo2, Fábio de Souza Terra3, Eliza Maria Rezende Dázio4, Roberta Seron Sanches5, Zélia Marilda Rodrigues Resck6 ISSN: 1981-8963 https://doi.org/10.5205/1981-8963-v12i6a234593p1532-15382018 Patient safety and the nurse’s performance… nurse countless opportunities to develop his practice focusing on safe care.8 OBJECTIVE ● To analyze the performance of nurses in patient safety in a hospital. METHOD A qualitative, descriptive study,9 carried out in a hospital in a large municipality of the south of Minas Gerais, with 279 beds, characterized as a general, regional, philanthropic hospital that treats 70% of UHS patients. The hospital, at the time of the survey, was accredited level 3 according to NAO. In its workforce, the institution had 734 Nursing professionals, of which 445 were Nursing technicians and auxiliary nurses and 289 were nurses.Patient Safety and the Nursing Performance in the Hospital

The hierarchical borad of the nurses consisted of one Responsible Technician (RT), five Nursing supervisors (administrative), 17 sector coordinators, 82 leading nurses (working together with the coordinator in different periods) and 184 level 1 nurses (characterization attributed by the institution to nursing assistants). For the selection of the participants, the following criteria was adopted: be working at the health institution as a nurse; have been working in the institution for at least one year and not be on the vacation period and / or leave. Firstly, prior contact was made with the nurse responsible for the institution’s technical knowledge and research. Then, the individual approach with the nurses was arranged to formalize the invitation, to present the purpose of the study and to schedule time and place for the interviews, and, finally, the collection was carried out in a place reserved for this purpose. Voluntary nurses were clarified about their rights to confidentiality, refusal to participate in the study without causing them any harm, and to sign the Free and Informed Consent Form (FICF) in two copies. Data was collected through a semistructured interview, between October 21 and 27, 2015 by the researcher herself. For the interview, a form containing the characterization of the participants and the following guiding questions was used: talk about what you know about patient safety; talk about what you do as a day-to-day nurse in patient safety in the unit and talk about any ideas or proposals you might have for patient safety at the facility. 1533 Silva AT, Camelo SHH, Terra FS et al. INTRODUCTION Due to the complexity of current social, political and economic transformations, health care demands pragmatic changes in the nurses’ performance in hospital institutions aiming at patient safety. The hospital environment presents numerous health risks to patients that may aggravate their health. Therefore, it is up to the professionals to identify the health risks present in each unit, to guarantee the safety of the patients and the restoration of their health, as well as to avoid or minimize the intercurrences during their stay in the institution. Care must be given without causing harm in order to permeate the whole of the care.1-2 Brazil, with a highly stratified hospital network, has implemented several programs and policies, such as the Quality of Hospital Management and Care, the National Humanization Policy (NHP), the National Accreditation Organization (NAO) and the National Patient Safety Program (NPSP), with the general objective of contributing to the qualification of health care in all public health facilities in the national territory, public or private, according to the priority given to patient safety by the World Health Organization (WHO).3-4 In this perspective, the Ministry of Health encourages health services to develop improvement actions, such as: identification of the patient; encouragement of hand hygiene; prevention, control and reporting of adverse events; safe surgery; safe administration of medication, blood and blood components; stimulation of the patient’s participation in the care provided and actions to prevent falls and pressure ulcers.5 In this context, Nursing seeks solid strategies to provide safe care, as a proactive member and a direct participant responsible for ensuring patient safety and promoting a safety culture, taking into account some strategies such as communication among the team, the analysis of errors as an opportunity for learning and the valuation of the professional through continuing education.Patient Safety and the Nursing Performance in the Hospital

6-7 Studies related to patient safety and the participation of nurses in the implementation of strategies to improve the quality and safety of care are necessary and at the same time recent and innovative and can help professionals in the area to get to know the causes and effects to the patient’s health, in addition to enabling adequate training to prevent new occurrences in the health services in general. This context points to the English/Portuguese J Nurs UFPE online., Recife, 12(6):1532-8, June., 2018 ISSN: 1981-8963 https://doi.org/10.5205/1981-8963-v12i6a234593p1532-1538- Silva AT, Camelo SHH, Terra FS et al. The statements were recorded on MP4 device and transcribed in sequence. Participating nurses were identified with the initials E1 through E42. The end of the data collection occurred as the information became recurrent, not resulting in new findings. The information obtained in the speeches was submitted to the analysis of dialectical hermeneutics,9 which works with the analytical categories that constitute the theoretical axes of research and the empirical and operational categories created from the field material. For this operation, the data was ordered through the transcription of recorded testimonies of the nurses, the re- reading of the material and the organization of the reports. The data was classified through cross- sectional reading that enabled the construction of sense nuclei, grouped by similarity, forming three categories: 1. Quality – basis for a safe praxis; 2. Patient safety and the pathways to the humanization of care and 3. Nurses’ performance in the hospital environment. Finally, the data according to the theoretical framework was interpreted and analyzed. The research was approved by the Research Ethics Committee (REC)10 of the Federal University of Alfenas, under CAAE n. 47827215.4.0000.5142. RESULTS Of the 42 nurses participating in the study, 37 (88%) were female, with a mean of 33 years of age; 31 (74%) had training time between one and ten years and 29 (69%) had been in the institution for more than five years. It was observed that 17 (40%) participants already worked in the institution as Nursing technicians and related professions before graduation in Nursing; 26 (62%) worked in the morning period; eight (19%) had another employment relationship and 30 (71%) nurses had Lato sensu specialization. It was found that, the higher the position, the more specializations the participants possessed. Quality: basis for a safe praxis The participants’ speeches revealed the improvements provided by the Accreditation process and the policies implemented by the institution aiming at the quality and safety of the patient. We are an institution that has acquired level 3 Accreditation, level of excellence, but this does not mean that we are excellent, it means that we have to seek English/Portuguese J Nurs UFPE online., Recife, 12(6):1532-8, June., 2018 Patient safety and the nurse’s performance… through the processes the improvement of patient care […] patient safety first. (E18) 2018 Nurses reported on the importance of correct processes for patient safety. Patient safety, that we work here in the institution, is that patient who has a correct entrance and a correct exit; as it arrives we have to return it without sequelae and without changes resulting from the period of hospitalization, whether phlebitis, fall or any other process that occurs during the period of hospitalization […]. Patient Safety and the Nursing Performance in the Hospital

(E8) In the testimony of E4, it is revealed how the risks to the health of the patient can be harmful to the institution. We have to do the best so that there is no risk with the patient in the institution, because the risk to the patient impacts on everything, it impacts the discharge, the rotation of beds, the diagnosis of the patient […]. (E4) Patient safety and the ways to humanize care The nurses pointed out the importance of client satisfaction, communication and patient / companion participation for the humanization and patient safety. We see the patient in a holistic way; customer satisfaction and the interrelationship with the patient is very important […]. (E28) Communication is very important in our area […] we have to orient and explain in the language patients understand … I have to explain it calmly, in a way that it understands […] I just I put it in her place and try to speak clearly. (E32) Another extremely important factor is the participation of the companion; if the companion is not involved in the process, it may be a problem; if he is not aware, if he knows the risks and the factors that can lead the patient to fall, he will not let it fall, he will help it to work well; we have in the ‘manga’ a factor that contributes a lot, which is the companion; we must involve it in the process itself, showing its importance […]. (E6) Nurses’ performance in the hospital environment It is identified that nurses’ praxis in patient safety in the hospital environment is linked to their care / management. We work with therapeutic design, professional evolution and multiprofessional visits, all in exclusive nursing assistance in the prevention of risks to the patient […] we have to check whether the team is also reporting the risks. (E8) We monitor the integrity of the patient’s skin, establish care prescriptions, organize and separate the caregiver for each 1534 ISSN: 1981-8963 https://doi.org/10.5205/1981-8963-v12i6a234593p1532-15382018 Patient safety and the nurse’s performance… At the same time, it is known that the good results developed in the hospital environment depend, in great part, on the hospital’s capacity to offer a humanized service to the population, making it necessary that its professionals constitute teams capable of promoting safety and the quality of care.13 By offering technologies and devices for the configuration and strengthening of these institutions, humanization points to the establishment of new sustainable pacts involving workers and managers of the system, fostering effective participation of the population and provoking innovations in terms Silva AT, Camelo SHH, Terra FS et al. individual patient; the employees are a line of care to the bedside, our function goes beyond the bedside, is management, nursing inspection actions. (E15) Regarding the adverse events present in the hospital, nurses learned the importance of health awareness and education to minimize errors, as presented by E16 and E18: […] (when there is any harm done to the patient) we immediately open the ‘adverse event’, evaluate the failure, gather the people involved and carry out a plan of action to prevent this from occurring again. (E16) Of course humanly there are flaws, nothing is 100%, but we seek from the permanent education, continuing education to raise awareness of the team […]. (E18) Work overload and overcrowding were pointed out, by nurses, as detrimental to their performance, as presented by E26 and E3. I believe that if we had more employees, the assistance would be better […]. sometimes the patient does not receive the ideal, perfect assistance because of this […]. Patient Safety and the Nursing Performance in the Hospital

(E26) Here it is for ten beds, but it has had times to get 22, 20 patients […] overcrowding is a risk; does not give time to pay attention to all […]. (E3) DISCUSSION Hospital institutions are increasingly concerned about ensuring quality care and insurance for their clients. The quest for quality is a complex issue and should be a priority for institutions and health professionals that integrate them. Among these, the most important are the Nursing professionals, who play a fundamental role in health organizations, focusing on individualized and adequate assistance to the best quality and safety practices.11 A study carried out with nurses in a private hospital in Belo Horizonte – MG shows that the Accreditation processes are influenced by the Nursing actions and, at the same time, they have important implications in the daily work of the team. Thus, it is imperative that nurses are aware of quality processes and that they seek constant improvements.12 In this scope of quality, patient safety, through risk management, stands out with the implementation of measures to prevent exposure to risks, as well as damages to the customer arising from health care. Since he spends most of his time in contact with the client, the nurse is one of the main professionals engaged in the identification and management of these risks.2 English/Portuguese J Nurs UFPE online., Recife, 12(6):1532-8, June., 2018 of sharing all care management.14 practices and In the field of human relations that characterize any health care, it is essential to add technical and scientific efficiency to the uniqueness of the human needs of both the user and the professional.13 The nurse, for having an integral view of the basic human needs of the patient , since their training, is able to favor care for both the patient and the family.15 It is added that good communication between Nursing professionals and patients can be considered a tool through which humanization is practiced.16 A study carried out with mothers of hospitalized children in a pediatric referral public hospital in Ceará, in August 2011, emphasized that the health professional, when providing information to mothers, should use simple and easy-to-understand language appropriate to their cognitive abilities, favoring the understanding of the information.17 In the hospital scenario, the presence of the companion next to the health services user is one of the strategies used to minimize the negative effects of hospitalization, especially those related to emotional aspects.16 In this context, the participation of nurses is necessary, demonstrating their ability to establish an interaction that can benefit the relationship of the Nursing team with the client, seeking to integrate the companion as an element in the recovery of the client and guide then throughout the health-sickness process, during the period of hospitalization, since the family generally needs to take responsibility for home care after hospital discharge.18 One of the tools that assists this interaction is the therapeutic design and/or care plan.Patient Safety and the Nursing Performance in the Hospital

This instrument organizes care in a feasible and beneficial way to the patient, since it 1535 ISSN: 1981-8963 https://doi.org/10.5205/1981-8963-v12i6a234593p1532-15382018 Patient safety and the nurse’s performance… the provision of care, in the management of the health team and in the organization of the nursing service as a whole.21,25 The implementation of best practices in patient safety, such as changing the workflow, using scales and checklists, electronic prescription, involving patients in decision making and promoting partnerships between service providers and community of the strategies used, mainly in the USA, to improve care in health institutions.26 At the same time, hospitals that have incorporated the NPSP in order to offer excellent care, reduce costs and ensure client satisfaction.4,8 Thus, it is incumbent upon nurses not only to expand their understanding of the health-disease process, but the adoption of a multidisciplinary approach that considers the emotional aspects, communication, norms and cultural values of the population.27 Patient safety studies can contribute to improved care, quality and the advancement of scientific knowledge among health professionals. It is pointed out, as limitation of this study, the fact that is was carried out only with nurses in a hospital organization. CONCLUSION This study demonstrated that the nurse’s praxis in the patient’s safety in the hospital environment is consolidated by the leadership in relation to the Nursing team, by the management and assistance based on the communication with a focus on light technologies (empathy and dialogue) and the valorization of strategies for continuing and permanent education. Nurses learn that it is their responsibility to provide safe and harmless care to patients and that the use of tools, such as protocols, therapeutic plans, adverse event reporting and action plans, broadens and improves their professional practice, the ethical principles of the profession. On the other hand, points that limit the nurses’ performance against patient safety in the hospital environment, such as overwork and overcrowding were considered. It is considered important that new studies related to the theme be developed in the training bases, in other spheres of health care, and based on the perception of other health professionals, in order to bring other problematizations that interfere in patient safety, emphasizing the value of ethics and the awareness of the professionals in adding competences in favor of the dignified and safe patient care. 1536 Silva AT, Camelo SHH, Terra FS et al. works with a multiprofessional and interdisciplinary approach.19 According to the National Curriculum Guidelines (NCGs), 20 the nurse professional must ensure that their practice is carried out in an integrated and continuous manner, with the other instances of the health system, being able to think critically, analyze the problems of society and seek solutions. The professionals must perform their services within the standards of quality and the principles of ethics / bioethics, taking into account that the responsibility of health care does not end with the technical act, but, rather, with the resolution of the health problem both in the individual level, as in the collective. …Patient Safety and the Nursing Performance in the Hospital