Aim: the aim of this paper is to investigate, from the perspective of nurse managers, the means/factors that facilitate the implementation process of patient safety strategies. Method: seventy-two nurse managers from four university hospitals of the state of Paraná participated, through an individual interview, which was recorded and guided by the question "Tell me about aspects that facilitate the implementation of safety strategies in this hospital." The statements were transcribed in full and were submitted for content analysis in the thematic modality. Results: two categories emerged from the speeches: "Management tools as facilitators in the implementation of patient safety strategies" and "Educational processes: means that facilitate the implementation of patient safety strategies". Conclusion: it was found that the support of the top management contributed greatly to the implementation of security strategies, as well as the militant leadership for this benefit and the improvement of human capital, which was strictly conveyed to the institutional teaching characteristic.
Descriptors: Patient Safety; Nurses; Nurse's Role; Health Management; Safety Management.
The evidence that the risks associated with care are concrete in health institutions has contributed to the fact that the quality which has been historically legitimized by this sector of production in the light of strategic resource management and consumer satisfaction, is also perceived from the point of view of safety(1). In this approach, the concept of patient safety emerges, which is understood as the reduction, to an acceptable minimum, of the risk of unnecessary harm associated with health care(2).
The promotion of patient safety should be a systemic organizational concern, especially in the hospital setting, where the advancement in terms of technological density in care is accelerated; diagnostic-therapeutic procedures are more complex; the work dynamics tend to be more troublesome and, therefore, the risk of harm to the client/patient is more palpable, thus becoming a continuous challenge to the institutions(3).
By recognizing the risks arising from assistance (and also from the need to intervene in this reality), a movement was recently created in Brazil through legal provisions and social need, to promote the implementation of security strategies for patients(2,4). They use institutionalized measures that intervene in the work process, in order to protect the client from damages, such as protocols, manuals and safety guides(2).
Among the emerging safety strategies in the modern hospital scenario, emphasis has been placed on the identification of patients, safe surgical service, prevention of falls and pressure ulcers, emphasis on hand hygiene to prevent infection, prescription, safe use and administration of medications and improvement in communication processes among health professionals(2,4).
It should be noted that the institutionalization of safety strategies must accompany the organizational culture, which is favorable to safe care(4). In this regard, the implementation of simple, but effective, strategies will have the potential to reduce risks and reduce incidents through the feasibility of protocols and safety barriers associated with the permanent education of human capital(5).
In the development of the implantation of safety strategies, the importance of the nurse has been mentioned, since their role in the work process passes synergistically by the dimensions of assistance and care; research and teaching, and administration and management(6). In this way, in addition to continuously assisting patients (especially those who have been hospitalized) and thus directly impacting care safety(3), the nurse also tends to be a crucial actor in the establishment of strategic measures that converge to ensure patient safety(5).
In health institutions, nurses sometimes hold positions in people management and also in leading hospital quality programs and systems(7). Through this, and in conjunction with the current scenario, these professionals certainly rely on safe care(5,7), making it possible to emphasize the fact that nursing management work is a foundation for patient safety strategies(5) and, therefore, articulation between the nurse's management and the establishment of safety strategies can be and deserves to be investigated.
Given the above, it is worth mentioning that investigating the nurse's role in the implementation of safety strategies (including the facilities perceived by this professional when acting in management) is important because their perceptions and opinions can support the (re)planning of more effective and efficient actions, with a view to overcoming difficulties and reaching the effective implementation of desirable patient safety strategies.
Based on the previous explanation, the following question arises: how do nursing managers of teaching hospitals perceive the factors that facilitate the implementation of patient safety strategies in the institution? In an attempt to answer this question, the present study aims to investigate the means and factors that will facilitate the process of insertion of these methods from the perspective of nurse managers.
This is a descriptive, exploratory and qualitative study, carried out with nurse managers from four medium and large public hospitals, located in the north, northwest, west and southeast regions of the state of Paraná, Brazil. The participants chosen for the study were nurses appointed by the Nursing Direction of each hospital who held leadership positions, that is, they were managers or supervisors of hospitalization units and/or indirect care hospital sectors, understood to be services of hospital organization. Some examples are: the Nursing Direction itself, the Continuing Education Service, the Hospital Infection Control Service, Risk Management, Quality Management, Epidemiological Surveillance Nucleus, and others, depending on each peculiarity of the investigation sites.
It is worth mentioning that the eligibility of participation, which was intentionally delimited in the light of the hospital management services, was due to the fact that it coincided with the purpose of the investigation. It was understood that, although the implantation of the safety strategies depends on the systemic organizational support, it is usually the leaderships’ responsibility to initiate their deployment and diffusion(2,4).
Data collection was conducted from January to March 2015 and was carried out as follows: after formal authorization of the institutions, the Nursing Direction of each hospital was contacted via telephone or electronic correspondence, in order to identify the participants who were eligible for the study. With these data, the selected nurses were contacted to clarify the purpose and form of conducting the research. Upon acceptance, a schedule was set for the interview.
The interviews took place individually, at a date, time and place agreed with each professional. On this occasion, the objective and means of conducting the study was reiterated and the acceptance of the participation of each nurse was confirmed by reading and signing the Informed Consent Terms, followed by the application of a form for socio-demographic and labor characterization of the participants and a semi-structured interview that was recorded and guided by the question "Tell me about aspects that facilitate the process of implementation of safety strategies in this hospital." The number of interviews was limited to the scope of the study. For this, the researcher defined as a criterion, the successive repetition of the content (responses) of the participants, in each hospital, separately.
All empirical material (testimonials) was fully transcribed. Afterwards, the corpus was submitted for content analysis, in the thematic modality, respecting the steps of pre-analysis, material exploration and data interpretation(8). The pre-analysis comprised the identification of the central ideas of the statements, which represented the key points of their responses, which were duly highlighted by the researcher through floating (primary) reading(8).
The exploration of the empirical material was the result of repeated readings of the corpus, a procedure that gave evidence of the central ideas previously highlighted and gave light to the nuclei of sense, which was derived from the in-depth reading of the content provided by the respondents(8). By means of the analysis of the sense nucleus, the data interpretation was performed, which gave rise to the categories, and possible thematic subcategories, coming from the previous stages and these categories meant the systematization of the semantic content provided by the respondents(8).
The verbal responses contained in thematic groupings were edited into a textual and grammatical cohesion, without, however, changing the primary meaning of the speech. Some terms and words were added in square brackets to facilitate the understanding of the content delivered by respondents. The respondents were identified with the letter "N" for "nurse" plus an Arabic number that referred to the chronological order of each interview per site. Next, the "H" notation signaled the "hospital", followed by a number from one to four, which related to the regions of the state of Paraná: "H1" was located in the capital, southeast region; "H2" was in the northern region; "H3" in the northwest region and "H4" in the west region.
It should be noted that all the ethical precepts inherent to research involving humans, set forth in Resolution 466/2012 of the National Health Council, were respected and the research project is registered under CAAE: 32206414.6.1001.0104.
In all, the 72 nurses managers who participated were distributed as follows: 19 were from hospital 1; 28 from hospital 2; 11 from hospital 3; and 14 from hospital 4. Among these professionals there was female prevalence (90%). The majority of the participants (37%) were between the ages of 30 and 39 years old and 39% of these professionals had worked in the institution for between one and nine years. From the responses of the participants, it was possible to apprehend content for two thematic categories.
Management tools as facilitators in the implementation of patient safety strategies
Nurses legitimized the assumption that, despite the fact that the implantation of patient safety strategies is a common duty in all organizational spheres, management is a decisive factor in achieving the goals from the top direction to the direct handling of the management of operational processes(2,4). The statements that signaled the support of top management confirmed this assertion as a facilitator element in the implementation of safety strategies:
“The support from the management was what made it easier. All meetings and contacts [...] were not as effective as at the time the leadership told us this: we are supporting you” (N7H1). “So in this support of the direction as a whole [...] they are really interested in this safety process [...] this awareness in terms of the importance of this process is what helps the implantation” (N15H2). “[...] another thing that facilitates is also when managers have the same vision. It has a staff that strongly supports the implementation of safety strategies” (N9H3).
The nurse managers did not only delimit the support of the top management as a determining factor for facilitating the establishment of safety strategies, since through other facets, such as the leadership of the nurse and of the multi-professional team that was militant for safety, was the managerial aspect that contributed to the process investigated:
“The facilitators in the implantation of patient safety strategies are the coordinators of the areas, in the different areas, not only of the nursing, but of the multi-professional team. [...] It's necessary to identify these leaderships so that they can be multipliers [of the safety strategies]” (N5H4).
“The capabilities are the leaders. Not only the nurses [...], but it is the nurses who always do safety-related supervision.” (E16H2).
Reinforcing the role of the nurse's leadership in the implementation of patient safety strategies, some have expressed the importance of the high position in this process:
“We have a superintendent director who is a nurse. So, her view, in relation to the implementation and development of patient safety strategies, is differentiated” (E5H1).
The importance in terms of top management support and leadership engagement for the successful development of risk reduction measures related to patient care is acknowledged(2,4), as stated by the interviewees. However, they also scored quality management and risk management as a guideline for managerial aspects and facilitating the achievement of organizational goals in the area of patient safety.
“I see that a very important issue [for implementing patient safety strategies] is to have the Quality Management Service and a multi-professional team working with it” (N4H1).
“The commitment of Risk Management to work on the subject and disclose it is important [for implementing patient safety strategies]. There is a lot of effort on it.” (N4H3).
Educational processes: means that facilitate the implementation of patient safety strategies
In addition to the support of senior management and other aspects inherent in hospital management, the development of nurses is in line with one of the basic principles governing health quality and influencing patient safety, i.e., continuous improvement in work processes through continuing learning(2,4-5). The following excerpt corroborates with this affirmation:
“[...] There is the issue of the training promoted by the Continuing Education Service. This training sometimes happens individually in the units, but with the Nursing Directorate, we have a Permanent Education Commission in Nursing that has supported the implementation of patient safety strategies” (N9H1).
It is worth noting that, despite recognizing lifelong education as facilitating the implementation of desirable patient safety strategies, nurses sometimes denote that educational practices are feasible because the investigated hospitals are university or teaching organizations:
“[...] the group we have here is a group that is always studying: the nursing and medical staff, and the pharmacy staff. [...] The whole group is involved because it is a university hospital that always conducts research [...]. So, it is easier [for implementing security strategies]” (N2H1).
“I think what facilitates the implementation of safety strategies is the existence of a group of people [...] working in a hospital-school. This facilitates the provision of training for the staff during working hours” (N5H2).
Regarding the facilities mentioned by nurse managers in relation to the establishment of safety strategies mediated by educational processes, there was a mention that it was favorable to postgraduate programs, with an emphasis on the residency course, both with regard to the training of the organizational human capital, as well as in the operationalization of actions and strategies.
“[...] I see this issue of having encouraged the training through improvement, specialization and also in partnership with the Department of Nursing [University], with the postgraduate, through the professional master's, academic masters and also residences” (N8H1).
“I think it was the residents. [...] I notice the commitment of nursing residents better. The participation of residents was a great facilitator in the implementation of safety strategies” (N4H4).
The participants, who held management positions in various areas, affirmed that the support of the hospital management was a facilitator to the implementation of safety strategies. This is relevant because, when the high organizational top management demonstrates commitment to the quality and safety of the patient, the search for reaching goals, including the implementation of punctual improvement strategies, tends to be facilitated(2).
It is recognized that, at present, many hospitals still have archaic organizational structures where management models tend to be centralizers, hindering the lines of communication and, consequently, the effective implementation of improvements and changes in care processes(9-10). In this sense, it is believed that the interviewees' perception regarding managerial support for the implementation of safety measures is salutary, because, although timidly, this may indicate a change in the hospital organizational culture.
It is worth noting the excerpt from N7H1 who stated that the direction of the hospital apparently signaled frank support for nurse managers in the implementation of safety strategies. This is possibly in line with the principles of collegial management, where the decision-making power is shared among members of a given team, and is not restricted to the hierarchical division of the hospital work(9). Thus, we come to the reflection that the approach of the top direction to the work team is elementary to the necessary search for safe care.
Contrary to the findings described above, a recent investigation carried out at one of the sites of this survey(10), which represents the hospital, did not mention the support of top management as a facilitating factor in the establishment of safety measures in care. Thus, the research(10), which aimed to analyze the perceptions of health professionals regarding the safety culture of the patient in its interface with the leadership, revealed that several hospital workers had mentioned that the high management, unlike the immediate leadership, did not favor the promotion of safe care.
In the globalized, competitive and dynamic world of today's service provider organizations, leadership emerges as managerial competency, which is essential to the effective achievement of the common goals of a group(11). In the context investigated, the nurse managers legitimized that the goal (implementing patient safety strategies) had its reach facilitated through the nurse's leadership and also via the multi-professional team, who were sensitized by safe care.
In accordance with what the participants of this investigation stated in terms of leadership in the interface with patient safety, an Asian study(12) that aimed to evaluate a program called "Patient Safety Leadership Walkabout", which identified the intervening factors to patient safety, indicated that, despite the express potential of this program, it was not the solution to all safety-related problems because it was necessary for the real commitment of the leaders and followers for reduced risk assistance. This observation reiterates the importance of the multi-professional team for safety, as expressed by the participant N5H4.
The fragments described above demonstrate that militant leadership for patient safety has taken the form of oversight and dissemination of the goals to be achieved. These actions can be understood as elementary to management in health services. Perhaps this is why the role of the nurse has been emphasized: the work process of this professional naturally includes management(6), which does not mean leadership, but can facilitate the development of this competence(11).
The excerpt from N5H1 harmonizes the sense nuclei in relation to the support of the top management and the leadership (especially of nurses) in favor of the implantation of the safety strategies. Supported by the aforementioned assertions, and also by the literature(5,11), it is hypothesized that, by designing their function, nurses(6) are the most qualified professionals to manage patient safety strategies.
Safety, which is not synonymous with quality, has gradually become consolidated as one of its critical elements(4). This is possibly due to the fact that service organizations need to use rational management strategies to leverage quality and ensure customer satisfaction - which, in turn, comes from the quality management movement itself, which is based on a set of systematic management policies, tools and practices, with the frequent use of periodic evaluation to support continuous improvement(13).
Given the above, it is perceived that quality management in hospital services, in response to social changes and the dynamism of organizational needs, must include patient safety as a desirable asset to be managed(1,4,13). In this regard, one participant confirmed that the quality management service was an important foundation for promoting the establishment of safety strategies. This fact is praiseworthy because the harmony between safety and quality deserves to be developed with dedication in the organizational daily life as a whole.
In addition to safety management being considered an important factor in the search for quality of care, risk management has recently been highlighted – as evidenced by N16H2 – as a factor that facilitates the implementation of safety strategies. Thus, risk management has the potential to systematically identify (with its own tools) the processes, which do not conform to what is valued as qualified and safe, strengthening decision making in order to reduce the risks inherent to care(14).
Still in the scope of risk management, a national study(14), which was also carried out with nurse managers, identified that the best practices in risk management conform to the critical analysis of reality, the multiple dimensions of management and permanent education as an axis of improvement of care processes. Thus, it was also possible to understand that, in the voice of the nurses interviewed, educational actions also stand as facilitators of patient safety strategies.
The testimony of N9H1 confirms the already established thought that the health work process, which is produced and consumed by people, deserves to be continuously improved. Therefore, the participant reveals the importance of the permanent education of human capital as a facilitating means to the implementation of patient safety strategies, which, in fact, is one of the main goals of any health organization(2,4).
Continuing Education in Health (CEH) determines a learning process that uses the problematization of the local reality with a view to building knowledge and training professionals in order to transpose the concepts of education in service and continuing education(15), making possible the reorganization of professional practices in order to improve the work process.
It should be noted that the requirement of patient safety in health services, and consequently, in the quality of care, has caused changes in the health-work process and in the need for constant improvement of nursing professionals. In this context, CEH, which aims to transform current practices by enabling the construction of contextualized strategies that promote dialogue between the general policies and the singularities of the care process(16), is aligned with the process of implementing the safety measures of patients, because, through educational actions, it can contribute to the insertion and empowerment of professionals in the organizational context and also in the formulation of safe strategies(17).
The issues of teaching at work and research in university and teaching hospitals (present in the excerpts) correspond to the literature(18), which points out that these organizations tend to facilitate the learning process, and the research and to implement safety strategies, as seen in the excerpts. Thus, there is the hypothesis (and the need for future research) in terms of the engagement of private institutions in favor of worker education and research investment - since these are undoubtedly predictive factors for improvements. Therefore, the type of institution should not be taken as an essential condition for the process in focus.
However, it is recognized that both the personal and work experience of the participants certainly influence their perceptions regarding the progress of the implantation of patient safety strategies. In this regard, nurses are expected to legitimize that university hospitals have valuable peculiarities to the search for innovative measures, as confirmed by N2H1.
Therefore, it is conjectured that, without the support of the top management, the involvement and appreciation of professionals and lifelong education, as well as safety strategies, will have difficulties in terms of their implementation. Therefore, an interpretative parallel of findings between the first and second categories of this study emerges: the importance of nurses as managers in favor of new strategies for care. In this perspective, it is understood that nurses are professionals who need managerial skills beyond just technical knowledge and who must recognize the importance of becoming involved and of being responsible for their own education (including the planning of activities) and they should also stand as facilitators of the educational actions proposed for themselves and their team(19).
Another study(20) points out that the implementation of new strategies in the work environment can be facilitated by the daily meeting of care interlocutors, which stimulates moments of reflection about the service. Therefore, it is considered that permanent education poses as a potential strategy to the team that seeks the quality and safety of care in all types of health institutions because, as mentioned, this type of education at work aims to overcome the centralizing practices of knowledge since it involves all social actors in the educational process(15).
The response of N8H1 signals the fact that the Nursing Department of the hosting university hospital has established a partnership with the theoretical, scientific improvement of nurses. This is productive and salutary, since the teaching and practice of safety strategies demands extensive knowledge in terms of the subject to be applied in the care field(5). Therefore, it is suggested that formal training, especially of nurses who often manage patient safety strategies(7), tends to be a foundation for good management practices.
Regarding the progress in terms of formal knowledge in patient safety, it is worth highlighting one of the specific objectives of the Programa Nacional de Segurança do Paciente (PNSP - Brazilian Patient Safety Program), which stipulates that the topic of patient safety should be fostered in technical, undergraduate, and postgraduate studies in the health area(2). Based on this assumption and on the results presented, the training through the postgraduate training of the nurses, in partnership with the Nursing Department, is possibly greatly leveraged by the implementation and operationalization of patient safety strategies.
In relation to the post-graduation in the establishment of safety measures, N4H4 clearly infers the importance of nursing residency, developed in the hospital field being investigated. Thus, it is known that the residence, a postgraduate modality characterized by in-service training, has the potential to develop skills and competences linked to the theoretical-scientific and technical development necessary to overcome problems encountered in the work reality(18).
It is worth noting the mention of the importance of the residency course in the context of nursing. This is important because two of the university hospitals investigated are residency teaching fields in the specialty, Nursing Services Management(18). This can be one of the factors that strengthen the nurses' work in order to develop, implement and disseminate measures, goals and strategies that leverage patient safety and care quality.
In general, nurse managers referred to the importance of lifelong education in the implementation of safety strategies and, therefore, in improving the care provided to the patient through the training of workers. Added to this, they emphasized the support of the top management and of the leadership that militates for the insurance service.
Based on the findings, it is considered that the process of implementing safety strategies is an issue that deserves to be managed systematically in the daily routine of the organization and that some aspects inherent to teaching hospitals can facilitate the implementation process of these measures. However, it was evident that the top management (present in all hospitals) needs to promote actions aimed at safe care.
It is worth mentioning that the study has limitations, such as the participation of a very homogeneous population and the use of individual and unique interviews. Nevertheless, its findings may contribute to the knowledge of supply related to the theme of patient safety, especially by addressing aspects that facilitate the implementation of its strategies.
Finally, it is hoped that further studies will be encouraged so that the subject of Patient Safety is continuously researched and disseminated in the academic and social environment. Therefore, we suggest investigations with different methodological approaches - to the example of analytical studies, focused on the impact of the managerial performance of nurses in favor of establishing safety measures that are also related to the safety indicators inherent to the work of the nursing team.
All authors participated in the phases of this publication in one or more of the following steps, in according to the recommendations of the International Committee of Medical Journal Editors (ICMJE, 2013): (a) substantial involvement in the planning or preparation of the manuscript or in the collection, analysis or interpretation of data; (b) preparation of the manuscript or conducting critical revision of intellectual content; (c) approval of the version submitted of this manuscript. All authors declare for the appropriate purposes that the responsibilities related to all aspects of the manuscript submitted to OBJN are yours. They ensure that issues related to the accuracy or integrity of any part of the article were properly investigated and resolved. Therefore, they exempt the OBJN of any participation whatsoever in any imbroglios concerning the content under consideration. All authors declare that they have no conflict of interest of financial or personal nature concerning this manuscript which may influence the writing and/or interpretation of the findings. This statement has been digitally signed by all authors as recommended by the ICMJE, whose model is available in http://www.objnursing.uff.br/normas/DUDE_eng_13-06-2013.pdf
Received: 03/13/2016 Revised: 02/06/2017 Approved: 02/20/2017