QU=
ALITY
ANALYSIS OF NURSING TECHNICIANS’ RECORDS IN A PEDIATRIC INPATIENT UNIT
ANÁLISE DA QUALIDADE DOS REGISTROS DOS TÉCNICOS DE ENFERM=
AGEM
EM UNIDADE DE INTERNAÇÃO PEDIÁTRICA
Gabrieli Patrício Riss=
i[1]
* Bi=
anca
Machado Cruz Shibukawa[2]
* Roberta =
Tognollo Borotta Uema[3]
* Herbert Leopoldo de Freitas Góes[4]
ABSTRACT
Objective: to
analyze the quality of nursing records performed by nursing technicians
from a pediatric inpatient unit of a public teaching hospital. Method: <=
/b>this
is a descriptive study of document analysis, with a quantitative approach,
conducted in a pediatric inpatient unit in southern Brazil, in 2019. Res=
ults:
the sample totaled 67 medical charts of children and
adolescents. All nursing technicians’ records were analyzed through a retro=
spective
audit. Regarding the classification of care, it was found that, in the gene=
ral
context, the records revealed poor nursing care. The evaluation of the reco=
rds
did not allow classification as quality records for any of the items survey=
ed. Final
Considerations: the study allowed for the acknowledgment of inaccuracie=
s in
nursing records, which had an impact on the quality of care, also, it allow=
ed
to acknowledge requirements that need to be improved in the nursing team’s =
work
process.
Keywords: Quality Management; Quality Improvement;
Quality of Health Care; Nursing Records; Pediatrics.
RESUMO
Objetivo: analisar a qualidade dos registros realizados pelos técn=
icos
de enfermagem em uma unidade de internação pediátrica de um hospital
universitário público. Método:=
trata-se de uma pesquisa descritiva de análise documental, com abordagem
quantitativa, realizada em uma unidade de
internação pediátrica no sul do Brasil, em 2019. Resultados: a amostra contou=
com
67 prontuários de crianças e adolescentes. Foram analisados todos os regist=
ros
realizados pelos técnicos de enfermagem, por meio da auditoria retrospectiv=
a.
Encontrou-se que, no que tange à classificação da assistência, no
contexto geral, os registros refletiam uma assistência de enfermagem sofrív=
el.
A avaliação dos registros não permitiu a classificação como registros de
qualidade para nenhum dos itens pesquisados. Considerações Finais:
Palavras-chave: Gestão da Qualidade; Melhoria de Qualidade; Qualidade da
Assistência à Saúde; Registros de Enfermagem; Pediatria.
INTRODUC=
TION=
In nursing, the quality of care began to become a subject of discuss=
ion
since the time of Florence Nightingale, who introduced an approach to the
process of improving quality in health, as well as reported the perceived
difficulties in changing practice. Currently, Nightingale’s findings are st=
ill considered
determinants in the quality of care, but more focused on the quality of car=
e as
a patient’s right(1-2).
Quality Management is understood as a
managerial restructuring of institutions. Its basic principles are focused =
on
the client, the teamwork arrangement, evidence-based decision-making, and
ongoing research to solve problems and reduce errors(3).<=
span
lang=3DEN-US style=3D'font-family:"Times New Roman",serif;color:windowtext;
mso-ansi-language:EN-US'>
Nursing professionals play important roles in the quality process in
health institutions, with nursing technicians representing 80% of the nursi=
ng
workforce in Brazil(4). Thus, the professional commitment to mee=
ting
the patient’s needs and the continuous search for knowledge through training
make the nursing team the holder of quality ideals(1). However, =
it
is noteworthy that the application of quality management models in this
population is intensely necessary, since professional practice is complex a=
nd
has weaknesses, particularly concerning written communication in nursing
Therefore, the meaning of Quality
Management, especially in the health context, is undeniable(5).
Improving the quality of care has become a worldwide priority, as it has no=
ble
and relevant objectives, such as ensuring patient safety, improving clinical
effectiveness, and providing opportunities for public responsibility(6=
).
Health audit aims to promote the quality of care, =
as
well as the management of expenses, to allow proper supervision, resulting =
in
desired care standards, satisfying both the client and the institution=
(7-8).
As the quality of care is closely related to
interprofessional communication and, therefore, to the suitable filling out=
of
medical charts, as they are permanent and unchanging communicati=
on,
it is crucial that the nursing team, the main providers of patient care, pay
attention to the necessity of completeness and consistency in the care reco=
rds.
It is important to keep in mind that the care provided to children a=
nd
adolescents must be done with caution, as this =
is a
fragile population that demands greater attention, as mistakes may cause se=
vere
consequences to this target audience. Therefore, the objective was to analy=
ze
the quality of nursing records carried out by nursing technicians in=
a
pediatric inpatient unit of a public teaching hospital.
METHOD
This is a descriptiv=
e,
observational, and document analysis study, with a quantitative approach,
carried out in a 15-bed pediatric inpatient unit of a public teaching hospi=
tal
located in southern Brazil.
The study sample was=
the
medical charts of children and adolescents hospitalized in the pediatric un=
it
of the aforementioned hospital, consisting of 67 records, where all records
made by nursing technicians during the patient’s hospitalization were analy=
zed.
It is important to mention that in the researched insti=
tution,
nursing assistants were not part of the study sample.
The inclusion criter=
ia considered
medical charts of children and adolescents hospitalized for at least 72 hou=
rs,
in the pediatric unit undergoing clinical or surgical treatment, in additio=
n to
having information recorded in medical charts by the nursing staff of each =
work
shift of the aforementioned inpatient unit.
Data collection was
conducted from July to September 2019. Data collection took place through a
structured instrument. An analysis of the quality of care was performed gro=
unded
on Saupe and Horr <=
sup>(9),
and an analysis of the quality of nursing technicians’ records based on
To analy=
ze
the quality of care, data on admission procedures, nursing reports and
procedures, compliance with a medical prescript=
ion,
and discharge/transfer process were extracted. At this stage, the answer
options of yes, no, and not applicable were used, besides the possibility of
including observations.
To analy=
ze
the quality of nursing technicians’ notes, nursing reports, prescriptions, =
and
procedures were evaluated. Each item was analyzed as complete, incomplete, =
blank,
or incorrect, in addition to the spaces for observations.
Information
from data collection was organized, categorized, and grouped in spreadsheet=
s in
the Microsoft Office Excel® 2016 program. The quality of the nursing staff
records held in the pediatric inpatient unit was assessed based on the scor=
es
resulting from the retrospective audit scripts.
To
analyze the quality of care, we calculated the percentage of the relative
frequency of positive answers (yes) and classified them according to the
methodological framework. This data processing method is known as the
Positivity Index (PI).
To analy=
ze
the quality of records, the percentage of absolute and relative frequencies
were calculated by adding the number of times of all scores
per item. The results were classified as recommended by Cianciarullo, Fugulin, an=
d Andreoni(10).
The study followed all the
recommendations in Resolutions no. 466/2012 and no. 510/2016 of the National
Health Committee. The research was evaluated and approved by the Standing
Committee on Ethics in Research with Human Beings and was approved under
opinion no. 3,401,500.
RESULTS
A total of 1,887 records were
analyzed in the medical charts of 67 children and adolescents. Of these, 56=
1 were
nursing prescriptions and 1,326 nursing notes. Concerning hospital stay, th=
ere
was an average of 8.4 days, with a median of 7 days.
Regarding the classification of =
care
proposed by Saupe and Horr=
(1982)(9) in the records made by nursing technicians, it was fou=
nd
that, generally, the records revealed poor nursing care. The results obtain=
ed are
shown in Table 1.
Table 1 Nursing technicians’ records PI%* Care classification** Admission procedures Records
of admission by the nursing technician 71.6 Borderline The
record describes the patient’s general conditions 61.3 Deficient Medical
prescription for admission was checked 75.8 Borderline Medical
prescription for admission was signed 45.2 Deficient Nurse’s evolution<=
o:p> Presence
of nurse’s evolution every shift 62.2 Deficient The
evolution indicates individualized care 51.6 Deficient Evolution identification 4.1 Deficient Nursing procedures=
Procedures were recor=
ded 31.7 Deficient Procedures were signe=
d 6.0 Deficient Execution of medical prescription The
medical prescription was checked 66.9 Deficient The
medical prescription was signed 50.1 Deficient Discharge/transfer
process Presence
of discharge/transfer record 53.7 Deficient Record
of physical conditions and/or complications 32.8 Deficient Notes: * PI: Positivity Index; **
Classification based on the Saupe and Horr criterion(9),
which classifies care as: 100% Desirable, 90 to 99% Adequate, 80 to 89% Saf=
e,
71 to 79% Borderline and <70% Deficient. Fonte: Os =
autores.
In the admission procedures attr=
ibuted
to the nursing technician’s duties, it was observed that the presence of an
admission report represented borderline assistance (PI 71.6%). However, con=
cerning
the description of the patient’s general conditions, it was deficient (PI 61.3%).
In the process of auditing the
medical charts, reports with inconsistent ambiguities were also observed, s=
uch
as the information of parenteral nutrition, when the patient was breastfed.=
It was identified that many medi=
cations,
such as antibiotics, corticoids, antipyretics, analgesics, anti-inflammatory
drugs, anticonvulsants, vitamins, and gastric protectors were not checked or with initials at all scheduled time=
s. We observed
a case of a premature newborn, who received a high dose of glucose solution=
, in
which 34 ml/h were infused instead of the prescribed volume of 34 ml in 24
hours, causing an increase in blood glucose in the patient, with notes of 2=
42
mg/dl. The dose administration error was registered and reported, and there=
was
a need to extend the child’s hospitalization because the child had signific=
ant
changes in capillary glycemia in the following days, with difficulty
stabilizing his clinical condition.
Regarding the nursing report per
work shift, a PI of 62.2% was reached, also characterizing deficient care. =
One
of the main factors observed that contributed to this rate was the presence=
of
only one report for the two work shifts.
About the individualized care
expressed in the reports of the nursing technicians, a PI of 51.6% was foun=
d,
which showed deficient care. Several misconceptions were found, which refer=
to
patient identification, clinical diagnosis, and the use of terminology and
medical-hospital devices.
As for the identification of the=
se
reports, which referred to the investigation of the day and time of the nur=
sing
record, as well as the proper identification of the professional who perfor=
med
it, characterized by the signature and registration number of the Regional
Nursing Board, there was a PI of 4.1%, an extremely low rate, indicating de=
ficient
assistance.
To show =
the
results of the second part of the script on the retrospective audit of nurs=
ing
technicians’ records, we elaborated Table 2. Regarding the nursing notes,
concerning the presence of professional identification, it was found that m=
ost
of the records were incomplete (66.2%). The night shift used to put the ini=
tials
of the whole team of nurses technicians in all r=
eports
of the shift, making professional identification difficult and violating
institutional norms.
|
Table
2 − Quality assessment of nursi=
ng
technicians’ records in medical charts of children and adolescents admitt=
ed
to the pediatric unit of the hospital under study. Brazil, 2019=
|
|
|||||||||||
|
Assessment criteria |
Complet=
e I=
ncomplete =
Blank |
=
Incorrect=
|
||||||||||
|
Nº |
% |
I* |
Nº |
% |
I* Nº |
% |
I* |
Nº |
% |
I* |
||
|
Nurse’s notes |
||||||||||||
|
Professional
identification |
180 |
32.5 |
-47.5 |
367 |
66.2 |
-51.3 |
6 |
1.1 |
+ |
1 |
0.2 |
-0.2 |
|
Nursing care |
313 |
56.4 |
-23.6 |
206 |
37.1 |
-22.2 |
7 |
1.3 |
+ |
29 |
5.2 |
-5.2 |
|
Complications |
221 |
39.8 |
-40.2 |
87 |
15.7 |
-0.8 |
212 |
38.2 |
-33.3 |
35 |
6.3 |
-6.3 |
|
Mobility dependency |
178 |
32.1 |
-47.9 |
266 |
47.9 |
-33.0 |
58 |
10.5 |
-5.6 |
53 |
9.5 |
-9.5 |
|
Dressings and/or equipment |
155 |
29.0 |
-51.0 |
267 |
49.9 |
-35.0 |
50 |
9.3 |
-4.4 |
63 |
11.8 |
-11.8 |
|
Patient’s emotional state |
233 |
41.9 |
-38.1 |
254 |
45.7 |
-30.8 |
68 |
12.2 |
-7.3 |
1 |
0.2 |
-0.2 |
|
Nurse’s prescription |
||||||||||||
|
Nursing care was <=
span
class=3DSpellE>checked |
361 |
68.1 |
-11.9 |
144 |
27.2 |
-12.3 |
20 |
3.8 |
+ |
5 |
0.9 |
-0.9 |
|
Nursing
care have the professional’s identification |
49 |
9.3 |
-70.7 |
411 |
77.7 |
-62.8 |
60 |
11.3 |
-6.4 |
9 |
1.7 |
-1.7 |
|
Nursing procedures=
|
||||||||||||
|
Oral hygiene |
197 |
35.1 |
-44.9 |
302 |
53.8 |
-38.9 |
52 |
9.3 |
-4.4 |
10 |
1.8 |
-1.8 |
|
Body hygiene |
327 |
67.0 |
-13.0 |
73 |
15.0 |
-0.1 |
47 |
9.6 |
-4.7 |
41 |
8.4 |
-8.4 |
|
Vital signs control |
374 |
68.1 |
-11.9 |
165 |
30.1 |
-15.2 |
5 |
0.9 |
+ |
5 |
0.9 |
-0.9 |
|
Patient weight control daily |
343 |
61.8 |
-18.2 |
13 |
2.3 |
+ |
187 |
33.7 |
-28.8 |
12 |
2.2 |
-2.2 |
|
Physiological eliminations
|
446 |
79.5 |
-0.5 |
90 |
16.0 |
-1.1 |
17 |
3.0 |
+ |
8 |
1.4 |
-1.4 |
|
Food
and fluids intake |
445 |
79.3 |
-0.7 |
90 |
16.0 |
-1.1 |
11 |
2.0 |
+ |
15 |
2.7 |
-2.7 |
Note:
*Index based on Cianciarullo, Fugulin
and Andreoni criteria (10), which co=
nsider
quality records the items that present: Complete > 80%, Incomplet=
e <15%;
Blank < 5% and Incorrect 0%
Regarding the report of
complications on nursing reports, none of the criteria reached a suitable
percentage to classify the item as a quality record. Thus, it was evident t=
hat
the complete evaluation criterion was 40.2% below the recommended, with a h=
igh
percentage of blanks (38.2%) and incorrect (6.3%) records.
Thus, the findings allowed us to
observe that several complications that were the nursing team’s duty were n=
ot
recorded, such as glycemic changes, considerable changes in weight, removal=
of tubes
and catheters, in addition to basic signs and symptoms, that may be observe=
d in
nursing procedures, as inflammatory signs in the umbilical stump and
genitourinary hyperemia.
Concerning the daily weight reco=
rd,
most records (61.8%) were filled out completely. However, except for the
incomplete aspect, all the other evaluation criteria demonstrated to be
non-compliant with the parameters validated in the literature. It is
noteworthy, in this regard, the percentage of blank records, which was 28.8%
above the recommended.
A positive thing to be highlight=
ed is
the indexes referring to the records of physiological eliminations
and food and fluids intake, which were within the established framework for=
the
blank evaluation criterion. It is noteworthy that the other criteria
came very close to reaching the recommended parameters, with a percentage of
complete records corresponding to 79.5% for physiological eliminations and
79.3% for food and fluids intake.
Finally, as for filling out the nursing prescription by the nursing =
technician,
it was found that, for the complete assessment criterion, most of the
prescribed care actions were checked (68.1%), however, the professional ini=
tials
were verified in only 9.3% of the records, with an index of 70.7% below what
the literature recommends.
DISCUSSION
Hospitalization, especially for
pediatric patients, causes instability and changes in the family routine, it
also creates feelings that unbalance their emotional state and increase
feelings of ephemerality and guilt, causing physical and emotional exhausti=
on(11-12).
Moreover, this process causes ma=
jor
changes in the child’s habits, and factors such as the length of hospital s=
tay
and the type of intervention may cause important consequences for child
development(11). Therefore, nursing care must aim at patient reh=
abilitation
and the decrease of hospital stay and not have the opposite effect.
The nursing notes must have enou=
gh
information to enable the continuity of care effectively, therefore, the
records need to include information about the procedures performed and the
materials used, so that the professional can assess the follow-up and the
repercussions on the health of the hospitalized child or adolescent(13=
).
Thus, the need for the nursing t=
eam
to provide more caring and conscientious assistance is reaffirmed. However,=
it
is known that they are often overwhelmed by the lack of structure and suffi=
cient
staffing(14).
It is emphasized the management =
significance
of providing physical, material, and human resources for the humanization of
both care and professional practice, in addition to providing better condit=
ions
for quality care, as the absence of these results in improvisations and
continuous efforts to achieve good results(14-15).
It is highlighted the significan=
ce
that the nursing team has in the precise and safe performance of procedures,
especially those involving the administration of medications, since the
consequences of errors considerably impact the client’s health, particularl=
y in
pediatric patients, due to its physiological characteristics and the
unavailability of adequate pharmaceutical forms for this audience(16-1=
7).
It is essential to highlight that
medication errors may occur at any stage of the process, whether prescribin=
g,
dispensing, or giving medication(16). However, the nursing team =
is
directly related to the end of this process, a fact that increases his/her
responsibility to identify flaws because the nurse’s task corresponds to the
last opportunity to prevent incidents(18).
The administration of medication=
s is
one of the most important tasks given the nursing team and the occurrence of
errors in this procedure, unfortunately, is part of the professional realit=
y(16).
However, often the error becomes a form of disapproval and judgment instead=
of
being seen as a way of professional improvement and growth, which makes the
professional not want to admit the error and learn from it(14,18).
A study
carried out in 2019(19), emphasizes that “safe care must be seen=
as
a patient’s right and the ethical commitment of the professional team
throughout the health care network”. However, although the health team must
provide safe care, it is emphasized that the prevention of errors and injur=
ies
must also be incorporated into the organization and the service’s implement=
ation
systems, which are generally the real causes of the occurrence of such
incidents(18).
Nursing
technicians need to be more aware of the notes they report, and also know t=
he
different vital parameters of the pediatric patient, to provide quality car=
e safety
for the user undergoing treatment(20).
Throughout the audit of the medi=
cal charts, it was observed a lack of knowledge re=
garding
the patient’s vital standards. It was also observed the recording of notes
without expected awareness of the child’s general conditions.
Regarding the date and time in w=
hich
the nursing record was referred, as well as the correct identification of t=
he
professional, such information proved to be insufficient. This issue is
highlighted, as the time recorded in the medical chart
corresponds to the period in which the health professional is legally
responsible for the patient.
The performance of safe practice=
s is
a duty of the whole nursing team, however, the t=
eam’s supervision
and management are exclusive activities of the nurse(19). Theref=
ore,
it is up to the nurse to perform a leadership based on the principles of
quality management, as this action directly interferes with the health team=
’s performance(15).
In this sense, it is highlighted
that the nurse is accountable for the leadership and organization of both
nursing services and their technical activities, from planning to the
evaluation of nursing care services(21). Thus, it is expected by
nurses that nursing technicians fulfill their professional skills and have
skills that meet the patient’s basic needs, including the description of vi=
tal
signs and the correct administration of prescribed medications(4).
The importance of vital signs is=
well-known
in the patient’s clinical assessment and, besides checking them, it is also=
the
responsibility of the nursing professional to record the physical indicator=
s of
bad vital parameters, especially if they show changes in the breathing patt=
ern
because the assessment of vital signs alone is not enough to carry out a qu=
ality
clinical assessment(13).
In pediatrics, the weights of
hospitalized children and adolescents must be checked and recorded daily, as
the lack of this procedure may impact the safety of drug administration and
delay decision-making on interventions in the patient’s treatment, resultin=
g in
a delay in hospital discharge(22).
A study carried out at the Child=
ren’s
Hospital of Philadelphia, aiming to increase the agreement in performing da=
ily
weights, found that the reasons for the miss outs in their daily registrati=
on
were related to the unimportance reported by the nursing professional, as t=
hey
considered other more essential and urgent procedures, as well as the overl=
oad
of activities associated with a shortage of time(22).
The results are consistent with =
the
literature found, where the records by the nursing team are based on the
acceptance of diet and the presence of physiological eliminations, which are
not considered enough for the effectiveness of care(13).
The findings were similar to the
study carried out by Padilha, Haddad, and Matsu=
da
(2014), who found that the incompleteness of nursing records was more inten=
sely
related to individualized nursing prescription and to checking and professi=
onal
personal identification in it(20).
In this regard, it is reported t=
hat
the absence of professional identification in nursing records can make it
difficult or impossible to clarify lawsuits or audits, losing one of its pu=
rposes.
Therefore, it is extremely important to consider all items established by the Federal Nursing Board in the
professional identification of nursing reports(8,13).
Therefore, it is asserted that t=
he
incompleteness of nursing records goes far beyond the classification of def=
icient
quality of records and care, as it can interfere with the identification of
health problems and, consequently, put the patient’s life at risk, especial=
ly,
in pediatrics.
Thus, it is emphasized that adeq=
uate
professional identification in patient records, especially in nursing
prescriptions, is essential not only to identify which professional perform=
ed
the care, but also to prove that the care was, performed, since just checki=
ng
the prescription is not enough to attest the nursing exercise(19,23).
The fact that only one scenario was investigated and the short time=
for
data collection make up study limitations, as the results may be different =
from
the reality of other services, besides not showing the continuous assistance
offered by the hospital. Therefore, it is important to conduct the study in=
other
hospital institutions over a longer timeframe.
FINAL CONSIDERATIONS
The resu=
lts
found allowed us to know the inadequacies that exist in pediatric care and
interfere with its quality. In this sense, it is crucial to highlight the n=
eed
to improve nursing records that have a direct impact on the quality of care=
, to
ensure patient safety, improve clinical effectiveness and ensure the legal
actions of nursing professionals.
Nursing records were found in th=
e medical
charts, but demonstrated mechanized and unthoughtful care, with limited rec=
ords
about the particularities of each patient. Most of the items analyzed expre=
ssed
a low positivity index, representing poor assistance. The assessment of the
records did not allow classification as quality records for any of the
researched items.
The study allowed to acknowledge
inaccuracies in nursing records, which had an impact on the quality of care=
, besides
enabling the identification of requirements that need to be improved in the
nursing team’s work process.
It is suggested that hospitals strengthen
their medical charts audit services, as well as strengthen the quality cont=
rol
of care, to achieve excellence in childcare. Furthermore, the validi=
ty
of raising awareness among professionals in the front line of care regarding
the consequences of absence, incompleteness, and errors in nursing records =
is
highlighted.
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Corresponding author:
Robert=
a Tognollo Borotta Uema. Rua Antonio Valdir Zanuto<=
/span>,
número 53. Jardim Novo Horizonte, Maringá, PR. CEP: 87010-100. E-mail:
robertaborotta@hotmail.com<=
span
style=3D'font-size:12.0pt;font-family:"Times New Roman",serif;mso-fareast-f=
ont-family:
"Times New Roman";mso-fareast-language:PT-BR'>
Fostering and
Acknowledgment: =
research
financed by the researchers themselves. We are grateful to the institution
where the research was carried out.
Submission: 2021-06-10
Approval: 2021=
-07-14
[1]=
Universidade Estadual de Maringá, Maringá,
Brasil. https://orcid.org/0000-0002-1702-4004
[2]=
Universidade Estadual de Maringá, Maringá,
Brasil. https:=
//orcid.org/ 0000-0=
002-7739-7881
[3]=
Univer=
sidade
Estadual de Maringá, Maringá, Brasil. https:=
//orcid.org/
0000-0002-8755-334X
[4]=
Univer=
sidade
Estadual de Maringá, Maringá, Brasil. https://orcid.org/ 0000-0002-6071-692=
X.
=
=