Factors that interfer in the quality of service to the critical patient

. The objective was to identify the factors that interfere with the quality of nurses' care to patients in the urgency and emergency service. This is a qualitative, exploratory and descriptive study, conducted in the months of September to November 2017 with 16 nurses, in the critical sectors of a public hospital referral in urgency and emergency in Teresina, Piaui, Brazil. The main factors identified that interfere with the quality of care provided by nurses were: inadequate conditions at work, improper physical structure in meeting high demand from patients, insufficient materials and equipment, dimensioning of inadequate personnel, in addition to a health care network that finds problems to achieve adequate patient flow. It is noted the need to develop institutional programs in the study hospital, in order to value and motivate the assisting professionals, since exposure to constant negative feelings can trigger physical and mental illnesses, in addition to exerting a great influence on the quality of the patients. services that are provided. [...] structure that the institution offers the integration and qualification of the multidisciplinary team in order to allow the service to flow with more quality, [...] the motivational question whether the institution offers conditions for him to be motivated, to always be updated in regarding health protocols. (E07)


Introduction
The hospital urgency and emergency service must have a flow system for the quality care of patients according to the risk potential, health problems or degree of suffering. The Unified Health System (SUS) is faced with the great challenge of organizing the health network in an interconnected way, enabling the attendance to different types of specialties (Figueredo, Veras, Silva, & Cardoso, 2018).
In order to solve the problems generated by the increase in assistance, the Ministry of Health (MS) dedicated itself to organizing the Health Care Network (RAS), one of which being the Emergency Care Network. For the integration to work, it was necessary to build a structure to base the actions on the three levels of federal, state and municipal management through the National Policy for Attention to Urgencies (PNAU) (Brasil, 2011;Oliveira et al. 2020).
The main objective of PNAU is to expand access and the quality of health care in SUS. As a result, the Priority Thematic Networks were implemented as an example, the Urgent and Emergency Care Network (UECN), whose main function is to extend and bring together conditions of dignified, comprehensive and humanized access to all SUS users in urgent and emergency conditions. emergency quickly and effectively (Brasil, 2013).
The Emergency Hospital Service (EHS) is one of the most critical sectors in relation to the promotion of quality of care due to the lack of hierarchy in the treatment of health problems and the disorder in the internal flows generated by the high demand of users for care (Hermida, Nascimento, Echevarría-Guanilo, Brüggemann, & Malfussi, 2018).
Urgent and emergency hospitals are places that need to offer quick and resolute responses to the patient's clinical conditions. They must have qualified and qualified professionals to make the right decisions when attending, always prioritizing the complexity of each case. However, in practice, urgent and emergency services have difficulties in offering quality care (Freire et al., 2019;Lacerda, Araújo, & Neta, 2017). The poor working conditions, the precariousness of the physical structure, the small number of professionals, the high demand for patients, the material resources and insufficient equipment and unprepared professionals are factors that hinder the guarantee of qualified care (Wihastuti, Rahmawati, Rachmawati, Lestari, & Kumboyono, 2019;Ferro et al, 2018).
Patient care is considered one of the most important aspects in the search for satisfaction, especially in urgent and emergency services. Moreover for patient care to be comprehensive, the entire multidisciplinary team must be involved. Nurses, together with nursing technicians, constitute the majority of the category of professionals in the sector, therefore, they are the ones who directly accompany patients. For the quality of care to be satisfactory, nurses must work with articulation and integration of the team, contributing to the interrelationship between the various professionals (Macedo, D'Innocenzo, 2019;Matos et al., 2017).
The humanization of health, especially in urgent and emergency services, is a challenge for nurses, as it involves the permanent construction of care, and new attitudes towards patients. Nurses have a central and articulating role that gives them opportunities to interact and influence professional actions in emergency services, in favor of the production of comprehensive care, this resolutive and humanized (Sousa et al, 2015;Rodrigues, Sousa, Magro, Andrade, & Hermann, 2017).
The present study aimed to identify the factors that interfere with the quality of nurses' care for patients in the urgency and emergency service.

Methods
It is a qualitative, exploratory and descriptive study. The research was carried out in the months of September to November 2017 in the Reception Rooms with Risk Classification, Trauma Room, Green Room and Stabilization Room of a public hospital reference in urgency and emergency in Teresina-PI.
The research participants initially understood according to the scales of the 28 nurses' sectors. Considering the applied inclusion and exclusion criteria, effective nurses with a minimum of one-year experience in the urgency and emergency sectors were included and, excluded, those were absent from the service due to sick leave or vacation during the collection period of the patients. Dice. The final sample, after adopting the criteria established above, was 16 nurses.
For data collection, the interview technique was used, using a semi-structured script. The first part of the instrument consisted of the characterization of the subjects: gender, age, title and length of experience in the urgency and emergency service. The second, for two open questions: "What are the factors that interfere in the quality of the nurse's care to the patient in the urgency and emergency sector?" and "What improvements in the service for the quality of care?".
The participants received explanations about the entire data collection process. To guarantee confidentiality and anonymity, the interviewees were identified with the letter E, followed by Arabic numerals following the interview.
Based on the nurses' consent, the time for the semi-structured interview was scheduled according to the availability of each participant. In order that no relevant information was lost or forgotten, a mobile device (MP4) was used in order to guarantee the authenticity of the statements represented in the interviewees' statements.
The reports obtained were transcribed in full, and then organized into categories. Data analysis was developed using the content analysis technique, in a thematic modality consisting of three stages: preanalysis, with a fluctuating reading of the interviews in order to systematize the initial ideas, then; exploration of the material, with identification of the core meanings of the speeches, grouping the related ideas; and finally the treatment of the data obtained (Queiroz & Sousa, 2017).
The study was approved by the Ethics and Research Committee of Fundação Hospitalar de Teresina,under CAAE 74753317.3.0000.5613 and report No. 2,261,192. Each interview was conducted only after clarification of the research objectives and the participant's consent, by signing the Informed Consent Form.

Results and discussion
Sixteen nurses participated in the research, of which 62.5% (n = 10) were females aged 26 to 39 years, and 37.5% (n = 6) male aged 26 to 35 years. Most participants had a lato sensu specialization as the highest degree of degree. And the period of work of professionals in the urgency and emergency sectors was two to seven years.
The collected data were organized, analyzed and grouped into two categories, which are presented below: Category 1: Factors that interfere with the quality of nurses' care to patients in the urgency and emergency sector According to the testimonies, overcrowding was cited as one of the main factors that interfere with the quality of nurse care in the urgency and emergency sector.
[...] The number of patients who have days that are overcrowded, the delay in procedures that are many, the insufficient number of professionals that are having in the hospital [...]. (E6) The overload of services due to the large number of patients who remain for a long time, because the turnover in the observation is not adequate, a reduced team of professionals, the lack of an adequate structure, there is a burden on the nurse [. The reports seem to confirm the data obtained in a study carried out in 2012, which recognizes that a crowded environment is a condition that occurs when the emergency sectors are unable to serve the public requesting the service or when it is unable to maintain an adequate flow for the service. patient, extending his stay in the hospital (Barrett, Ford, & Ward-Smith, 2012).
Professionals experience several implications due to working in an environment with an increase in the demand for services, generating several conflicts such as physical and mental exhaustion, and noncompliance with patients' rights, thus disrespecting the moral and structural values of the work team (Santos & Santo, 2014).
It highlighted another important factor that interferes with the quality of care provided by nurses in the emergency, which is the dimensioning of nursing staff. Sizing is considered a crucial tool in the allocation of nursing staff. Due to the fact that the sector has peculiar characteristics such as fluctuation in demand, among others, it is difficult to classify patients, especially for the time necessary for individual care, making it difficult to calculate the dimensioning. The dimensioning of nursing staff is a guarantee of production and quality in the care provided to hospital institutions, guaranteeing the constant continuity of the activities developed by the nursing professional (Machado & Poz, 2015).
Working conditions for health professionals are essential so that they can perform activities with engagement, and when there are no adequate conditions for performance, there will consequently be difficulties in performing activities (Magnano, Lisboa, Griep, Zeitoune, & Tavares 2010).
Both E09 and E16 cited working conditions as factors that most influence the lives of professionals. And the way the activities are developed, lead to setbacks. Health work encompasses several elements in the search for excellent care that, when not in line, end up affecting the results. Some aspects in common with the E07 show that it is recommended that the environment has favorable working conditions as a qualified team, and that the institution provides a motivating atmosphere for the professional. Evidenced by the following statements.
[...] better working conditions. And the negative points that are the high demand from patients, the insufficiency of professionals, the lack of supplies and materials to provide assistance, this interferes a lot causing stress and inconvenience for the team. [...] structure that the institution offers the integration and qualification of the multidisciplinary team in order to allow the service to flow with more quality, [...] the motivational question whether the institution offers conditions for him to be motivated, to always be updated in regarding health protocols. (E07) Authors put the work environment is a set of diverse elements that are constituted to produce a final object. Other researchers argue that the fulfillment of activities in the health field does not result only from the professional's capacity and commitment, but from work situations and interpersonal relationships between users and the health team (Brotto & Dalbello-Araujo, 2012).
Interpersonal relationships are of great relevance within the scope of nursing work, since it is a group that needs to act with respect to differences, in order to develop teamwork. The relationship between the multiprofessional team is a facilitating instrument in the work environment, it appears that there is an influence related to the presence of fragility that invades the relationship between the nursing team as verbalized in the following transcripts: This highlighted weakness, refers to the failure in the integration between the multiprofessional team or in one of its members, this causes inaccuracies in living with the team itself. In the testimonies of the surveyed subjects, the importance of organization, supply and maintenance of materials was clear. Since the lack of material is pointed out as a constant problem in the emergency department. Some testimonies illustrated this difficulty experienced by nurses: The hospital environment is not always provided with conditions that aim at quality standards to satisfy both users and health workers. It is necessary for the hospital to have an architectural plan, where comfort, sustainability and above all, the quality and satisfaction of the public who are destined for the services provided in urgency and emergency.
At the hospital, where critical and stressful situations are frequent, involving interpersonal relationships and people with a certain degree of suffering, whether physical or psychological, environmental and structural aspects are relevant factors to be observed during the development of the construction project (Brazil, 2014).
An important factor is the structure that the institution offers and the qualification of the multidisciplinary team, so that the service can flow with more quality [...]. (E7) Some professionals point out the importance of continuing education aiming, therefore, to improve practice, this is important information, as they realize that continuing education is an essential tool, for the good performance of their functions within the principles of SUS, mainly in urgency.
Permanent education is a significant instrument with the purpose of keeping the population informed and aware of health problems. From the didactic point of view, permanent education is situated in the context of the distinction of professional education thinking, in which work is valued as a learning process. This education does not seek to transform problems into educational issues, but to search for gaps in the work process that are filled by acquired knowledge (Brasil, 2004).
Authors say that if the first step is to motivate the professional, the second step is precisely to bring education closer to everyday life, to raise the real needs of the service organization and routine practices, foreseeing to transform daily situations into learning (Coelho et al, 2013).
The main factors that interfere with the quality of care are: inadequate work conditions, improper physical structure to meet the high demand for patients, insufficient materials and equipment, dimensioning of inadequate personnel, in addition to a health care network that encounters problems to perform the patient's proper flow.
Category 2: Improving the quality of care in urgent and emergency situations The Reception with Risk Classification (RRC) is seen as a driver of quality in the urgency and emergency sector, and nurses play a very important role in this process. With the purpose of ensuring continuous, resolute and humanized care, executed with competence and knowledge. The RRC is used as a tool in the quality of care, it is linked to qualified listening practices, directing the flow, systematized care according to the severity of the case or the risks of aggravation and weaknesses manifested by the patient (Brasil, 2009).
The RRC when implanted in the institutions provides positive results for being inserted in the National Policy of Humanization of Attention and Management. Incorporated in this policy, a risk classification protocol approved by the Ministry of Health was implemented, which determines care flows and risk classification in order to provide a humanized reception, improving the flow of patients in the sector.
In the case of the hospital under study, the reception and risk classification are performed, but with limitations, due to having insufficient professional numbers in the risk classification sector.
Both E01 and E12 are similar to E04, E05 and E16, in reporting the importance of risk classification with flow chart for patients. Important instrument in improving the quality of care. Observed in later reports: The reception and risk classification is the gateway to any service, as the demand is great and there is only one nurse to perform the risk classification of patients, it becomes difficult to perform the work [. Another factor mentioned was permanent health education, implemented to contribute to changes in the scope of work, providing workers with critical thinking skills, an overview of real needs, new postures in professional practice. Where qualification becomes a necessary attribute to perform activities in the urgency and emergency sector due to being a dynamic place that needs agile, skilled, quick-thinking staff, with technical and scientific knowledge.
Authors state that, for health establishments to evolve, become competitive and achieve the expected results, it is essential to introduce policies within institutions that value not only practical knowledge, but that develop their skills (Manzo, Brito, & Corrêa, 2012).
It is observed in the speeches of the informants that the qualification contributes to a better coping with the adversities, guaranteeing a quality assistance. Need reported in the speeches: Knowledge of pathologies, agility, a good relationship with the multidisciplinary team and having a holistic view of the patient to perceive any changes. (E06) He needs to gather a series of knowledge that has his first contact in college and is improving in the work environment, knowing how to handle equipment and having knowledge of intensive therapy. (E07) First scientific knowledge, technical skill, especially working as a team and searching is always improving. (E10) Leadership is an event that involves an entire group and that needs everyone's dedication to achieve good results. Teamwork improves care and generates a pleasant work environment (Moura, Bernardes, Balsanelli, Zanetti, & Gabriel, 2017).
The qualification of urgency and emergency, quality update courses that give an adequate experience to the professional. (E03) The nurse must exercise leadership so that he can positively influence the entire team, stimulating and creating bonds in order to promote a pleasant environment, guaranteeing teamwork, thus improving the quality of care provided. Being perceived in the speech of E11.
Linked to this, there is a lack of characterization of care due to the fact that the sector is in high demand from patients, increasing the amount of nursing work, making their dimensioning of staff inadequate, compromising the quality of care. It can be evidenced in the following statements of E02, E05, E09 and E15.
By increasing the number of professionals, having enough material for patient care. (E2) [...] human resources I talk about is having the staff to provide assistance, because it overloads, there is stress, there is no way to provide adequate assistance. (E5) The adequate dimensioning of professionals, permanent education, the availability of materials. (E9) The nurse evaluates the client, you know, in a very holistic way, he evaluates as a whole, he tries to solve all the pending issues in the sector so that he can prioritize the improvement of his assistance, so we go from a diet, to transfer issues [... ] the nurse is the fundamental piece in this link of the patient to have this improvement in this assistance. (E11) Correct dimensioning of personnel, availability of sufficient inputs to be able to carry out procedures with agility. (E15) The performance of health professionals in the current times involves several criteria related to charges by employing institutions that are increasingly competitive and demanding and from users themselves with a demand for services with excellence. And inserted in this context is the professional who lives the dualism of enduring pressure and at the same time trying to stay motivated. Studies show that in the medium and long term, constant negative feelings and sensations trigger disease and exert a great influence on the quality of services provided (Chang & Chan, 2015). This condition is confirmed by the interviewees of the service studied in the following statements: The nurse must be committed to the service, have technical and scientific knowledge [. Work is the result of the interaction of several factors: environmental, human, organizational processes. Where health work encompasses relational, subjective and emotional aspects producing care. In which working conditions play a decisive role in the well-being of the professional and in the impact on the quality of care. In which inadequate working conditions, management issues, reduced resources, insufficient inputs and equipment, prevent the planning and implementation of health care interventions affecting the quality of care developed, generating dissatisfaction on the part of users and professionals for being exposed to a vulnerable environment to predisposition to harm your health.
An articulated health care network proposes defragmenting care through interconnection with the other components of the network, contributing to the provision of an equitable, comprehensive and quality service in urgencies and emergencies. Where it is proven in the speech of E06.
In line with E05, E07 and E08 when agreeing to report that the structure interferes with the quality of care provided, as it is a sector that requires speed and clarity in their attitudes, a determining factor for preventing preventable deaths or complications in a patient in the sector. As shown in the following statements: It needs resources and organization, structure when I talk about resources I talk about having all the inputs, having all the equipment you need to provide quality assistance, and the human resources I talk about is having the staff to give assistance, because it overloads, it has stress cannot provide adequate assistance. (E05) Structuring the neighborhood and countryside hospitals to reduce the flow of patients here at the hospital. (E06) Firstly, to offer an adequate structure, to have more material and equipment because of the demand [...]. (E07) He participates in the entire care process for any patient [...], if he is in an optimal environment he will perform his actions better. (E08) In this category, it can be emphasized that in order for an improvement in care to occur, a set of actions and services that are interconnected can sensitize everyone involved in the process of direct or indirect care, contributing to continuous, resolute and quality care.
This study has limitations, related to the method adopted. Because it is a qualitative study, it took place in only one institution and it is cross-sectional, which does not allow the subjects to be followed up.

Conclusion
The nurse as an important part in the execution of care and for staying longer with him needs technical scientific knowledge and assistance, managerial and educational skills that are performed simultaneously by the professional for developing a holistic perception in care.
This context in which institutions increasingly demand professional qualification and the development of activities with excellence. In order to achieve good results and obtain satisfaction from the person receiving the care, it becomes important to know the precepts of permanent education inserted as a policy within the institution to ensure the continuity and updating of the knowledge that will contribute to the provision of quality care.