WHAT DOES IT MEAN TO WORK IN AN ACCREDITED HOSPITAL ? PERCEPTIONS OF THE NURSING

Objective: to get to know the perception about the Accreditation process in the routine of the Nursing team of a university hospital in the evaluative dimensions of structure, process and outcome. Method: a quantitative, exploratory and descriptive study, with 563 professionals. For the data collection, the Likert Scale was used and data treatment was carried out using descriptive statistics and the Cronbach Alpha test. Results: in the analysis of the results, it was observed that the Nursing team showed a perception with a higher degree of favorability for the process dimension, with a mean score of 0.7463 (sd ± 0.1466); followed by the result dimensions, with 0.7256 (sd ± 0.1804), and structure, with 0.6800 (sd ± 0.1714), showing that the benefits derived from Hospital Accreditation are recognized by the members of the Nursing team. Conclusion: less favorable scores resided in the structure dimension, requiring more attention from managers, since a more adequate structure increases the probability of better quality care. The study allowed for the understanding on the context of Hospital Accreditation in the environment of the practice suggesting possible interventions to improve this process. Descriptors: Hospital Accreditation; Quality, Access and Evaluation of Health Care; Quality Assurance of Health Care; Quality of Health Care; Patient safety; Nursing. Descriptors: Hospital Accreditation; Health Care Quality, Access, and Evaluation; Quality of Health Care; Quality Assurance Health Care; Patient Safety; Nursing. RESUMO Objetivo: conhecer a percepção acerca do processo de Acreditação no cotidiano da equipe de Enfermagem de um hospital universitário nas dimensões avaliativas de estrutura, processo e resultado. Método: estudo quantitativo, exploratório e descritivo, com 563 profissionais. Para a coleta de dados, utilizou-se a Escala de Likert e o tratamento dos dados foi realizado por meio de estatística descritiva e o teste Alpha de Cronbach. Resultados: na análise dos resultados, observou-se que a equipe de Enfermagem demonstrou percepção com maior grau de favorabilidade para a dimensão de processo, com escore médio 0,7463 (dp±0,1466); seguida pelas dimensões resultado, com 0,7256 (dp±0,1804), e estrutura, com 0,6800 (dp±0,1714), evidenciando que os benefícios derivados da Acreditação Hospitalar são reconhecidos pelos membros da equipe de Enfermagem. Conclusão: os escores menos favoráveis residiram na dimensão estrutura, requerendo maior atenção dos gestores, tendo em vista que uma estrutura mais adequada aumenta a probabilidade de uma assistência de melhor qualidade. O estudo permitiu compreender o contexto da Acreditação Hospitalar no ambiente da prática sugerindo possíveis intervenções para a melhoria desse processo. Descritores: Acreditação Hospitalar; Qualidade, Acesso e Avaliação da Assistência à Saúde; Garantia da Qualidade dos Cuidados de Saúde; Qualidade da Assistência à Saúde; Segurança do Paciente; Enfermagem. RESUMEN Objetivo: conocer la percepción acerca del proceso de Acreditación en el cotidiano del equipo de Enfermería de un hospital universitario en las dimensiones evaluativas de estructura, proceso y resultado. Método: estudio cuantitativo, exploratorio y descriptivo, con 563 profesionales. Para la recolección de datos, se utilizó la Escala de Likert y el tratamiento de los datos fue realizado por medio de estadística descriptiva y la prueba Alpha de Cronbach. Resultados: en el análisis de los resultados, se observó que el equipo de Enfermería demostró percepción con mayor grado de favorabilidad para la dimensión de proceso con puntaje medio 0,7463 (dp ± 0,1466); seguido por las dimensiones resultado, con 0,7256 (dp ± 0,1804), y estructura, con 0,6800 (dp ± 0,1714), evidenciando que los beneficios derivados de la Acreditación Hospitalaria son reconocidos por los miembros del equipo de Enfermería. Conclusión: los puntajes menos favorables residían en la dimensión estructura, requiriendo una mayor atención de los gestores, teniendo en vista que una estructura más adecuada aumenta la probabilidad de una asistencia de mejor calidad. El estudio permitió comprender el contexto de la Acreditación Hospitalaria en el ambiente de la práctica, sugiriendo posibles intervenciones para la mejora de ese proceso. Descriptores: Acreditación de Hospitales; Calidad, Acceso y Evaluación de la Atención de Salud; Calidad de la Atención de Salud; Garantía de la Calidad de Atención de Salud; Seguridad del Paciente; Enfermería. PhDs, Hospital of PUC-Campinas. Campinas (SP), Brazil. E-mail: alinetogni@yahoo.com.br ORCID iD: http://orcid.org/0000-0001-59116639; E-mail: mileidempena@gmail.com ORCID iD: http://orcid.org/0000-0002-4658-6524; PhD, Campinas Pontifical Catholic University. Campinas (SP), Brazil. E-mail: inhaiap@uol.com.br ORCID iD: http://orcid.org/0000-0001-65712744 ORIGINAL ARTICLE Braga AT, Pena MM, Pinhel I. What does it mean to work in an accredited... English/Portuguese J Nurs UFPE online., Recife, 12(6):1524-31, June., 2018 1525 ISSN: 1981-8963 https://doi.org/10.5205/1981-8963-v12i6a231347p1524-1531-2018 In health, there are many factors that involve quality, starting with the quality of caregiving that depends on the clinical capacities of the professionals, 1 being, also, dependent on the level of differentiation, specialization, training standards of scientific studies and official recommendations. The incessant search for the improvement of the quality of health services is the way for the institutions that fight for the permanence in the competitive market and that value the excellence of service. For this reason, hospitals seek new care models and other forms of management in order to guarantee the improvement of the quality of the service offered. The Accreditation process is widely seen as a form of quality assurance that often feeds on process improvement activities aligned with organizational priorities. Consistency is observed in this strategy when an organization and its team realize that Accreditation aligns with their beliefs, context and service delivery model; the improvement actions are proposed in response to observations, feedback or self-reflection in light of the current scenario; there is alignment in the concepts influenced by individual characteristics, internal and external factors. On the other hand, the Accreditation process, is not simple, but it is of great significance for a health institution, employees and users of the service, since its results can promote more assertiveness in decision-making, monitoring and contribute to the development of strategies for the implementation of improvements in health services. For Nursing, the Accreditation process has great value since it standardizes the care and administrative processes, facilitates and guides the team at the moment of carrying out the procedures, as well as improving communication, training for continuous improvement, the valuation of professionals and the humanization of the caring process. Through this reflection and considering that the Accreditation process goes beyond the implementation of norms and routines and that the involvement of the Nursing team is crucial for its implementation, the question arises whether, in fact, the Nursing team is committed to the proposal of quality or only follows orders and standards, in a simple fulfillment of tasks. What would these professionals perceive about Hospital Accreditation? ● To get to know the perception about the Accreditation process in the routine of the Nursing team of a university hospital, in the evaluative dimensions of structure, process


ORIGINAL ARTICLE
English/Portuguese J Nurs UFPE online., Recife, 12 (6):1524-31, June., 2018  1525  In health, there are many factors that involve quality, starting with the quality of caregiving that depends on the clinical capacities of the professionals, 1 being, also, dependent on the level of differentiation, specialization, training standards of scientific studies and official recommendations. 2e incessant search for the improvement of the quality of health services is the way for the institutions that fight for the permanence in the competitive market and that value the excellence of service.For this reason, hospitals seek new care models and other forms of management in order to guarantee the improvement of the quality of the service offered. 3e Accreditation process is widely seen as a form of quality assurance that often feeds on process improvement activities aligned with organizational priorities.Consistency is observed in this strategy when an organization and its team realize that Accreditation aligns with their beliefs, context and service delivery model; the improvement actions are proposed in response to observations, feedback or self-reflection in light of the current scenario; there is alignment in the concepts influenced by individual characteristics, internal and external factors. 4 the other hand, the Accreditation process, is not simple, but it is of great significance for a health institution, employees and users of the service, since its results can promote more assertiveness in decision-making, monitoring and contribute to the development of strategies for the implementation of improvements in health services. 5r Nursing, the Accreditation process has great value since it standardizes the care and administrative processes, facilitates and guides the team at the moment of carrying out the procedures, as well as improving communication, training for continuous improvement, the valuation of professionals and the humanization of the caring process. 6rough this reflection and considering that the Accreditation process goes beyond the implementation of norms and routines and that the involvement of the Nursing team is crucial for its implementation, the question arises whether, in fact, the Nursing team is committed to the proposal of quality or only follows orders and standards, in a simple fulfillment of tasks.What would these professionals perceive about Hospital Accreditation?
• To get to know the perception about the Accreditation process in the routine of the Nursing team of a university hospital, in the evaluative dimensions of structure, process and outcome.
A quantitative, exploratory and descriptive study, carried out in a large tertiary university hospital, located in the city of Campinas, in the interior of the State of São Paulo.Exclusion criteria were: professionals who were on vacation, medical leave and in an experience period at the time of data collection.
The data collection instrument consisted of two parts: the first one containing the sociodemographic data of the participants and the second one with 24 propositions concerning the dimensions of structure, process and result, being 13 assertive, with positive attributes, and 11 with negative attributes randomly distributed to avoid that the participant maintained a tendency to respond.A Likert scale was used to obtain the answers with five degrees of variation: degree 1 -totally disagree (TD) and the opposite end degree 5 -totally agree (TA); the intermediate point, degree 3 -indifferent (I) and degrees 2 and 4 -partially disagree and agree (PD and PA).The obtained data was analyzed from the favorability scores, comparing the averages obtained in the three parameters (structure, process and result) and leading to the conclusion of the most evaluated dimension and the least favorable dimension.
In order to verify if the content was representative of the theoretical universe that was intended to be measured, the instrument was validated by six judges specialists on the subject with competence to validate the construction of the instrument.
The internal consistency reliability of the instrument was evaluated using Cronbach's Alpha, obtaining a result of 0.81, which means measuring 81% of the actual process considered a reliable value.It should be noted that this value can vary from zero to one and, the closer it is to one, the greater the reliability of the instrument.
Data was stored in an Excel® spreadsheet for processing.The data treatment, to compare the scores in the three dimensions, used the non-parametric Friedmam and Kruskal-Wallis tests 7 .
The study met the requirements for research involving humans with CAAE nº 19054813.1.0000.5481.563 professionals of the Nursing team participated in this study and were, distributed in 117 (20.8%) nurses, 406 (72.1%)Nursing technicians and 40 (7.1%)Nursing auxiliaries.The mean age of participants was 34.74 years (SD = ± 8.07) and the median was 33 years.The mean training time was 8.32 years (SD = 5.80) and the median was seven years; the mean time in the institution was 6.06 years (SD = ± 6.02) and the median, four years.
Table 1 presents the propositions of the structure dimension, which includes physical and material resources, Nursing staff and infrastructure.Table 3 presents the propositions referring to the result dimension, which consists of the evaluation of the Nursing team about the desired result for Nursing care after the Accreditation process.I am pleased to be part of the staff of an Accredited Hospital.The comparisons between the scores of the structure, process and result dimensions are shown in table 4 and are made up of measures of central tendency and variability.It is intended, here, to highlight what is the perception of the Nursing team in relation to the object of the study.The higher the score, the more favorable the attitude of the subject and vice versa.The mean score in the structure dimension was 0.6800 (SD ± 0.1714); in the process dimension, 0.7463 (SD ± 0.1466) and result, with a value of 0.7256 (SD ± 0.1804).Note that the most evaluated dimension was the one of process, followed by the result dimension.
In relation to the structure dimension, the propositions with the highest percentage of agreement were related to the clarity about the meaning of Hospital Accreditation (84.4%), the motivation of its superior for issues related to Hospital Accreditation (77.2%) and about having never received guidance / training on Hospital Accreditation (77.2%).The percentage of professionals who stated that they had never received orientation or training regarding the Hospital Accreditation process is noteworthy, considering that the same percentage claims to be motivated by their superior to the issues related to the topic.At the same time, 66.8% of respondents reported not knowing the Accreditation methodology adopted at the institution, although 84.4% affirmed clarity as to the meaning of Hospital Accreditation.
Numerous strategies must be adopted for the involvement of the different actors, within the organization, viewing to achieve Accreditation.Leaderships are constantly challenged in this process and perceive the most complex management and must increase their actions for success in the certification objective. 8t is worth remembering that the development of people should be part of every quality initiative.However, it is pointed out that, regarding the implementation of the quality management system in hospitals, the subjective dimension of the employees' involvement, the integration of professionals and the reconciliation of interests between workers and managers have not been considered.] The role of the nurse, as leader and multiplier of the Accreditation process, is recognized not only by the Nursing team, but also by other professionals directly related to care.This finding indicates that the actions of the nurse as a leader are fostered not only within the scope of Nursing, but also by other hospital professionals who experience or have experienced the Accreditation process. 11hus, when the Nursing team, participating in the study, reports not having been oriented or motivated by their superiors to participate and/or contribute to the Accreditation process, it is suggested that the strategies used by the leaderships for the diffusion of this knowledge be re-evaluated.
It was possible to verify that the Nursing team plays a fundamental role in the implementation and maintenance of the Hospital Accreditation process.Thus, investments in the human potential of the category should be encouraged so that the team stays motivated and updated, establishing an organizational culture for the quality and safety of the patient.
Regarding the Process dimension, 75.7% considered that in the Hospital Accreditation process, the Nursing team is more overloaded in relation to other health professionals and 74.6% stated that they actively participate in the Hospital Accreditation process.The development of the Hospital Accreditation process makes the day to day at work or work performance difficult for 72.1% of the professionals.However, the same percentage of respondents feel motivated to cooperate with this process.
The incorporation of activities into the daily routine for the Accreditation process may have contributed to these findings, such as the need for formalization and records of activities, the policy for reporting adverse events, standardized work, among others that require time and dedication of the professional.This finding is fundamental to understand and act on such variables requiring special attention from the institution's managers.
Some authors discuss the stress and work overload arising from the Hospital Accreditation process and emphasize that the work overload results from the need for attention to the bureaucracy, in addition to the common tasks, while the demands and stress fall into the premise of quality and perfection.  It also added that the unbridled search for results, demands on the improvement of performance and professional practice have

DISCUSSION
English/Portuguese J Nurs UFPE online., Recife, 12(6):1524-31, June., 2018 1529 led to the exhaustion of many health professionals evidencing weaknesses in the practice of people management when it comes to quality certification in the hospitals. 9n spite of the relevance of the increase in quality in care directed by Acredditation, it is worth emphasizing the importance of the Nursing team in the achievement of such merits, since these professionals are known to assist the users in the hospital during the 24 hours of the day, every day, in an uninterrupted way.In addition, the nurse's role in the Accreditation process deserves to be highlighted, since this professional, as a team leader, has a direct link with the multiprofessional actions, with the definition of strategies for the necessary changes in the care process and operational models for the provision of care. 14 study that identified and compared the work environment of nurses from an Accredited and a Non-Accredited hospital, through the Nursing Work Index -Revised -Brazilian Version (B-NWI-R), showed that the differences presented were in relation to the work and satisfaction with salary, because in the organization that did not undergo the Accreditation process, the nurses had a shorter working day and were more satisfied with the salary.15 The culture of quality is an organizational good that must be shared systemically in health services.Because it is not part of the formal structure of the organization, the promotion of a quality culture depends, first and foremost, on the individual professional position that, together with the collective, can influence the systemic organizational culture 16 .For this, it is necessary for the professional to understand their role in the Accreditation process, the reasons for the inclusion of tasks and the desired objectives, bringing meaning to the work process and reducing the perception of overload.
Communication and information play a fundamental role in the Hospital Accreditation process, as they enable organizational processes attesting to the quality of care provided.In the construction of strategic planning oriented to Accreditation, the understanding of communication and information, as gears of the operation system of hospital organizations, allows for gains in quality, in smaller time spaces, since these enable the understanding of norms and reasons of the changes in the processes, the motivation for the engagement in the changes and the basis for the definition of indicators and for the discussion and evaluation of the results. 17n the comparison between the positive aspects considered by the professionals and the negative arguments discussed, it is suggested that the valorization and knowledge acquired by each worker overcome stress and work overload, since it is impossible to achieve improvements in care without increasing responsibilities. 13n the result dimension, 92.3% of the professionals agreed that Hospital Accreditation facilitates the interpersonal relationship in the Nursing team and an expressive percentage reported that the Accreditation process brings improvements to the hospital (87.1%) and to its work ( 85.4%).Despite some negative affirmations regarding the dimensions of structure and process, it is perceived that the results derived from the process of Hospital Accreditation are recognized by the members of the Nursing team.
In the literature, the main impacts of Acredditation that were identified were standardization of processes, compliance with external programs, organizational culture contributing to quality and safety, continuous quality improvement activities and leadership. 18] In addition, it is important to remember that the Accreditation has, as a result, a seal or certificate of quality that allows for the recognition of the Institution by society and may even be of international level. 21oth managers and employees recognize that Accreditation entails changes in the hospital in terms of operational, structural, financial and cost aspects; in high hospital management and also in quality management.These changes unfold in changes considered broad and positive in the dimensions of the Donabed Triad (structure, process and results).Such changes can be exemplified with the standardization and mapping of care processes; the increase of physical structure and work organization; improvements in the management of hospital costs; positioning of strategic vision in the market; inclusion of participatory leadership, as well as other initiatives that promote quality management. 14t is observed that the most evaluated dimension by the Nursing team was that of process, while the least favorable was the English/Portuguese J Nurs UFPE online., Recife, 12(6):1524-31, June., 2018 1530 structure, inferring the need for a more indepth analysis of the propositions contained in this item, such as the re-evaluation of the training model of professionals that provide assistance.
The study allowed one to get to know the perception of the Nursing team about the Hospital Accreditation process, reinforcing that for the implementation of the quality process, it is imperative to know the perception of those who work 24 hours in the direct assistance of the patient.
The dimension with the highest degree of favorability was the process one, followed by the result dimension, evidencing that the benefits derived from Hospital Accreditation are recognized by the members of the Nursing team.It should be noted that the less favorable scores resided in the structure dimension, requiring greater attention of the managers to these aspects, since a more adequate structure increases the probability that the assistance provided is of better quality.
The study presents theoretical and practical implications for understanding the context of Hospital Accreditation in the practice environment, suggesting possible interventions to improve this process.Thus, it is expected that new research regarding the theme will be developed, given the relevance of the nursing professionals' performance in the Accreditation process and the influences on daily work and patient satisfaction.

Table 2 .
Percentage of the answers regarding the propositions of the Process dimension.

Table 3 .
Percentage of the answers regarding the propositions of the Result dimension.Campinas (SP), Brazil, 2014.

Table 4 .
Distribution of mean values, standard deviation (SD), median, minimum and maximum scores attributed by the nursing team in the dimensions of structure, process and outcome.Campinas (SP), Brazil, 2014.