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Factors related to quality of nursing care


How to cite this article:
Flores-Alpízar CA, Ponce-Moreno R, Ruíz-Jalomo MR, Corral-Quiroz RJ. Factores relacionados con la calidad de atención de enfermería. Rev Enferm Inst Mex Seguro Soc. 2015;23(3):143-8.

Factors related to quality of nursing care

César Augusto Flores-Alpízar,1 Rebeca Ponce-Moreno,1 María del Refugio Ruíz-Jalomo,1 Rosalba de Jesús Corral-Quiroz2

1Alumnos del curso Postécnico de Enfermería en Cuidados Intensivos, 2Subjefatura de Educación de Enfermería y Técnicos. Instituto Mexicano del Seguro Social, Culiacán, Sinaloa, México

Correspondence: Rebeca Ponce-Moreno

Email: rbk_sgirl@hotmail.com

Received: March 27th 2014

Judged: June 17th 2014

Accepted: August 19th 2014


Introduction: The quality of nursing care can be described in two ways: in the strictest way, it is a set of techniques that ensure the maintenance and performance of standards, and the efficiency and efficacy of nursing care.

Objective: To establish the factors that influence patient care provided by the nursing staff at the Instituto Mexicano del Seguro Social’s Regional General Hospital 1.

Methodology: Descriptive study applied to 71 nurses of both sexes, from all shifts, and from the Adult Emergency and ICU (Intensive Care Unit) departments. The main variable was factors that influence the quality of nursing care. The method was direct and we used an instrument consisting of six grouped factors. For the statistical analysis we used the statistical software Stata 8, with p > 0.05 considered significant.

Results: 63.30 % were technicians, 28.17 % were specialist technicians, and 8.45 % had a college degree. Out of them 70 % were emergency personnel and 30 % belonged to the ICU. According to the main variable, the most significant factors that influence the nursing care were training (92.96 %), patient allocation (76.06 %), and knowledge (25.35 %).

Conclusions: Academic level was one of the factors that had the most influence in nursing care. In a high percentage of the population under study, “training” was a factor influencing nursing care.

Keywords: Quality of health care; Nursing care


Recent studies on the meaning of nursing care see this sort of care as a synonymous of timely, rapid, continuous, and permanent attention aimed at solving particular problems affecting the personal dimension of individuals who need institutionalized service.1

The professional stage of nursing starts in the nineteenth century, with greater emphasis in the twentieth century. From that first moment significant changes are made and significant intellectual reflection is given to the work of nursing. For this there is a line of conceptual analysis, which had its origins in the nineteenth century, when Florence Nightingale made a series of observations that led to recognizing the value of care.2

In Mexico nursing has been promoted since 1907, for which a need was seen for academic preparation for the role of the nurse. The first official school for nursing education in Mexico opened on February 9th 1907.3

In our country, the care provided by health personnel must have a system that responds with quality and respect to the needs and expectations of people. This is in order to improve the quality of health services, which means ensuring a dignified treatment of users and providing them with complete and timely care.4
In healthcare, quality nursing must be secured, planned, monitored, controlled and evaluated.5 So, there must be a unified structure for the identification and classification of characteristics or quality attributes, such as understanding, responsibility, continuity, and coordination. Structural attributes include hospital characteristics, organizational units of nursing, staff attitudes, levels of perception and education, and people’s satisfaction in their work.5

Quality of care can be described in two ways; the strictest sense is a set of techniques that ensure the maintenance and improvement of standards, efficiency and effectiveness of nursing care; in a broader sense, it is an activity of control of the practice. This is a challenge for the nursing administrator to demonstrate the effectiveness of the services that they administer.6

Satisfaction is a complex process that is related to many factors conditioned by individual subjectivity of each subject, their previous experiences, their previous expectations, certain psychosocial factors (age, sex, level of education), social context, and the process of interrelation produced between the provider and the recipient of services.7,8

In order to unify the criteria for the implementation of policies on quality and safety in patient care and goals such as integrating and guiding efforts for continuous improvement in quality in the provision of health services, the Comité de la Coordinación General, the Comisionado Nacional de la Comisión Nacional de Arbitraje Médico (CONAMED) and as a member, the Comisión Permanente de Enfermería emerged, among others involved in the subject. As a result, actions, especially preventive, and the development and dissemination of standards, procedures or recommendations that the Comisión Permanente de Enfermería and CONAMED made together, will be strengthened and solidified.9

The commitment to continuous improvement in the delivery of health services refers to the comprehensive strategy that we called Sistema Integral de Calidad en Salud (SICALIDAD). The actions are intended to prevent and reduce nosocomial infection, provide quality maternal care, have integrated and high quality medical records, develop units of palliative care for terminally ill patients, and improve the care and resolution of emergency services. This does not forget improving the quality of life for professionals and health workers, giving attention to their proposals and recognizing their performance in the dignified treatment and good practice through the stimulus program.9

SICALIDAD, through projects, guidelines, and instruments aimed at users, health professionals, and organizations, helps to raise the quality of services and patient safety in the Sistema Nacional de Salud.9

SICALIDAD’s strategy responds to the idea of ​​putting quality on the permanent agenda of the Sistema Nacional de Salud, and positions both quality of care and patient safety as sector priorities.9

In October 2007, the Pan American Health Organization (PAHO) stressed the importance of quality of care and patient safety as an essential tool for achieving national health objectives, improving the health of the population, and the sustainable future of the healthcare system.10

As a response, PAHO proposed five lines of action aimed at improving the quality of health services:

  • Position the quality of care and patient safety as a sector priority.
  • Promote citizen participation in issues of quality.
  • Generate information and evidence regarding quality.
  • Develop, adapt, and support the implementation of quality-related solutions.
  • Develop a regional strategy for strengthening the quality of healthcare and patient safety.10

They mentioned that for nursing care, diagnostic labels are used for planning interventions; these labels are the product of many years of work and international collaboration to standardize a language of nursing. The taxonomy of diagnoses of the North American Nursing Diagnosis Association (NANDA) has been the basis for countries to validate applying this classification system and for them to keep shaping the major diagnostic categories that can be used by a majority of nurses.10

It is indisputable that the identification of diagnostic labels for nursing will draw attention to the need to train and promote the professionalization of the attention of actual or potential problems that must be addressed with knowledge and a high degree of professionalism to identify and act facing the specific needs of each patient.10

Clinical records constitute the ultimate source of information to document, explicitly, the needs of patients in order for nurses to plan appropriate interventions. However, to date, few clinical record formats are designed so that both aspects can be documented.10

The development of a clinical care guide allows such unification, integrating essential elements to give adequate care by applying evidence-based nursing, which provides sufficient and up-to-date scientific basis to incorporate the best evidence and strength of recommendation.10

The clinical guide should include theoretical and methodological elements from a nursing discipline perspective, which will provide effective, efficient, and safe care to people who present changes in their health. A clinical guide should contain the following elements:

  • User guide: people who might use the instrument.
  • Target population: people who stand to benefit from the application.
  • Operational definition: conceptual definition of basic elements.
  • Algorithm: linear graphic representation of the essential elements to conduct a procedure.10

Moreover and to reinforce the above, it is emphasized that clinical guidelines are an excellent opportunity for decision-making and application, as they favor the proper management of resources, disseminate the technical and scientific framework of nursing performance, and improve the quality of practice, which influences nurse-patient communication. Its current contents provide a useful tool in continuing education for health professionals. For this we must take into account that a clinical guideline should be constantly renewed and updated to be grounded in the best evidence and strength of recommendation.11
The guidelines encourage the proper management of resources; disseminate the technical and scientific framework of the performance of nursing; improve the quality of care, making it possible to develop practice risk-free; and with its current content, provide a useful tool in continuing education for health professionals.12

As a discipline, nursing cannot become a profession as such if it does not strengthen research practice, although in recent decades this has shown remarkable progress and contribution to the process of professionalization. Research is, in this sense, the bridge between theory and practice in the process of constant search for knowledge; this base helps to form a judgment and a foundation for the actions of nursing.12

It is critical that nurses be able to demonstrate and describe their professional contribution to the health of individuals, groups, communities, and the general population, developing research focused mainly on nursing care for the establishment of a body of knowledge proper to the field.12

Society, demanding care, now is not content with receiving assistance, but further wants it to be of quality; that is, to meet certain characteristics or requirements. It is the customer or user who, according to their needs and expectations, defines the characteristics of what care needs to be considered quality in their opinion, and it is the customer who finally assesses whether it suits them or not, to decide where to go to get it. Since the creation of the Sistema Único de Salud, in Cuba the principles behind it are aimed at meeting the needs of patients and families, so that service quality control has been a systematic task, which in turn has allowed changes to the services, as well as educational and research activities.12


A descriptive study was conducted at the Hospital General Regional 1, Instituto Mexicano del Seguro Social in the state of Culiacán, Sinaloa, Mexico. The sample selection was 71 nurses, using a non-probabilistic convenience sample, which included nurses who agreed to participate voluntarily in the study, of both sexes, from the morning, evening, and night shifts in emergency services and the adult intensive care unit, with the rank of specialist nurse or general nurse, with fixed service contracts, working during the study period; nurses in these areas who were on vacation, disability, training, substitutes, nursing assistants, managers, and nurses who did not want to participate were excluded; three incorrectly conducted interviews were eliminated.

The variable of interest was determined by the factors influencing the quality of nursing care. It was defined as follows: When the nurses mentioned directly associated causes, which influenced their providing quality comprehensive care to the user. Among those causes were: training, assigned area, organizational climate, patient allocation, knowledge, and application. The measurement scale considered it Present when the nurse mentioned to us one of the causes (above) that influence their providing quality care, and Absent when the staff presented no cause. The other variables were: age, time working there, shift, sex and service.

The method was carried out directly, through an interview with the nursing staff. For this an instrument consisting of 22 items was used, which were grouped into six factors:

  • General information about nursing staff.
  • Staff training.
  • Area assigned to staff.
  • Organizational climate of staff.
  • Nurse-patient assignment.
  • Knowledge and applications.

Pilot testing for reliability and validity were taken. Its structure was taken from existing references, research, and the SICALIDAD program.

In the statistical analysis for qualitative variables, frequencies were used, while percentages, measures of central tendency, and standard deviation were used for quantitative variables. All data were analyzed using the statistical package Stata 8, and an association of variation was done to check the chi-square p > 0.05.

The project was approved by a research ethics committee before the study began. Participation in the research by competent individuals was voluntary and anonymous. Ethical considerations were taken into account in accordance with the Declaration of Helsinki, which states:

  • Every precaution should be taken to respect the privacy of the person involved in the investigation and the confidentiality of their personal information to minimize the impact of the study on their physical, mental, and social integrity.
  • The potential subject must be informed of the right to participate or not in the study or to withdraw consent at any time without reprisal.
  • After ensuring that the subject has understood the information, the appropriately qualified person must request, preferably in writing, the informed and voluntary consent of the person. If consent cannot be given in writing, the process to achieve it should be formally documented and witnessed.


The study involved a population of 71 nurses, of which 86% were women and 14% men; the average age was 40 years with a standard deviation of 7; with an average age of 14.4 years in service with standard deviation of 8. 72% were general nurses and 28% nurse specialists; 63.30% were technicians, 28.17% technical specialists, and 8.45% professional level. 70% belonged to the emergency room and 30% to the Intensive Care Unit; 25% were from the morning shift, 37% the evening and 38% the night.

The main variable (factors influencing the quality of nursing care) was obtained with the following results: the predominant factor was training with 92.96%, nurse-patient allocation with 76.06%, knowledge and application with 25.35%, organizational climate with 2.82%, assigned area with 1.41%, and we found an absence of factors with 1.41%. Considering the number of factors by service assigned to staff, we found that, unlike expected, the emergency department staff had a greater frequency of combining two and three factors (Table I).

Table I. Combination of factors present in nursing staff of the two services
Factors Emergency service
AICU service
Absence of factors 0 1.4
Training 8.4 12.6
Nurse-patient assignment
Knowledge and applicability of procedures
43.6 12.6
Nurse-patient assignment
Knowledge and applicability of procedures
15.5 2.8
Training of personnel
Area assigned to personnel
Organizational climate of staff
Nurse-patient assignment
1.4 0
Training of personnel
Area assigned to personnel
Organizational climate of staff
Nurse-patient assignment
Knowledge and applications
1.4 0
AICU = adult intensive care unit

No significance was found statistically at the intersection of variables, but it was found clinically, because we saw that having one or more factors present influences the nursing staff to give care to the user with quality and safety in critical areas.


Taking into account reviewed research study papers, we note that one in particular, held at the Universidad Autónoma de Baja California in 2011, shows that the workload of the nursing staff does influence the quality of nursing and that academic level does not. This compared with our results in which academic level was one of the factors that most influence the quality of care. Our results only agreed with this reviewed research in terms of workload, which in our study we defined as nurse-patient assignment.

Of the total study population of emergency services and the adult intensive care unit, at least one factor was presented related to care. General nurse was the one with the highest frequency of factors.

According to the association of variables, our study showed a statistical significance of p = 0.03 between the number of factors and service in which they work, with a high percentage between two and three factors both in the ER and in the AICU. The three most important factors in high percentages were:

  • Training.
  • Nurse-patient allocation
  • Knowledge and applicability of procedures.

Ongoing training is a priority to increase the quality of care provided and to promote actions aimed to improve working conditions to increase the level of knowledge of nurses and let staff know the nurse-patient ratio according to regulatory guidelines. Based on the above we consider it important to update staff by their assigned service as to clinical procedures and electro-medical equipment, as well as continuing feedback on the nursing process and NANDA, NIC, NOC taxonomies, to raise productivity and quality of nursing care, remembering that the quality provided influences the care that is provided to the user.

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