TRAI NI NG PROGRAM ON MI CROBI OLOGI CAL TEST COLLECTI ON MATERI AL METHODS AT
A TEACHI NG HOSPI TAL: I NVESTMENT AND RESULT ASSESSMENT
Mar li de Car v alho Jer icó1 Valér ia Cast ilho2 Már cia Galan Per r oca3
Jer icó MC, Cast ilho V, Per r oca MG. Training pr ogram on m icr obiological t est collect ion m at er ial m et hods at a t each in g h ospit al: in v est m en t an d r esu lt assessm en t . Rev Lat in o- am En f er m agem 2 0 0 6 set em br o- ou t u br o; 1 4 ( 5 ) : 7 4 9 - 5 4 .
Th is st u dy aim ed at ev alu at in g t h e r esu lt s, dir ect cost s an d in v est m en t of a t r ain in g pr ogr am on m icrobiological t est m at erial collect ion at a t eaching hospit al. Test collect ions t hat did not follow t he est ablished crit eria ( failure) were considered as t he result m easure. Variable and absorpt ion cost ing were used t o calculat e dir ect cost s and inv est m ent s, r espect iv ely . Of t he 11, 893 collect ed m at er ials, failur es w er e ev idenced in 59 ( 0 . 5 % ) . Dir ect cost cor r espon ded t o R$ 1 5 4 . 1 0 an d R$ 2 , 4 3 1 . 2 9 w as in v est ed in t r ain in g. Th ese f in din gs r ev ealed t hat t he ev idenced num ber of anom alies ( failur es) r epr esent ed a low per cent age in r elat ion t o t he t ot al collect ed m at erial for m icrobiological exam s. Therefore, t his should not be considered a crit ical point t hat j ust ifies t he cont inuit y of t he t raining and, consequent ly, t he invest m ent .
DESCRI PTORS: cost s and cost analysis; educat ion; nursing; m icrobiology; laborat ory t echniques and procedures
PROGRAMA DE CAPACI TACI ÓN SOBRE EL MÉTODO DE COLECTA DE MATERI AL PARA
ANÁLI SI S MI CROBI OLÓGI CO EN UN HOSPI TAL-ESCUELA: I NVERSI ÓN Y EVALUACI ÓN DE
LOS RESULTADOS
Est e est udio t iene com o obj et ivo evaluar los result ados, los cost os direct os y la inversión en un program a d e cap acit ación p ar a la colect a d e m u est r as p ar a an álisis m icr ob iológ ico en u n h osp it al- escu ela. Fu er on consider adas com o m edida de r esult ados las colect as de análisis que no siguier on los cr it er ios est ablecidos ( anom alía) . Los sist em as de cost o v ar iable y por absor ción fuer on ut ilizados, r espect iv am ent e, par a calcular los cost os direct os y la inversión. De las 11,893 m uest ras recogidas, se m anifest aron anom alías en 59 ( 0,5% ) . El cost o direct o fue de US$ 84.67, y la inversión t ot al en el program a de US$ 1,335.87. Los result ados perm it ieron con clu ir qu e el n ú m er o de an om alías ev iden ciadas sign if icaba u n baj o por cen t aj e con r espect o al t ot al de m at erial recogido para análisis m icrobiológico y no const it uía un punt o crít ico que j ust ificase la cont inuación del capacit ación y la consecuent e inv er sión.
DESCRI PTORES: cost os y análisis de cost o; educación; enfer m er ía; m icr obiología; t écnicas y pr ocedim ient os de labor at or io
PROGRAMA DE TREI NAMENTO SOBRE MÉTODO DE COLETA DE MATERI AL PARA EXAME
MI CROBI OLÓGI CO EM UM HOSPI TAL DE ENSI NO: I NVESTI MENTO E AVALI AÇÃO DOS
RESULTADOS
Est e est udo t eve por obj et ivo avaliar os result ados, os cust os diret os e o invest im ent o de um program a d e t r ein am en t o sob r e colet a d e m at er iais p ar a ex am e m icr ob iológ ico em u m h osp it al d e en sin o. For am consider adas com o m edida de r esult ados as colet as de ex am es que não seguir am os cr it ér ios est abelecidos ( anom alia) . O sist em a de cust eio v ar iáv el e por absor ção for am ut ilizados, r espect iv am ent e, par a cálculo dos cust os dir et os e invest im ent o. Dos 11.893 m at er iais colhidos for am evidenciadas anom alias em 59 ( 0,5% ) . O cu st o dir et o f oi de R$ 1 5 4 , 1 0 , e o in v est im en t o n o t r ein am en t o, de R$ 2 . 4 3 1 , 2 9 . Os ach ados per m it ir am concluir que o núm er o de anom alias ev idenciadas r epr esent ou um baix o per cent ual em r elação ao t ot al de m at erial colhido para exam es m icrobiológicos, não se const it uindo em pont o crít ico que j ust ificasse a cont inuidade do t r einam ent o e conseqüent e inv est im ent o.
DESCRI TORES: cust os e análise de cust o; educação; enferm agem ; m icrobiologia; t écnicas e procedim ent os de lab or at ór io
Disponível em língua port uguesa na SciELO Brasil w w w .scielo.br/ rlae
I NTRODUCTI ON
T
he cost of qualit y has been defined as any ser v ice ex pense ex ceeding planned lev els, pr ov ided t hat t he act ivit y has been car r ied out cor r ect ly since t h e b eg in n in g( 1 ). I t can b e classif ied as v olu n t ar y ( p r ev en t ion an d assessm en t cost ) an d in v olu n t ar y co st , r esu l t i n g f r o m i n t er n al an d ex t er n al er r o r s. I nt ernal errors occur before t he service is t ransferred t o t he client and are associat ed wit h rework expenses, av oidable losses in t he pr ocess and ot her s( 2).I n t his st udy, w e aim ed t o ident ify int er nal failur es in t he m icr obiological t est m at er ial collect ion m et hod aft er t he im plem ent at ion of a t raining program by t he Cont inuing Educat ion Cent er ( CEC) of a healt h care inst it ut ion. These failures were called anom alies, accor ding t o t ot al qualit y pr ogram t er m inology. The t er m an o m al y can b e d ef i n ed as d ev i at i o n s f r o m norm al and expect ed condit ions for t he funct ioning of a st andar dized pr ocess( 3 ).
I n h o s p i t a l o r g a n i z a t i o n s , m a i n t a i n i n g p e r m a n e n t t r a i n i n g p r o g r a m s i s i m p o r t a n t , a s preparing hum an resources is t he best way t o im prove car e qu alit y an d con t r ol or r edu ce h ospit al cost s( 4 ). Holding t r aining pr ogr am s t hat achiev e a m ax im um r esu lt lev el at m in im u m ex p en ses st ar t ed t o b e a ch a l l en g e f o r CEC( 5 ) n u r ses. I n o t h er w o r d s, a n y inv est m ent s m ade ar e ex pect ed t o gener at e r et ur n. Th u s , i t b e c o m e s e s s e n t i a l t o a s s e s s or ganizat ional pr ocesses and pr ogr am s( 6 ). Ther e ar e f o u r a s s e s s m e n t s t a g e s : p a r t i c i p a n t s ’ r e a c t i o n , learning, behavior and organizat ional result s( 7). A fift h l e v e l - Re t u r n o n I n v e st m e n t ( ROI ) ca n a l so b e a d d ed( 8 ). W h i l e so m e r e se a r ch e r s( 7 ) o n l y i d e n t i f y program benefit s, ot hers( 8) convert t hese benefit s int o m o n e t a r y v a l u e s a n d c o m p a r e t h e m w i t h t h e pr ogr am ’s t ot al cost .
I n i n t e r n a t i o n a l l i t e r a t u r e , e c o n o m i c assessm en t of n u r sin g t r ain in g pr ogr am s h as been em p h asized t h r ou g h cost - b en ef it an d cost - ef f icacy an aly ses. A st u dy on v en ipu n ct u r e t r ain in g( 9 ) in t h e Unit ed Kingdom ident ified t he cost of r esour ces and t h eir im p act on t h e n u r ses’ d aily r ou t in e. An ot h er st udy at an Am erican inst it ut ion com pared t wo t raining cost assessm en t m et h od s( 1 0 ). Yet an ot h er r esear ch developed a proport ion form ula t o calculat e t he cost -efficacy of st aff t raining program s. This form ula t akes in t o accou n t cost / p ar t icip an t / h ou r, cost of lear n in g a cq u i si t i o n , co st o f l e a r n i n g a p p l i ca t i o n , co st o f r einfor cem ent and addit ional cost s( 5).
I n c o n t i n u i n g n u r s i n g e d u c a t i o n , n u r s e m anager s ar e pr ogr essiv ely leav ing behind concer ns a b o u t t h e q u a n t i t a t i v e a sp ect o f t r a i n i n g a n d i t s im m ed iat e im p act . I n st ead , t h ey b ecom e aw ar e of t he need t o act ually m easur e t he r esult s and assess t he cost s of t hese pr ogr am s.
When nur ses ar e called upon t o par t icipat e in a cost r educt ion policy, t heir acquir ed k now ledge can act ively cont ribut e t o a m ore effect ive cont rol of resources at t heir work unit , inst ead of m erely serving as a deposit or y of adm inist r at iv e infor m at ion. Thus, t hey can pr opose m easur es t o av oid r esour ce w ast e and rework by t he nursing t eam( 11).
OBJECTI VES
- I dent ify t he incidence of anom alies in m icrobiological t est m at erial collect ion at a t eaching hospit al; - Exam ine t he direct cost s of laborat ory m at erial and labor in t he inadequat e collect ion of t his m at erial; - Assess t ot al invest m ent s in t he t r aining pr ogr am .
MATERI AL AND METHOD
D u r i n g 1 9 9 9 , t h e Co n t i n u i n g Ed u c a t i o n Cent er ( CEC) of a large t eaching hospit al in São José d o Ri o Pr et o o r g an i zed a t r ai n i n g p r o g r am ab o u t m icr obiological t est m at er ial collect ion, aim ed at all nur sing t eam m em ber s.
To dev elop t h is descr ipt iv e an d ex plor at or y st u d y, w e con sid er ed m icr ob iolog ical t est m at er ial collect ion t ech n iq u es t h at d id n ot com p ly w it h t h e e st a b l i sh e d cr i t e r i a a n d o r i e n t a t i o n s b y t h e CEC t r aining pr ogr am ( anom aly ) .
D a t a w e r e c o l l e c t e d t h r o u g h a n o m a l y not ificat ions t he m icr obiology labor at or y sent t o t he CEC b e t w e e n Ju n e a n d D e c e m b e r 1 9 9 9 , a f t e r o b t a i n i n g a u t h o r i za t i o n f r o m t h e Resea r ch Et h i cs Com m it t ee at t he place of st udy.
The invest igat ed anom alies were cat het er t ip, spu t u m , su r gical w ou n d secr et ion , feces, u r in e an d blood cult ures. A list of m at erial t o be used for each procedure w as obt ained from t he CEC, as w ell as all collect ed m at er ial fr om t he Micr obiology Cost Cent er. The hospit al pur chase sect or pr ov ided t he unit cost for each m at er ial.
all v ar iable ( dir ect and indir ect ) cost s. I ndir ect fix ed cost is t reat ed as an expense direct ly in t he result( 12). Th is sy st em is r ecom m en d ed f or t h e m an ag em en t area because it ident ifies act ually consum ed resources in service product ion, which is very useful for decision m ak in g .
Labor cost was verified in view of t he act ivit ies per for m ed by t he nur sing aux iliar y w ho collect s t he m at erial, and t he operat ional auxiliary responsible for t ransport ing m at erial from t he laborat ory t o t he unit . Ca l cu l a t i o n s co n si d er ed t h e b a se sa l a r y f o r ea ch cat egory as well as t he m ean t im e needed for collect ion and t r anspor t act ivit ies, est im at ed at 15 m inut es.
I n v est m en t s in t h e t r ain in g p r og r am w er e calcu lat ed t h r ou g h t h e ab sor p t ion cost in g m et h od , char act er ized by t he appr opr iat ion of all pr oduct ion, fix ed, v ar iable, dir ect an d in dir ect cost s, w h ich ar e
eq u ally d ist r ib u t ed am on g ser v ices, w h ile in d ir ect cost s w er e allocat ed( 13). To assess t ot al inv est m ent s in t he t r aining pr ogr am , w e used t he sum of dir ect ( t ot al t raining cost ) and indirect invest m ent s ( hum an resource t im e m ade available for learning at t he CEC t im es each cat egor y ’s salar y per w or k hour )( 14). The r e a l ( R$ ) a n d t h e a v e r a g e d o l l a r r a t e f o r 1 9 9 9 ( R$1.82) w er e used in all calculat ions.
RESULTS AND DI SCUSSI ON
We w i l l p r e s e n t a n d d i s c u s s t h e r e s u l t s accor ding t o t he pr oposed st udy obj ect iv es, t hat is, incidence of anom alies, places of occur r ence, dir ect cost of sam p les f or lab or at or y t est collect ion an d inv est m ent s in t he t r aining pr ogr am .
Table 1 - Percent age dist ribut ion of m at erial t ype collect ed for m icrobiological t est ing by nursing auxiliaries and incidence of anom alies bet w een June and Decem ber 1999. São José do Rio Pr et o, 1999
M AT = Mat erial; C = Collect ed; A = Anom aly; CT = Cat het er Tip; SPU = Sput um ; FEC = feces; URI = Urine; SW S = Surgical Wound Secret ion; BC = Blood cult ure.
Data in Table 1 show that 11,893 m aterials were collect ed an d n ot if ied t o t h e CEC. An om alies w er e ident ified in 59 of t hese ( 0. 5% ) . This figur e r ev eals technical quality in the collection of this m aterial and m ay represent the im pact of the training program on trained pr ofessionals’ per for m ance, as no ear lier assessm ent was available to com pare the obtained results.
Catheter tip collections were responsible for 28 (47.5% ) anom alies, which m ainly occurred in June, when eight ( 7.4% ) cases were found. The highest anom aly incidence level was found in Septem ber, with 11 (10.9% ) cases, in com parison with the other m onths under study.
The following were charact erized as anom alies in m icr obiological t est m at er ial collect ion : Cat h et er t ip larger t han 5 cm and/ or im m ersed in physiological solut ion; sput um in non- recom m ended recipient and/ o r n o t c o l l e c t e d f r o m f i r s t s a m p l e a n d / o r s e a l violat ion; use of inadequat e recipient for feces cult ure collect ion; urine in non- st erilized cont ainer; insufficient qu an t it y an d/ or in adequ at e con dit ion in g of su r gical w ound secr et ion collect ion.
I n c o r r e c t m a t e r i a l c o l l e c t i o n e n t a i l s i m p l i ca t i o n s f o r cl i e n t s ( d i sco m f o r t , r i sk , l o n g e r h o sp i t a l i za t i o n p e r i o d , i n a d e q u a t e d i a g n o si s a n d
h t n o
M MAT CT SPU BL FEC URI SWS Total
n u
J C 108 322 34 49 1254 160 1927
A 8 1 1 0 0 0 10
A
% 7.4 0.3 2.9 0 0 0 10.6
l u
J C 113 430 60 42 1332 42 2112
A 4 4 2 0 0 0 10
A
% 3.5 0.9 3.3 0 0 0 7.7
g u
A C 53 423 40 38 1181 38 1930
A 2 5 0 0 1 0 8
A
% 3.8 1.2 0 0 0.1 0 5.1
t p e
S C 74 269 47 33 1054 33 1574
A 7 4 0 0 0 0 11
A
% 9.4 1.5 0 0 0 0 10.9
t c
O C 68 220 54 38 996 38 1502
A 3 4 2 0 0 0 9
A
% 4.4 1.8 3.7 0 0 0 9.9
v o
N C 51 242 4 46 1036 46 1511
A 2 3 0 2 0 2 9
A
% 3.9 1.2 0 4.3 0 4.3 13.7
c e
D C 48 131 10 43 997 43 1337
A 2 0 0 0 0 0 2
A
% 4.2 0 0 0 0 0 4.2
l a t o
T 515 2037 249 289 7850 289 11893
A 28 21 5 2 1 2 59
A
t r ea t m en t ) ; f o r t h e n u r si n g t ea m a n d l a b o r a t o r y ( l o n g e r t i m e , r e w o r k ) a n d f o r t h e i n s t i t u t i o n ( u n n e ce ssa r y u se o f m a t e r i a l a n d h i g h e r co st s) . Th er ef or e, t h e iden t if icat ion an d im plem en t at ion of act ions t o correct anom alies should be a const ant and s y s t e m i z e d p r o c e s s( 3 ) i n n u r s e s ’ c l i n i c a l a n d m anagem ent pr act ice, as w ell as in t he coor dinat ion of int egr at ed m ult idisciplinar y t eam act ions.
I n com binat ion wit h t raining, t he definit ion of m ethods and processes together with the work team have been indicat ed as det er m inant fact or s t o r educe t he num ber of hum an er r or s ( anom alies)( 14). Ot her v er y important measures are the uniform realization of technical procedures and m aking involved professionals aware of h ow u n desir able ef f ect s ( an om alies) can n egat iv ely interfere in the achievem ent of reliable results(15).
s ê
M Jun Jul Aug Sept Oct Nov Dec Total
N % s t i n u e r a c l a c i t i r c -n o N
A 1CT 1CT
U P S
1 2SPU 1SPU
U P S 1 C E F
2 1CT 10 16.9
B 1CT 1 1.7
C 1CT 1 1.7
D 1CT 1CT 2 3.4
E 1SPU 1URI 1CT 3 5.0
F 2SPU 2SPU 4 6.8
G 3CT 2SWS 5 8.5
H 1BC 1 1.7
l a t o t -b u
S 3 4 5 6 1 7 1 27 45,7
s t i n u e r a c l a c i t i r C
A 1CT
C B
1 1CT 1CT 4 6.8
B 1CT 1CT 2CT 4 6.8
C 1CT 1CT 2 3.4
D 1CT 1CT 1CT 2CT 5 8.5
E 1CT 1 1.7
F 1SPU 2SPU 1CT 3CT
U P S
1 8 13.6
G 2BC 1BC 3 5.0
H 1SPU 1SPU
T C
1 2SPU 5 8.5
l a t o t -b u
S 7 6 3 5 8 2 1 32 54,3
l a t o
T 10 10 8 11 9 9 2 59 100
Table 2 - Percent age dist ribut ion of anom alies and hospit al wards ( non- crit ical and crit ical care unit s) bet w een June and Decem ber 1999. São José do Rio Pret o, 1999
CT = Cat het er Tip; SPU = Sput um ; BC = Blood cult ure; SW S = Surgical Wound Secret ion; FEC = feces.
According t o Table 2, during t he st udy period, t h e gr eat er par t of t h e an om alies occu r r ed in n on -crit ical care unit s A ( n = 10) and G ( n= 5) , and in t he cr it ical car e u n it s F ( n = 8 ) , D an d H ( n = 5 ) . Non -crit ical care unit s ( general and specialt y m edical and s u r g i c a l u n i t s ) w e r e r e s p o n s i b l e f o r 4 5 . 7 % o f
an om alies, w h ile cr it ical car e u n it s ( in t en siv e car e u n i t s - I CUs , o p e r a t i o n r o o m , e m e r g e n c y w a r d ) cor r esp on d ed t o 5 4 . 3 % . Usin g a st at ist ical t est t o com par e per cen t ages, w e f ou n d v ar iat ion s f r om 4 1 t o 67% ( p- value = 0.6) . I n ot her words, t hese findings w er e not st at ist ically significant .
Table 3 - Dist ribut ion of direct m at erial and labor cost s used for m icrobiological t est m at erial collect ion ( currency US$) pr esent ing anom alies, bet w een June and Decem ber 1999. São José do Rio Pr et o, 1999
h t n o
M Labor
y r a i l i x u a l a n o i t a r e p O r o b a L y r a i l i x u a g n i s r u
N Material
l a t o T N % n u
J 3.84 6.59 5.05 15.48 (18.3
l u
J 3.84 6.59 2.96 13.39 (15.8
g u
A 3.84 6.59 2.41 12.84 (15.2
t p e
S 4.23 7.25 4.12 15.60 (18.4
t c
O 3.46 5.93 3.35 12.74 (15.1
v o
N 3.07 5.27 1.81 10.15 12
c e
D 1.15 1.97 1.26 4.38 5.2
l a t o
T 23.43 40.19 20.96 84.58
Table 3 sh ow s t h at , in t h e t ot al am ou n t of dir ect cost s of m icr obiological t est s w it h an om alies during t he st udy period ( $ 84.58) , labor was t he highest cost , m ainly nur sing aux iliar ies, w hich r epr esent ed $ 4 0 . 1 9 ( 4 7 . 5 % ) . Mat er ial w er e r esp on sib le f or t h e sm allest part of t ot al cost s, i.e. $ 20.96 ( 24.8% ) . The highest oper at ional cost s for m at er ial collect ion w er e found in Sept em ber $ 15.60 ( 18.4% ) and June $ 15.48
( 1 8 . 3 % ) . Th e l ow est op er at i on al cost occu r r ed i n Decem ber $ 4.38 ( 5.2% ) .
A st u d y t o a sse ss h y g i e n e a n d n u t r i t i o n ed u cat i o n ap p l i ed t o k i n d er g ar t en em p l o y ees an d par ent s r ev ealed a differ ent m at er ial and labor cost dist r ibu t ion . I n t h at r esear ch , m at er ial r epr esen t ed 8 7 . 5 % of t ot al cost s, again st on ly 1 2 . 5 % f or labor cost( 16).
h t n o
M Jun Jul Aug Sept Oct Nov Dec Total
N %
t n e m t s e v n I t c e r i
D 107.69 52.17 124.38 52.56 103.04 51.70 26.57 518.11 38.8
t n e m t s e v n I t c e r i d n
I 265.36 85.41 195.60 85.41 110.19 61.26 14.48 817.71 61.2
l a t o
T 373.05 137.58 319.98 137,97 213.23 112.96 41.05 1,335.82 100
Table 4 - Dist r ibut ion of dir ect , indir ect and t ot al inv est m ent s in t raining about m icr obiological t est m at er ial collect ion ( cur r ency US$) bet w een June and Decem ber 1999. São José do Rio Pr et o, 1999
Th e t r a i n i n g p r o g r a m a t t e n d e d 1 7 1 p ar t icip an t s ( m on t h ly av er ag e of 2 4 p er t r ain in g ) . I n it ially, t h e CEC aim ed t o t r ain t h e en t ir e n u r sin g t eam dur ing t he y ear, w it h a m ont hly av erage of 72 part icipant s. Table 4 shows t hat , in t ot al ( sum of direct and indirect invest m ent s) , $1,335.92 was invest ed in t raining about m icrobiological t est m at erial collect ion. Dir ect inv est m ent ( t ot al t r aining cost ) cor r esponded t o $ 518.11, against $ 817.71 for indirect invest m ent s ( hum an resource t im e m ade available for learning at t he CEC t im es each cat egory’s salary per work hour) . Average per capit a cost w as $ 8.79.
A st udy of t hr ee t r aining cases ( cannulat ion p r a c t i c e , v e n i p u n c t u r e a n d i n t r a v e n o u s d r u g adm inist r at ion) in t he Unit ed Kingdom( 9) found a per cap it a cost of £ 9 1 5 . A com p ar at iv e st u d y of t w o t raining m et hods in t he Unit ed St at es( 10) ident ified per cap it a cost s of US$ 7 . 3 3 ( u n it - b ased m et h od ) an d US$ 5 . 6 4 ( al l - d ay m et h o d ) . Hy g i en e an d n u t r i t i o n educat ion of par ent s and k inder gar t en em ploy ees in Br a zi l sh o w e d a n a v e r a g e co st o f R$ 2 4 . 5 4 p e r em ploy ee( 16). How ever, a st udy of t raining pr ogram s at a Brazilian hospit al inst it ut ion( 17- 18) found a per capit a invest m ent of US$ 27.41, t hat is, 9.2 t im es lower t han t he global r efer ence value of US$ 252.
Or gan izat ion s com m on ly f ace dif f icu lt ies t o ident ify t raining needs ( what should be t rained, t arget public and reason for invest m ent ) , as well as t o define t r aining obj ect iv es. Specialized lit er at ur e also r epor t t hat m any t raining program s’ lack of success is m ainly due t o t he lack of adequat e needs assessm ent( 19).
Consider ing t hat t r aining needs assessm ent s u p p o r t s p l a n n i n g , t h e CEC n u r s e m a n a g e r i s
responsible for an obj ect ive diagnosis, based on dat a collect ion and not only on nurses’ st at em ent s. I n t his st udy, t he lack of a survey before t he im plem ent at ion of t he t raining program , t o be com pared wit h post erior d at a, cr eat ed d ou b t s ab ou t t h e p er t in en ce of t h is t r ain in g.
Since anom alies were m ore frequent at non-crit ical care unit s A and G and at non-crit ical care unit s F and G, t he CEC m anager’s decisions should focus on t he nursing t eam in t hese unit s, as well as on cat het er t ip collect ion an d sp u t u m cu lt u r e, w h ich w er e t h e pr edom in an t an om alies.
A low num ber of anom alies was found ( n= 59 - 0 . 5 % ) i n co m p a r i so n w i t h t h e t o t a l n u m b er o f m at er ials collect ed f or m icr ob iolog ical t est in g ( n = 11,893) . Hence, t his is not a crit ical point t hat would j u st if y t h e con t in u it y of t rain in g an d, con sequ en t ly, in v est m en t .
An analy sis of public healt h ser v ice net w or k t raining( 20) showed t hat t raining has been im plem ent ed in a cent r alized for m at t hese ser v ices, w it hout any con n ect ion w it h a st r at eg ic st af f d ev elop m en t an d t r ain in g plan at t h ese in st it u t ion s. Th e sam e st u dy highlight s t he non- observat ion of part icipant inclusion cr it er ia, w hich const it ut es a w ast e of r esour ces and m a k es i t d i f f i cu l t f o r p a r t i ci p a n t s t o t r a n sf er t h e pr oduced k now ledge t o t heir act iv it ies.
CONCLUSI ONS AND RECOMMENDATI ONS
cr eat e cost s ( r epair, t im e, m at er ial, et c.) and do not add value, represent ing losses t o t he inst it ut ion. The underst anding of cost s as a m anagem ent t ool for CEC n u r ses pr ov ides in f or m at ion f or oper at ion al act iv it y p l an n i n g , b en ef i t s r eso u r ce al l o cat i o n an d g u i d es r elev an t in v est m en t s.
Con sider in g t h at h ealt h in st it u t ion s u su ally d o n o t h a v e a f o r m a l i z e d i n v e st m e n t p o l i cy, w e
r ecom m en d t h at CEC n u r ses: alig n p r og r am s w it h t he inst it ut ion’s st r at egic needs; est ablish par t icipant i n c l u s i o n c r i t e r i a b a s e d o n t r a i n i n g n e e d s assessm en t ; d esi g n co n t en t s w i t h p r o b l em - b ased t e c h n i q u e s ; m e a s u r e t h e o b t a i n e d r e s u l t s , e s t a b l i s h i n g t a r g e t l e v e l s f o r i m p r o v e m e n t s i n a n o m a l y r a t e s ; a n d a d d c o s t s t u d i e s t o t h e assessm en t of t h eir pr ogr am s.
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