Development and content validation of the Nursing Result "Customer satisfaction: delivery process"

Fernanda de Souza Freitas Abbud1, Luiza Hassad Pedrosa Rafful1, Suellen Cristina Dias Emidio2, Antonieta Keiko Kakuda Shimo1, Elenice Valentim Carmona1

1 State University of Campinas, SP, Brazil

2 Federal University of Tocantins, Palmas, TO, Brazil

ABSTRACT

Objective: To develop and validate the content of the Nursing Result (RE) "Customer Satisfaction: The Delivery Process". Method: Methodological study of RE content validation by nine specialists, using the Content Validity Index (CVI) in 33 puerperal women.   Results: The final version of the RE was composed of 25 indicators. The CVI was greater than or equal to 0.8 for all criteria evaluated for most indicators after the second evaluation of the specialists.  Discussion:  The RE "Customer Satisfaction: Delivery Process" was defined as "an extension of the positive perception of women regarding the care provided by the health team during the delivery process". Conclusion:  It is considered that the use of RE nursing outcomes classification although recent in our care practice, represents a possibility to evaluate care related to the delivery process.

Keywords: Childbirth. Patient satisfaction. Classification. Nursing process. Obstetric Nursing.

INTRODUCTION

The assessment of user satisfaction of health institutions is one of the most important measures to improve the indicators of care excellence(1). User satisfaction can be defined as the alignment between the experiences lived and the expectations of the individual during the use of health services. This assessment is subjective and is based on cognitive, emotional, social aspects, as well as on previous experiences. Measuring the perceptions and experiences of users regarding the satisfaction of the care provided is still a challenge, because there is no consensus in the evaluation proposals(2).

As for obstetric care, several nuances have modified the user satisfaction. The promotion of vaginal delivery without interventions, and the decrease in the number of cesarean sections, new clinical protocols based on scientific evidence and the conception that obstetric violence can interfere in the measurement of women's satisfaction, especially during labor(3).

Brazilian studies with a quantitative approach on women's satisfaction related to the parturition process are scarce. Most of these studies portrayed the reality of a given institution and did not use validated instruments for data collection, however, it made it possible to identify that the presence of the companion, agility in implementing technical procedures that minimize discomfort, related to pain, respect for decisions and participation in the decision-making process were related to the greater satisfaction of women with the delivery process(4).

Evaluating satisfaction in the parturition process is a challenge for health professionals, since the concept of satisfaction is multidimensional and, in relation to labor and delivery, it is closely associated with personal control and expectations(4).

Thus, a path to be followed in the nursing scope is envisaged, capable of filling this gap, using the Nursing Outcome Classification (NOC)(5) to evaluate the satisfaction of women in this context, because the said nursing classification presents several Nursing Results (NR) aimed at customer satisfaction. This classification enables a standardized professional language that can be used by nurses to evaluate the results of nursing interventions, but not only these professionals.

The description of the results evidences the participation of nurses as members of a multidisciplinary team, supporting the development of the nursing knowledge base, necessary for the advancement of practice(5). Therefore, the present study aimed to develop and validate the content of the nursing result "Customer Satisfaction: The Delivery Process".

METHOD

A methodological study with quantitative approach performed in two stages. The first of these, which occurred between March and June 2016, was the development of the NR "Customer Satisfaction: The Delivery Process", which consists of the title, its definition and indicators. Thus, an integrative review of the literature of the indicators of the NE studied and construction of the conceptual, operational and magnitude definitions was performed. These definitions are important to support the proposed NR, as well as to help experts evaluate its content.

The second stage, which occurred between March and June 2017, was the validation of the content by consensus of the indicators proposed for the NR studied, considering its conceptual, operational and previously constructed magnitude definitions. The consensus content validation method was used, which was measured by the Content Validation Index (CVI). According to this technique, a construct is obtained after the opinion of specialists in the chosen theme, which supports the qualification of the care process and deepens the knowledge about nursing taxonomies in clinical practice in different specialties. The proportion of agreement among the specialists was measured by the CVI.

The selection of specialists took place from the academic and professional curriculum obtained by the Lattes Platform, and nine specialists were selected. The specialists were defined by the presence of at least two of the following criteria: clinical experience in obstetric nursing for at least five years; specialization course in obstetric nursing; master's and/or doctorate related to obstetric nursing; master's and/or doctorate related to NOC; publication of studies on women's satisfaction with the delivery process; publication of studies on Nursing Classifications; publication of studies on Customer Satisfaction. There is no consensus in the literature on the amount of experts needed to perform content validation, however, it is recommended that it be an odd number of specialists and that, preferably, they are between 5 and 10 judges (6).

When the specialist agreed to participate in the research, after previous contact by e-mail, the Free and Informed Consent Form (TCLE) was sent, as well as the form containing the content proposed for the NR under study, requesting an evaluation of the title, definition, indicators, conceptual, operational and magnitude definitions and possible suggestions for each proposed indicator.

Specialists were asked to judge conceptual, operational and magnitude definitions, considering the criteria of simplicity, clarity and relevance(6). Thus, they assigned the following notes: -1 (criterion not met, i.e., definition/indicator not appropriate); 0 (indecision as to the adequacy of the criterion, i.e., definition/indicator in some appropriate way) or +1 (criterion met, i.e., appropriate definition/indicator). For grades 0 or -1, suggestions were asked for the experts.

Based on these values, the CVI was calculated, which indicated the extent to which the experts' opinions are congruent. This calculation was given by the sum of the +1 points assigned by the experts for each of the criteria related to conceptual, operational and magnitude definitions, and the result was divided by the maximum possible total points (equivalent to the number of specialists).

The desirable CVI was greater than or equal to 0.8(7) in this study. When the CVI was less than 0.8 for any criterion analyzed, the contents were reviewed and sent back to the specialists.  The experts recommended the relevance of this indicator for the indicators that presented CVI below 0.70.

After the validation of the NR content by the specialists, a test was performed by applying it to the puerperal women in September 2017. The NR test was performed in a rooming-in accommodation unit of a public teaching hospital that has 32 beds, a reference for high-risk pregnancies.

The sample foreseen for the result test was 30 puerperal women. Since there is no consensus in the literature about the ideal sample size for this test, we used the pre-test recommendations for the process of constructing instruments of measures in the health area(7).

The subjects of this study were: women who were hospitalized at this location, aged 18 years or older; hospitalization time equal to or greater than 24 hours; literate puerperal women, oriented in time and space. The sample predicted for the result test was 30 puerperal women(8).

The indicators were presented to women and for each of them they should say if they felt: "dissatisfied"; "unsatisfied", moderately satisfied", "very satisfied", "completely satisfied" or still "does not apply", when the woman did not experience the situation. Both the content of the indicators and the answer options were available for consultation throughout their application.

The women were personally invited to participate, an opportunity in which the researcher briefly presented the study and what it meant to participate in it. After accepting the invitation, the woman read and signed the ICF. After the RE test with the women, the researcher made an evaluation of the feasibility which consisted of investigating with them whether it was easy to understand the indicators and mark the answers. The data were saved in an Excel for Windows® spreadsheet and later analyzed with the help of statistical software Statistical Package for the Social Sciences (SPSS), version 20.0. Descriptive statistics were analyzed.

The study followed the recommendations of Resolution No. 466/2012 of the National Health Council and was approved by the Research Ethics Committee of the State University of Campinas, under Opinion No. 1,873,714, with CAAE: 59371816.7.0000.

RESULTS

After reviewing the 17 NRs proposed by NOC to assess customer satisfaction in different contexts, it was found that the one that would have content more related to the NR that was planned to be developed would be the "Customer Satisfaction", even though it is general and does not contemplate the specificities of the delivery process.  Although other NR's on customer satisfaction also present important indicators to assess satisfaction in the context of labor and delivery.

Thus, the developed NR  was named as "Customer Satisfaction: the delivery process" and was composed of a title, title definition and 27 indicators. For each indicator, conceptual, operational and magnitude definitions were developed. These contents were analyzed by nine experts, who evaluated the criteria of simplicity, clarity and relevance, as well as offering  suggestions to improve what was proposed by the researcher.

After the first round with the specialists, two indicators were excluded: "Questions answered completely" and "Information provided about the delivery process and expected changes".

Among the 25 indicators validated for the developed NR, 13 did not require adjustments after the test with the women, because they did not show to have doubts throughout their application. They are: "Protection of the legal right of the presence of a companion"; "Aid and/or stimulus for desired position changes during the delivery process"; "Assistance in choosing and accessing food and liquids for consumption"; "Assistance to maintain comfort; The team presents information in an understandable way"; "Cleaning of the care environment"; "Waiting time to have the needs met"; "Knowledge and skill demonstrated by the health team during the delivery process"; "Team communicates with the patient without demonstrating judgments"; "Consideration demonstrated by the team regarding the feelings and opinions of women"; "Safety regarding the identification of the patient on a bracelet and bed"; "Information and conduct to prevent falls throughout the delivery process"; "Proper use of vaginal examination". Chart 1  presents the content of the NR that was validated by the experts after the second round:

The NR test together with the puerperal women demonstrated the need for adjustments in 12 indicators, despite the fact their CVI of all the titles of the indicators were higher than 0.80 after the second round with the specialists. It was discussed with the authors and we opted for terms that could replace the ones misunderstood by women. These terms were inspired by the conceptual definitions themselves, which were used with women to facilitate understanding when only the title of the indicator was not sufficient.

After applying the studied NR, the instrument was used to evaluate the feasibility of this result, and 32 answered the instrument. Regarding the ease of understanding the instructions offered on the ER, the majority of women (20 = 63%) fully agreed that they were easily understood. Most of them also reported that they easily understood the indicators presented, which represented 66% (21) of the women; while 88% (28) fully agreed that it was easy to mark the answers regarding the indicator.

DISCUSSION

Studies on women's satisfaction with the delivery process, in line with the NR content proposed here, highlight the need to look more closely at this phenomenon, as well as to pay attention to the relevance of obstetric nurses being able to evaluate subjective issues, name nursing phenomena, propose interventions, as well as plan the results to be obtained and evaluate them, taking into account the client's needs.

The proposed title for the ER was “Client Satisfaction: delivery process” in order to maintain correspondence with the existing ERs in the NOC that use the word “client” (5) and contemplate the female aspect of this experience. The definition of the NR initially proposed was modified considering the health team and not just the nursing team, which also directed the indicators to become “an extension of the positive perception of women regarding the care provided by the health team during the childbirth process ”. Thus, "health team" was the term used to describe the professionals involved in care throughout the delivery process, since NOC itself (5) proposes that the results can be used by other professionals, considering that the care to clients in the health field, mostly, are offered by several professionals.

Regarding the indicator "Care for pain control", it was suggested to divide it into "Non-pharmacological care for pain control" and "Pharmacological care for pain control", since the performance of the health team differs in each type of care. In addition, the literature highlights these two ways of alleviating pain during the delivery process(9).

Considering the conceptual definition of the indicator "Information received on pain relief methods", it is emphasized that the sensory and emotional experience of pain is not always unpleasant. In this proposition, we used the definition of pain in labor proposed by NANDA-I(10), as well as the study that clinically validated the nursing diagnosis "labor pain". Thus, the conceptual definition was modified for "Information received from the health team regarding options to mitigate variable sensory and emotional experience of pain during the delivery process, covering a non-pharmacological method and/or pharmacological method".

The non-pharmacological methods "immersion bath" and "positioning" were not found in the integrative review, but were indicated by the specialists.  Such indications were accepted for the description of the operational definition related to non-pharmacological care, as they are pointed out by international guidelines recognized in Obstetrics(11) and are applied in care practice.

The specialists who participated in this study highlighted that the health team should not only allow the presence of the companion, but also stimulate it, since, despite the existence of a law that supports this care, there is still resistance in its execution(12), thus constituting the indicator "Protection of the legal right of the presence of a companion" a relevant factor to be evaluated.

In addition to dialogue, the empathy of the team, the decision-making together during labor, the parturient preferences were important points highlighted in the women's statements. This offered support for the proposition of the indicator "Personal preferences were considered throughout care".

The indicator "Aid and/or stimulus for desired changes in position during the delivery process" is based on the fact that women during the delivery process do not always need to be assisted to move, but they need freedom and stimulation so that movement is possible, whenever they want (2).

When investigating experiences related to the delivery environment, women state that remaining in the same place in labor, childbirth and immediate postpartum is a positive aspect of their experience. While others point out that the logistics of changing room or clinic during the expulsion period and needing to wait for the professional who will attend their delivery was a negative experience(14). To investigate the satisfaction of women, considering such statements and the suggestions of the specialists, the indicator "Continuity of care as the woman is transferred from one environment to another" was suggested.

The literature brings situations in which women request water, but were allowed only to wet their lips. Diverging from this approach, another study points out that the intake of clear fluids does not affect the duration of delivery and the cesarean section rate, and is associated with greater satisfaction with delivery(15). Another review study did not identify harm related to food and liquid restriction, concluding that women can eat during the delivery process, if this is their desire(16) and that this will probably happen in a small number of women. No study evaluated the opinion of women who were fasting. Thus, the indicator defined for this context after validation by the specialists was "Assistance in the choice and access to food and liquids for consumption".

It can be observed in the literature that women feel insecure and undecided when they do not receive information from health professionals(17). In addition, some of the interviewees reported that communication was more important than technological devices. Therefore, the following indicators were proposed: "Instructions to improve the participation of women in the delivery process", "The team presents information in an understandable way" and "The team communicates with the client without demonstrating judgments".

It is verified that when planning a delivery, the factor "time" was present in the decisions of the families. The suggested indicator was "Waiting time to have the needs met". The perception of women in relation to time is quite subjective. Thus, following the literature and the recommendations of the experts, a numerical time value specification was not proposed.

The literature indicates that women, when receiving information about their delivery process, can perceive the technical capacity of the team and thus feel safe during the process, becoming more satisfied even in the postpartum period. They also state that the hospital environment can ensure fast care, when an intervention is necessary, because they believe that professionals will know how to act in the face of any of their needs  (18). Thus, the proposition of the indicator "Knowledge and skill demonstrated by the health team during the delivery process" was considered relevant.

The hospital was described by the women as a safe place to give birth. This safety was attributed to available medical equipment, if necessary; as well as a qualified health team  to attend delivery, the indicator "Access to supplies and equipment" is suggested.

Sharing the same environment with other clients in labor was described by women as a factor that affected their privacy(14). Privacy can also be both disregarded and respected throughout the physical examination and the delivery service itself as a whole. The literature discusses the exposure of areas of the body associated with sexuality and intimacy, also highlighting the number of unknown people to women during the delivery process as factors that compromised their satisfaction(4). This gave rise to the proposition of the indicator "Promotion of privacy".

Client care goes beyond the use of hard technology. In order to care for people it is necessary to understand biological, physical and cultural needs. When the health team or a given professional disconsiders the context in which the woman in the process of delivery is inserted, the woman feels like a working machine and classifies care as dehumanized. Based on these considerations, the indicators "Integration of cultural beliefs into care", "Courtesy demonstrated by the team" and "Consideration demonstrated by the team regarding the feelings and opinions of women"(19) .

It is considered that by identifying the woman by her name, she feels treated as an individual. It is important for the safety of the woman that the team know her name and use it when talking to her. Using different names for the same person, such as nicknames and/or preferred names, can lead to errors. Considering the satisfaction of the woman, as well as the quality and safety of care are inseparable aspects, thus, the indicator "Use of the client's name throughout care" was proposed.

Also from this perspective, the indicators "Safety regarding identification on wristbands and printed materials" and "Safety regarding the prevention of falls" were proposed, based on the clinical experience of the researcher, even though they were not identified in the integrative review. But in view of the regulations of Resolution No. 36/2013 of the National Health Surveillance Agency, which highlights the importance of implementing programs related to patient safety.

The indicator "appropriate use of vaginal examination" was inspired by an already existing indicator "appropriate use of touch", since, among different examinations made to women, this is a specific examination during the delivery process, which can negatively interfere in the satisfaction of women if it is not well conducted (20).

The studies highlight some aspects related to interventions during the delivery process that may interfere with women's satisfaction, such as continuous monitoring of cardio fetal beat, epidural anesthesia, artificial rupture of membranes, vacuum extractor, forceps, episiotomy and use of synthetic oxytocin(11, 19).

The change in the interventional care model is still a challenge that requires efforts from managers and health staff. As, even in Brazilian institutions dedicated to the change of this model, harmful practices were found in the care provided: horizontal supine position and pressure on the bottom of the uterus; as well as useful interventions, but which are used inappropriately: amniotomy, oxytocin, analgesia, episiotomy(17). In view of these findings and reflections, the indicator "Interventions and maneuvers in the delivery process" was suggested.

Among the 25 indicators that were  validated by the experts, 12 indicators needed to be explained with the use of conceptual definitions in order to be understood by women. This may be related to the construction of the indicator, but also to the profile of the women participating in the study. The low level of schooling of some participants may have made it difficult to understand the developed indicators,  especially those that presented scientific language. Thus, it is important to apply it to women with different cultural levels to confirm this finding and direct the review of the statements.

One limitation of the study may have been that the NR was applied by the researcher who developed it. As the researcher had full mastery of the indicators presented to women, it may have facilitated understanding in some way. When it is a standardized nursing language, it is desirable that the NR be widely applied and studied in different contexts. This is in order to verify that other nurses also understand the RE "Customer satisfaction: delivery process", as well as women.

CONCLUSION

The RE "Customer satisfaction: The delivery process" composed 25 validated indicators, of which 12 were adjusted after the applicability and evaluation of the women participating in the study. Thus, it was possible to perform the content validation of this NR.

Some indicators proved difficult for women to understand, which denotes the need to rethink how these descriptors were written.

It is considered that the use of NOC, although recent in our care practice, represents a possibility to evaluate care related to the delivery process. On the other hand, the scarcity of studies in obstetric nursing related to standardized language in nursing was an obstacle faced to deepen the discussion. Thus, the present study may contribute to further research to be developed in the area, as well as to support clinical practice and teaching.

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All authors participated in the phases of this publication in one or more steps to follow: (a) substantial participation in the conception or preparation of the manuscript or the collection, analysis or interpretation of the data; (b) preparation of the work or conducting a critical review of the intellectual content; (c) approval of the version submitted.

Received: 10/20/2020

Revised: 01/11/2021

Approved: 02/11/2021