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06-01-2015
Elderly families of South of Brazil in the Health Strategy
Revista Brasileira de Enfermagem. 2015;68(3):406-413
Abstract
Elderly families of South of Brazil in the Health Strategy
Revista Brasileira de Enfermagem. 2015;68(3):406-413
DOI 10.1590/0034-7167.2015680305i
Views0See moreABSTRACT
Objective:
to characterize families and health status of the elderly in the Family Health Strategy and to verify the association of family composition with sociodemographic characteristics and health of the elderly.
Method:
population-based study with 215 families and 266 elderly, linked to the Family Health Strategy from a city of Rio Grande do Sul state.
Results:
there was predominance of nuclear family composition, considered as the main source of informal support, families of female elderly (62.6%) and cardiovascular complication. The nuclear structure was signifi cantly associated with female gender (PR = 0.77; p = 0.025) and smoking (PR = 1.35; p = 0.009).
Conclusion:
the results reinforce the need to maintain a network of formal and informal support to the elderly and their families to preserve the independence or to postpone the decline in functional capacity.
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06-01-2015
From real to ideal – the health (un)care of long-lived elders
Revista Brasileira de Enfermagem. 2015;68(3):398-405
Abstract
From real to ideal – the health (un)care of long-lived elders
Revista Brasileira de Enfermagem. 2015;68(3):398-405
DOI 10.1590/0034-7167.2015680304i
Views0See moreABSTRACT
Objective:
to analyze similarities and dissimilarities in the meanings assigned to health care by long-lived elders and nursing professionals in a healthcare setting.
Method:
ethnographic qualitative research, based on the Spradley-McCurdy method and the interpretive anthropology of Geertz and Kleinman. The sample consisted of 20 key informants. Data were collected through participatory observation and ethnographic interviews from March to October 2013 and analyzed in domains, taxonomies and cultural themes.
Results:
Six domains and cultural taxonomies emerged and revealed reasons, attributes, and resources in providing care in relationship to long-lived elders and nursing professionals; fi nally, the following cultural theme emerged: the real to the ideal – the health (un)care of long-lived elders.
Conclusion:
The study showed the distance between the desired and actual health care provided to aged people in the scenario studied.
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06-01-2015
Rescuing the pleasure of playing of child with cancer in a hospital setting
Revista Brasileira de Enfermagem. 2015;68(3):391-397
Abstract
Rescuing the pleasure of playing of child with cancer in a hospital setting
Revista Brasileira de Enfermagem. 2015;68(3):391-397
DOI 10.1590/0034-7167.2015680303i
Views0See moreABSTRACT
Objective:
to dimension spaces and people that act on playing of children with cancer in outpatient treatment.
Method:
qualitative research developed with the creative sensitive method. A total of twenty two family members of seven children with cancer in outpatient treatment at a public hospital in Rio de Janeiro participated of this research. Data were generated in the family members’ homes, from September 2011 to May 2012.
Results:
after the diagnosis of childhood cancer, there was a change of scene and in the people who interact and play with children. Hospital has a central place for it, since children discover the pleasure of playing in this setting.
Conclusion:
the health care professional, especially nurses, who work on hospital care needs, should develop the ability of facilitate playing and therefore, enable care that promotes childhood development.
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06-01-2015
Child Health Surveillance: nurses perspective
Revista Brasileira de Enfermagem. 2015;68(3):384-390
Abstract
Child Health Surveillance: nurses perspective
Revista Brasileira de Enfermagem. 2015;68(3):384-390
DOI 10.1590/0034-7167.2015680302i
Views0See moreABSTRACT
Objective:
to analyze conceptions of nurses on child health surveillance in family health units.
Method:
a qualitative study with thematic analysis of the data, based on the paradigm of Health Surveillance. Interviews were conducted with 13 nurses in a countryside city in the state of Sao Paulo.
Results:
nurses conceived child health surveillance as an active monitoring, which should be comprehensive, identifying risks/vulnerabilities, through multidisciplinary and intersectoral actions that are dependent on maternal involvement. We found partial development of these assumptions in practice, due to diffi culties such as lack of maternal involvement in the proposed actions, lack of time for discussion and adoption of measures in the units and disarticulation between levels and sectors of the city.
Conclusion:
a greater political and technical investment is needed to ensure the adoption of this model in different sectors and levels of care of the city.
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06-01-2015
As diversas faces da Integridade em Pesquisa: por uma Enfermagem íntegra!
Revista Brasileira de Enfermagem. 2015;68(3):375-377
Abstract
As diversas faces da Integridade em Pesquisa: por uma Enfermagem íntegra!
Revista Brasileira de Enfermagem. 2015;68(3):375-377
DOI 10.1590/0034-7167.2015680301i
Views0Recentemente, tivemos oportunidade de participar da 4ª Conferência Mundial de Integridade em Pesquisa, no Rio de Janeiro. Para nós, pesquisadores, docentes, autores, pareceristas e editores científicos de periódicos de Enfermagem foi um evento divisor de águas: de ora em diante precisamos apertar o passo para alcançar as áreas que já têm as questões de Integridade […]See more -
06-01-2015
The many sides of Research Integrity: For Integrity in Nursing!
Revista Brasileira de Enfermagem. 2015;68(3):375-377
Abstract
The many sides of Research Integrity: For Integrity in Nursing!
Revista Brasileira de Enfermagem. 2015;68(3):375-377
DOI 10.1590/0034-7167.2015680301i
Views1We recently had the opportunity to participate in the 4th World Conference on Research Integrity in Rio de Janeiro. For us researchers, professors, authors, reviewers and scientific editors of nursing periodicals, the event was a watershed: From this point forward, we must step up our game and catch up with other areas that already discuss […]See more -
01-01-2015
Professional Master’s Degree: potential contribution to Advanced Practice Nursing
Revista Brasileira de Enfermagem. 2015;68(6):1186-1189
Abstract
Professional Master’s Degree: potential contribution to Advanced Practice Nursing
Revista Brasileira de Enfermagem. 2015;68(6):1186-1189
DOI 10.1590/0034-7167.2015680626i
Views0See moreABSTRACT
A reflection articleabout the contribution of Master’s Degree Programs in Advanced Practice Nursing and the Universal Health Coverage and the Universal Health Access, topicsthat have been discussed by the Pan American Health Organization, and which the Brazilian Nursingrequires not just appropriate, but further studyto reflect in order to define directions for our profession.
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01-01-2015
Concept of family insufficiency in the aged: critical literature analysis
Revista Brasileira de Enfermagem. 2015;68(6):1176-1185
Abstract
Concept of family insufficiency in the aged: critical literature analysis
Revista Brasileira de Enfermagem. 2015;68(6):1176-1185
DOI 10.1590/0034-7167.2015680625i
Views0See moreABSTRACT
Objective:
to identify the attributes of the “family insufficiency” concept of the aged in the literature.
Method:
critical literature analysis.
Results:
family insufficiency is characterized as a complex process of psychosocial interaction, founded mainly on low social support of the aged and impaired family ties. Its antecedents are found in contemporary transformations within the family system, intergenerational conflicts, impaired family relationships and social vulnerability of the family. The consequences of family insufficiency include social vulnerability of the aged, decline of psychological and functional health, lower quality of life and unsuccessful aging. An original theoretical proposal was elaborated for the concept of family insufficiency in the elderly, with the identification of its attributes, antecedents and consequences.
Conclusion:
the findings of this study constitute a theoretical advancement in the Family Insufficiency Syndrome in elderly people and provide data for future field research in developing the concept.
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ORIGINAL ARTICLE12-04-2023
Burnout, ethical climate and work organization in covid-19 intensive care units: mixed method study
Revista Brasileira de Enfermagem. 2023;76:e20220684
Abstract
ORIGINAL ARTICLEBurnout, ethical climate and work organization in covid-19 intensive care units: mixed method study
Revista Brasileira de Enfermagem. 2023;76:e20220684
DOI 10.1590/0034-7167-2022-0684
Views0See moreABSTRACT
Objectives:
to analyze the association between burnout and the perception of the ethical climate in nursing professionals in the covid-19 Intensive Care Unit and the relationship with the organization of work from the perspective of managers of these units.
Methods:
mixed method study conducted in three university hospitals in southern Brazil from December 2021 to March 2022. A cross-sectional study was developed with 110 nursing professionals, followed by an exploratory-descriptive study through semi-structured interviews with six managers. Descriptive and analytical statistics and discursive textual analysis were used.
Results:
the prevalence of burnout was 10% and the perception of negative ethical climate was 24.5%. The association between burnout and ethical climate revealed overload and fatigue during working hours, related to tension, fear, and stress that emerged from the consequences of the organization and relations of work in the covid-19 Intensive Care Unit.
Conclusions:
there was an association between burnout and ethical climate and elements of the work organization.
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ERRATUM02-26-2024
ERRATUM
Revista Brasileira de Enfermagem. 2024;77(1):e20160061
Abstract
ERRATUMERRATUM
Revista Brasileira de Enfermagem. 2024;77(1):e20160061
DOI 10.1590/0034-7167.20247701e03
Views2In the article “Nurses in the labor market: professional insertion, competencies and skills”, with DOI number: , published in Revista Brasileira de Enfermagem, 2017;70(6):1220-6, on page 1225:Include before REFERENCES:[…]See more -
ERRATUM06-14-2024
ERRATUM
Revista Brasileira de Enfermagem. 2024;77(2):e2024n2e06
Abstract
ERRATUMERRATUM
Revista Brasileira de Enfermagem. 2024;77(2):e2024n2e06
DOI 10.1590/0034-7167.20247702e06
Views2In the article “Is there scientific relevance to the plot of films and documentaries about eating disorders?”, with DOI number: , published in Revista Brasileira de Enfermagem, 2024;77(1):e20220547, page 7:Where it read:[…]See more -
ORIGINAL ARTICLE07-29-2024
Educational technology for multidisciplinary training for managing waiting lists for elective patients
Revista Brasileira de Enfermagem. 2024;77(3):e20230299
Abstract
ORIGINAL ARTICLEEducational technology for multidisciplinary training for managing waiting lists for elective patients
Revista Brasileira de Enfermagem. 2024;77(3):e20230299
DOI 10.1590/0034-7167-2023-0299
Views1See moreABSTRACT
Objectives:
to construct and assess an educational technology for managing patient waiting lists for multidisciplinary training.
Methods:
study supported by Instructional Design – ADDIE model, whose stages of construction of educational technology were developed in the form of a multi-professional training course. Its respective content assessment was carried out by a committee of experts from 2021 to 2022. The analysis occurred based on the proportion of content adequacy with 95% Confidence Interval.
Results:
seventeen products were created as educational technology learning objects: five storyboards; four videos; three comic books; two pedagogical action plans; a mind map; and a YouTube® playlist. Nine experts assessed content adequacy, which reached 0.89.
Conclusions:
this educational technology contributes to the performance of professionals who manage waiting lists by reducing inequalities, alleviating differences, in addition to promoting equity in care and good health for patients in the Brazilian Health System.
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REVIEW11-22-2024
Spirituality and religiosity in children, adolescents and their families in a vulnerable context: a scoping review
Revista Brasileira de Enfermagem. 2024;77(5):e20230425
Abstract
REVIEWSpirituality and religiosity in children, adolescents and their families in a vulnerable context: a scoping review
Revista Brasileira de Enfermagem. 2024;77(5):e20230425
DOI 10.1590/0034-7167-2023-0425
Views1See moreABSTRACT
Objective:
to map evidence in the literature on the spirituality and religiosity of children, adolescents and their families in social vulnerability.
Methods:
this is a scoping review based on the JBI methodology, with the search without delimiting the time period, in English, Portuguese and Spanish, in the Virtual Health Library, PubMed, Embase, Cochrane Library, Scopus and Web of Science databases.
Results:
twenty-two studies were identified. The most studied population were adolescents, followed by children and their families. Regarding the setting, the context of vulnerability related to the low socioeconomic level experienced by these populations was highlighted. Furthermore, spirituality and religiosity were considered important for coping, social support, purpose and strength.
Conclusion:
there is an influence of spirituality and religiosity in the lives of children, adolescents and families, being a protective factor and a source of comfort, playing essential tools for living in context.
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ORIGINAL ARTICLE12-13-2024
Stress in nursing workers caring for people with COVID-19
Revista Brasileira de Enfermagem. 2024;77(5):e20230542
Abstract
ORIGINAL ARTICLEStress in nursing workers caring for people with COVID-19
Revista Brasileira de Enfermagem. 2024;77(5):e20230542
DOI 10.1590/0034-7167-2023-0542
Views1See moreABSTRACT
Objectives:
to analyze stress from the perspective of nursing workers caring for people with COVID-19 in a public hospital in the Recôncavo region of Bahia.
Methods:
this is an exploratory qualitative study, conducted through semi-structured interviews. The data were analyzed using word clouds, similarity trees, and content analysis.
Results:
nursing workers were exposed to stress while attending to patients with COVID-19. The reported stressors in the workplace included: work overload, lack of planning, speed in performing tasks, fatigue, lack of participation in decision-making, lack of support from management, technological changes, excessive responsibility without preparation, interpersonal conflicts, and professional undervaluation.
Conclusions:
exposure to these stressors leads to emotional exhaustion and demotivation, which were intensified during the COVID-19 pandemic.
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ORIGINAL ARTICLE01-13-2024
Knowledge, Attitudes, and Practices of nurses regarding blood culture collection
Revista Brasileira de Enfermagem. 2024;77(6):e20230424
Abstract
ORIGINAL ARTICLEKnowledge, Attitudes, and Practices of nurses regarding blood culture collection
Revista Brasileira de Enfermagem. 2024;77(6):e20230424
DOI 10.1590/0034-7167-2023-0424
Views2See moreABSTRACT
Objectives:
to investigate the knowledge, attitudes, and practices of nurses regarding blood culture collection.
Methods:
a cross-sectional study was conducted in five Brazilian public hospitals with 112 nurses. Data were collected using an adapted questionnaire and analyzed through descriptive and inferential statistics.
Results:
nurses who did not consider themselves capable of collecting blood cultures had a 72% lower chance of performing the collection at the recommended site and an 83% lower chance of using the same needle for blood inoculation into the vials. Nurses working in the emergency department had a 75% lower chance of knowing the international benchmark for blood culture contamination rates, and those with less than 5 years in the position decreased their chance of accuracy in this matter by 79%.
Conclusions:
there are gaps in the knowledge, attitudes, and practices of nurses regarding blood culture collection. Standardization of the technique, periodic education, supervision and guidance of the collection team, and process auditing are recommended coping strategies.
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ORIGINAL ARTICLE01-10-2024
Inventory of ethical problems in mobile pre-hospital care
Revista Brasileira de Enfermagem. 2024;77:e20230539
Abstract
ORIGINAL ARTICLEInventory of ethical problems in mobile pre-hospital care
Revista Brasileira de Enfermagem. 2024;77:e20230539
DOI 10.1590/0034-7167-2023-0539
Views1See moreABSTRACT
Objective:
to construct and validate the content of an inventory of ethical problems experienced by nurses in mobile pre-hospital care.
Method:
a psychometric approach study, developed with the following stages: (1) instrument construction through a theoretical matrix based on deliberative bioethics, scoping review and online qualitative research; (2) content validity by judges; (3) pre-testing with Mobile Emergency Care Service nurses in various Brazilian states. For content validity analysis, the Content Validity Ratio was calculated (CVR>0.45 for judges and CVR>0.35 for the target population).
Results:
the instrument had 44 items, distributed across four dimensions.
Final considerations:
the constructed instrument presented sources of evidence of content validity, providing good psychometric measurements and constituting a useful tool for nurses’ practice in the pre-hospital setting.
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ORIGINAL ARTICLE05-18-2020
Women in situations of sexual violence: potentialities and weaknesses of the intersectoral network
Revista Brasileira de Enfermagem. 2020;73(4):e20190856
Abstract
ORIGINAL ARTICLEWomen in situations of sexual violence: potentialities and weaknesses of the intersectoral network
Revista Brasileira de Enfermagem. 2020;73(4):e20190856
DOI 10.1590/0034-7167-2018-0856
Views0See moreABSTRACT
Objectives:
to identify potentialities and weaknesses of the intersectoral network for women in situations of sexual violence, from the perspective of Intervention Bioethics and the Universal Declaration on Bioethics and Human Rights.
Methods:
qualitative study conducted with multidisciplinary team members who work in intersectoral care services for women subject to sexual violence. It was held in a municipality in southern Brazil. An intentional sample, totaling 30 professionals. Semi-structured interview was used from January to April 2016. Interviews were analyzed by Thematic Analysis.
Results:
two categories emerged: potentialities and weaknesses related to the intersectoral network. Potentialities confirm the importance of the articulated intersectoral network; weaknesses such as lack of organized flow and disarticulation of services result in women revictimization and care fragmentation.
Final Considerations:
it is necessary to articulate services and qualify professionals. The Intervention Bioethics and the Universal Declaration on Bioethics and Human Rights foster discussions that contribute to how to organize and sustain the intersectoral network.
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REVIEW07-17-2020
Approaches to workload in psychiatric and mental health nursing
Revista Brasileira de Enfermagem. 2020;73:e20190620
Abstract
REVIEWApproaches to workload in psychiatric and mental health nursing
Revista Brasileira de Enfermagem. 2020;73:e20190620
DOI 10.1590/0034-7167-2019-0620
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Objective:
to investigate approaches to workload in psychiatric and mental health nursing in Brazilian and international production of knowledge
Methods:
integrative literature review using six databases, covering January 2005 to March 2019. Articles in full in English, Spanish and Portuguese were included.
Results:
the sample consisted of 23 original articles classified as quantitative or emotional. The quantitative dimension was addressed in 12 articles and included: assessing patient care needs, identifying activities performed by the team, measuring time spent and developing and validating a measurement instrument. The emotional dimension included 11 articles the focus of which was on identifying stressors in the workplace, psychosocial risks and coping strategies.
Conclusion:
strategies were found for measuring workload and assessing the impact of stressors on nursing teams.
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ORIGINAL ARTICLE06-24-2020
Interprofessional relationships of a patient assistance team in critical care
Revista Brasileira de Enfermagem. 2020;73(4):e20190420
Abstract
ORIGINAL ARTICLEInterprofessional relationships of a patient assistance team in critical care
Revista Brasileira de Enfermagem. 2020;73(4):e20190420
DOI 10.1590/0034-7167-2019-0420
Views0See moreABSTRACT
Objectives:
to identify perceptions of teamwork according to the professionals of an Adult Intensive Care Unit.
Methods:
descriptive research with qualitative approach. The methodological framework was thematic content analysis. The theoretical framework of the work process was used to guide the interpretation of the data. Data collection: A semi-structured interview was conducted with 38 professionals in a public teaching hospital in the state of Minas Gerais. Results: three thematic categories emerged from the interviews: Work Organization, which is related to work performed through tasks/routines, with or without coordinated actions; Non-material Work Instruments, which reveal that teamwork is based on communication/collaboration; Insufficient Material Resources, which indicate that lack of material creates conflicts between professionals.
Conclusions:
Teamwork requires effective communication and collaboration, integrated work and appropriate professional training. On the other hand, fragmentation and rigidity at work, poor collaboration/communication and lack of material make teamwork difficult. We emphasize the need to revise the curriculum of health courses, with a view to including and/or improving discussions about teamwork in order to train professionals for a more integrated and perhaps even sympathetic health practice.
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ORIGINAL ARTICLE04-09-2020
Nursing work and competence in hemotherapy services: an ergological approach
Revista Brasileira de Enfermagem. 2020;73(3):e20180775
Abstract
ORIGINAL ARTICLENursing work and competence in hemotherapy services: an ergological approach
Revista Brasileira de Enfermagem. 2020;73(3):e20180775
DOI 10.1590/0034-7167-2018-0775
Views0See moreABSTRACT
Objetives:
to analyze the ingredients of the competence that the nurses use in the performance of their work in hemotherapy.
Methods:
qualitative study with 22 nurses, accomplished through documentary study, observation and semi-structured interview, with resources of Atlas.ti software based on the foundations of Historical Materialism Dialectic and Ergology. Performed Content Analysis.
Results:
the domain of specific knowledge of hemotherapy and the time of experience in the area, allied to the motivation of the worker and the ability to work in a team favor the competent action in the work activities. On the other hand, the lack of adequate work conditions, especially in relation to adequate materials, equipment and structure, impairs the work of the nurse in hemotherapy.
Final Considerations:
experience gained is critical to successful decision making. In addition, adequate working conditions, updating of knowledge and ability in teamwork favor a scenario of safe practices.
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ORIGINAL ARTICLE08-30-2021
Historical aspects in pain management in palliative care in an oncological reference unit
Revista Brasileira de Enfermagem. 2021;74(5):e20200761
Abstract
ORIGINAL ARTICLEHistorical aspects in pain management in palliative care in an oncological reference unit
Revista Brasileira de Enfermagem. 2021;74(5):e20200761
DOI 10.1590/0034-7167-2020-0761
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Objective:
Describe the actions implemented for pain management in palliative care oncology and analyze the contribution of Hospital do Câncer IV, as a reference unit at the National Cancer Institute.
Methods:
Study of the history of the present time, whose sources were written documents and interviews with five participants. The collection took place from February to June 2018. The analysis of the written sources took place through internal and external criticism of the documents, considering their chronology and theme.
Results:
Professionals contributed with actions for pain management in palliative oncology care: in discussions and final drafting of ordinances, as rapporteurs at national and international events, in the elaboration of humanization conducts and systematization of assistance in addressing pain.
Final considerations:
These actions favored assistance in palliative oncology care at various levels of health care for patients and families, with greater technical and scientific recognition for all.
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06-28-2021
Validation of an instrument for systematizing nursing care in pediatrics
Revista Brasileira de Enfermagem. 2021;74:e20200222
Abstract
Validation of an instrument for systematizing nursing care in pediatrics
Revista Brasileira de Enfermagem. 2021;74:e20200222
DOI 10.1590/0034-7167-2020-0222
Views0See moreABSTRACT
Objective:
to verify the validity of indicators’ content referring to the instrument for data collection in children aged 0 to 5 years hospitalized in a pediatric clinic.
Method:
a cross-sectional methodological study was carried out with 11 experts between January and May 2018. For data collection, the steps for validating the instrument’s content were respected. For data analysis, Content Validity Index and Kappa agreement analysis were used.
Results:
after content analysis, a Content Validity Index of 0.94 and Kappa 0.71 was issued according to the experts’ suggestions 81.9%. Therefore, the instrument was suitable for applicability.
Conclusion:
the instrument proved to be valid in terms of content for pediatric care, contributing significantly to improving care for hospitalized children aged 0 to 5 years.
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06-11-2021
Severe acute postoperative pain self-reported by children after ambulatory surgeries: a cohort study
Revista Brasileira de Enfermagem. 2021;74:e20200151
Abstract
Severe acute postoperative pain self-reported by children after ambulatory surgeries: a cohort study
Revista Brasileira de Enfermagem. 2021;74:e20200151
DOI 10.1590/0034-7167-2020-0151
Views1See moreABSTRACT
Objectives:
to estimate the incidence and the risk factors for severe acute postoperative pain self-reported on the first day after hospital discharge.
Methods:
cohort study with 279 children from both sexes (5-12 years old), indicated for ambulatory surgery in two Brazilian hospitals. Children were assessed at the pre-surgery, immediate postoperative and first postoperative day. Faces Pain Scale-Revised and Yale Preoperative Anxiety Scale Modified were used. Severe postoperative pain was defined as score ≥6. Cox regression analyses were used.
Results:
the incidence of severe postoperative pain was 15.8% (95%CI:10.7%-20.4%) on the first postoperative day. Preoperative anxiety (HR=2.23; p=0.049), severe preoperative pain (HR=2.78; p=0.031) and having undergone two surgical procedures (HR=2.91; p=0.002) were associated with severe postoperative pain.
Conclusions
the incidence of severe postoperative pain self-reported after hospital discharge was high. Anxiety and severe preoperative pain, in addition to performing two surgical procedures at the same time were confirmed as risk factors.
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REFLECTION09-07-2020
Public health nursing: regulation and public health policies
Revista Brasileira de Enfermagem. 2020;73(6):e20190550
Abstract
REFLECTIONPublic health nursing: regulation and public health policies
Revista Brasileira de Enfermagem. 2020;73(6):e20190550
DOI 10.1590/0034-7167-2019-0550
Views0See moreABSTRACT
Objective:
To analyze regulation and public policies related to nursing and the specialist nurse in community and public health nursing.
Methods:
Analysis of the legal and normative framework of community and public health nursing in Portugal, as well as current public health policies, regarding the competences and intervention of this nurse, articulated with the attributions of the Public Health Unit.
Results:
The intervention of this nurse deserves a broad reflection, in the sense of maximizing the activities of community and public health, essential for the implementation of public policies and obtaining health gains.
Final considerations:
This nurse has competences foreseen in the regulations and standards for public health interventions, in line with the attributions of the Public Health Unit, of the National Health Service, in which specialties are identified for their performance in the current structure.
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